By: Sinead Killeen
In the intricate world of behavioral healthcare, where reimbursement policies and insurance claims are critical to operational success, a new and concerning trend has emerged, potentially impacting how providers manage their financial operations. This silent contracting trend involves Florida Blue’s recent policy changes regarding laboratory service claims and their significant implications.
Florida Blue, a major payor in healthcare insurance, began denying all out-of-network (OON) laboratory claims in 2021, compelling providers to utilize Quest Diagnostics as the sole participating laboratory in Florida Blue’s network. This pivot meant behavioral healthcare providers had to adjust to using Quest for their lab services, expecting continuity in Florida Blue’s payment of lab services.
However, after providers transitioned to Quest, Florida Blue began denying these lab claims, informing Quest and the providers that the rehab per diem rate now encompassed the lab services—a bundling approach that was not previously enumerated in its provider agreements and the shift in payment policy was never communicated to providers. This shift has resulted in providers facing substantial outstanding bills from Quest, as these labs were suddenly deemed part of an all-inclusive rate that was not increased to make up for the financial responsibility for lab bills.
For behavioral healthcare providers, this bundling trend has far-reaching implications:
- Financial Strain: Providers are left with unexpected liabilities, as lab services they have to order as part of their treatment plans are no longer reimbursed separately, leading to financial strain.
- Operational Disruption: Adjustments to billing processes are required, potentially leading to confusion and inefficiencies in managing claims. Further, providers will need to seek to renegotiate their Florida Blue network agreement to request a rate increase.
- Legal Challenges: Providers may face legal battles, either in response to claims from laboratories like Quest or in seeking proper reimbursement from insurers like Florida Blue.
These developments underscore a potential systemic issue that could extend beyond Florida to impact behavioral healthcare providers nationwide. From a legal standpoint, this situation presents several potential avenues for challenge and resolution:
- Class Action Opportunities: The inconsistent application of bundling policies by Florida Blue could be grounds for a class action lawsuit, potentially involving multiple affected providers across the state or even nationally.
- Direct Action Against Insurers and Labs: Legal action against Florida Blue to compel payment for lab services, or against Quest for billing under disputed terms, may be viable strategies.
Attorney Sinead Killeen is currently defending a suit initiated by Quest against a significant behavioral health provider in Florida. She has significant experience in navigating complex reimbursement challenges such as these as well as expertise in optimizing reimbursement processes can be invaluable for providers facing similar challenges.
For behavioral healthcare providers, understanding this trend and its implications is crucial for maintaining financial stability and ensuring compliance. Engaging legal expertise through professionals like Sinead Killeen can help develop strategies tailored to your organization’s needs.
Next Steps:
- Engage Key Stakeholders: Involve your CFO, billing director, and other critical team members who manage your revenue cycle to analyze whether this Florida Blue policy has impacted your facility. They should connect with legal experts to understand potential impacts and strategies.
- Explore Legal Options: Consider reaching out for a consultation to assess your situation and explore potential legal actions. These consultations can help clarify your options without initial costs.
- Review Contracts and Policies: Assess your current contracts and billing practices to ensure alignment with evolving policies and regulations.
In the face of these challenges, proactive engagement and strategic planning are essential. By understanding the trends and leveraging expert guidance, behavioral healthcare providers can safeguard their financial health and continue delivering essential services.
For further assistance and to schedule an exploratory consultation, reach out to Sinead Killeen, who specializes in these reimbursement issues across Florida and nationwide.
