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When to Dispute Vendor Reimbursements

Suppose a patient visits the dental office for a crown to address a cracked tooth. The patient’s insurance is expected to cover 50% of the cost, with the patient responsible for the remainder. As the dental office is in-network with the patient’s insurance provider, the vendor is obligated to reimburse the dental office for half of the procedure’s cost. However, if the insurance company fails to cover its agreed-upon portion of the cost, the dental office has the right to dispute the reimbursement. 

Determining when to dispute vendor reimbursements requires assistance from healthcare law lawyers who are well-versed in this area. Our experienced healthcare practice attorneys can help you navigate these complexities to ensure you receive fair compensation for the healthcare services provided. 

Below, you will find more details on when to dispute vendor reimbursements. We are here to address any questions you may have regarding insurance reimbursements within the healthcare industry. 

What Are Vendor Reimbursements?

As briefly described above, vendor reimbursements in healthcare refer to the process in which healthcare providers, such as hospitals, clinics, convalescent homes, long-term care facilities, or doctor’s offices, receive payment from government programs or commercial insurance companies for the services provided to patients. 

For healthcare providers to receive reimbursement from federal payors, like Medicare and Medicaid, or commercial payors, like Blue Cross Blue Shield or Aetna, they must comply with specific laws and regulations to guarantee accurate compensation.

Oftentimes, the insurance company, or vendor, will require healthcare providers to sign a contractual agreement to ensure the rules are followed and standards are met adequately. Claims submitted for reimbursement undergo careful examination and auditing by the insurance company to verify correct payment amounts and proper allocation of government funding in cases involving federal payors. 

Circumstances In Which Vendor Reimbursement Disputes Are Acceptable

We advise healthcare providers to consult an experienced reimbursement attorney early on in the process, especially upon receiving a record request from an insurance payor. Here are specific circumstances in which disputing a vendor reimbursement with the assistance of a healthcare practice attorney may be necessary. 

  • Billing errors. Healthcare providers may consider disputing a reimbursement if the vendor has submitted incorrect or duplicate payments. Look out for any errors or discrepancies in the vendor’s invoice compared to the agreed-upon terms or previously provided services.  
  • Breach of contract. If the vendor fails to fulfill the terms of the agreement, a reimbursement dispute may arise. Let’s say the vendor misses a deadline, the healthcare provider may have grounds to dispute for additional reimbursement.  
  • Authorization denial. If the insurance company denies reimbursement for healthcare services that were pre-approved and authorized according to the contract, a dispute over vendor reimbursement may be acceptable. This might involve cases where the services were deemed medically necessary and met all the criteria for coverage but were still denied by the payor.  

Contact a Healthcare Reimbursement Attorney Today

If you are facing issues regarding vendor reimbursement disputes, we highly suggest working one-on-one with a Los Angeles healthcare reimbursement attorney who specializes in this matter. Our healthcare practice offers a team of knowledgeable and experienced attorneys who can guide you through the healthcare reimbursement process and advocate for you on your behalf according to the law. Contact us at (310) 444-5244 or fill out the form on our website today to connect with a healthcare practice lawyer.