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Out-of-Network Denials

Representing Non-Participating Providers

Abril Law is experienced in the representation of Non-Participating Providers, and the hurdles they face in receiving adequate compensation for their services in a payor dictated environment. Managed Care Organizations will commonly question the reasonableness of a provider’s billed charges to justify underpayment or outright denial of these medically necessary services. To overcome this, we establish the usual, customary, and reasonable reimbursement for out-of-network providers. We rely on both internal, proprietary databases, along with a network of outside experts to exhaustively document the provider’s proper payment for similarly billed claims in your area.

The firm frequently seeks judicial intervention to dispositively define acceptable rates, and thereby ensure the prospective payments applicable to the disputed claims.

In-hospital providers, such as pathologists, radiologists, anesthesiologists, etc., may fall outside the scope of the facility’s contractual relationship with the payor. Therefore, those providers would be considered out-of-network, subjecting their reimbursement to the discretion of the payor. We at Abril Law will fight zealously on behalf of our clients to always obtain the maximum compensation for their services.

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