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Leading Attorneys In Health Care Reimbursement And Illegal Discount Litigation

Over the last ten years, consumers and medical providers across the country have watched their insurance company reimbursements decrease as their medical bills are reduced by quickly evolving insurance company reduction schemes and wrongful denial practices. The most prominent of which has been the Ingenix database UCR rate reductions on out-of network bills. Despite billing managers, CFOs, and medical auditing firms expending great time and effort fighting the good fight against these unfair and financially devastating insurance company practices, insurance companies still ignore their demands for full payment. To level the playing field, medical providers are in need of attorneys who have the healthcare and medical reimbursement litigation knowledge and track record to successfully recover in court the large reductions and denials taken by insurance companies. 

At Phillips & Garcia, P.C., we have spent the last decade focused on helping medical providers identify and recover revenue lost to insurance company underpayments.  Pioneers of revenue recovery litigation (long before the term "denial management" had even been used) and the fight against UCR rate reductions, Silent PPOs and managed care contract under-payments, we are dedicated to educate, protect and assist consumers and health care providers fighting against big insurance companies that reduce, deny or delay payments. We are also on the cutting edge of new reduction and denial practices which underpay medical providers such as the Rescission of Insurance, Down-Tiering and Prompt-Pay violations.

Practicing out of North Dartmouth, Massachusetts, and representing clients across the country, after ten years of working on these issues for providers, we have developed a working strategy for recovering lost revenue for medical providers on aggregated medical claim reductions and denials. 

Here is what we do:  

1. Identify the illegal discounts or denials taken by an insurer by examining sample EOBs or EORs along with the  provider's managed care contract and insurance benefit information. By the time the providers comes to us, they typically have an understanding of the type of reduction or denial involved, and we apply a laser focus to the problem.

2. Establish legal claims against the insurer through in-depth, healthcare-specific legal research and analysis. 

3. Demand payment from the insurance company through dispute resolution such as arbitration or through individual lawsuits, mass action lawsuits, or class action lawsuits. 

Due to the demand for our services, we focus our representation on specific and repeated insurance company tactics that cause large individual or aggregate reductions or denials of medical charges that add up to big potential losses.  We focus on industry-wide problems such as UCR reductions, Silent PPOs, non-compliance with fee schedules, contractual underpayments, down-tiering, prompt payment violations and retroactive denials.  

Leading Attorneys In Healthcare Reimbursement And Illegal Discount Litigation

Although many health care providers already have billing managers, CFOs, medical auditing firms and lawyers working with them to negotiate managed care contracts, track UCR reductions and watch for Silent PPOs, many times receiving full reimbursement from insurance companies requires specialized assistance. We are one of very few firms that focus on these issues, and who also have a long, extensive and deep knowledge of the industry-wide denial and reduction schemes by insurance companies that affect a medical providers' cash flow. We learned this information "in the trenches" battling insurance companies in court cases.

We filed the first Silent PPO class action in the country in Massachusetts in 1998 and went on to successfully represent thousands of Florida medical providers in federal court who were victims of Silent PPO discounts taken by numerous auto insurers, some of whom were the largest auto insurers in the nation.  All of our Florida Silent PPO cases settled and the aggregate class benefits for the Florida medical providers exceeded $30 million.  More importantly, all the insurers we sued stopped the Silent PPO discounting of automobile insurance PIP claims in FL.  

We have also litigated UCR rate class actions against insurers and currently have individual UCR rate cases pending for our medical provider clients.  

The American Medical Association estimates that medical providers lose tens of millions of dollars per year to Silent PPO schemes - while most medical provider victims of this practice are utterly unaware of the reason for their dropping revenues. At Phillips & Garcia, we want to inform and educate medical professionals on how these unfair and illegal activities can be discovered and prevented. 

We have written the original and only book on Silent PPOs:  The Provider's Guide to Silent PPOs:  How Insurance Companies Steal Your Money and How You Can Protect Yourself. This book has been reviewed and requested by many medical providers and medical auditing companies over the years and has been referenced in numerous healthcare industry magazines and newsletters. We just revised and updated this popular book for this website because we realized that medical providers are still confused by this practice and fall victim to it every day.

The revised book, now called The Ultimate Providers Guide to Silent PPOs, answers some of the most frequently asked questions about Silent PPOs, such as: 

* What is a Silent PPO?

* How do Silent PPO schemes work?

* What is "Cherry Picking"?

* Why are the new Silent PPO laws tigers with no teeth?

* What terms should we include in our PPO contract to stop losing money?

* How can we protect our practice against Silent PPOs?

* How can we audit our claim payments?

* How can we recover the money that we've already lost? 

Do You Have Questions About How to Maximize Medical Reimbursement?  Contact Us. 

Whether you are a medical provider billing manager, a medical provider CFO, a medical auditing firm or the lawyer for a medical provider, we want to help you with your potential payment abuses and improper discounts. We invite you to contact us with your questions and concerns either by calling us toll-free at (877) 892-5620 or by filling out the electronic contact form located on the right hand side of this page.

Reduced and Denied Health Insurance Claims

Across the country, insurance companies are fleecing health care providers through “cost-containment” strategies that systematically delay reimbursement or underpay medical providers on valid claims. At Phillips & Garcia, we are dedicated to holding these insurance companies accountable and recovering the revenue lost by medical providers through violations of managed care contracts, UCR reductions, PPO discounts and other wrongful denials and reductions which prevent maximum reimbursement. Contact us today for more information.

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