Avoiding Internal Legal Conflict When A Payor Is A Provider

Law360 (September 10, 2020, 5:07 PM EDT) -- Historically, with a few notable exceptions, there has been a clear distinction between payors — health insurance companies — and providers, which include hospitals, physicians and other medical professionals. This line of demarcation is reflected not only in the regulatory regimes governing the health care system, but also in the litigation positions that payors and providers take on issues such as the following:

What constitutes the usual, customary and reasonable rate for health care services;

The validity of health plans' medical necessity and level of service guidelines;

The enforceability of anti-assignment clauses and the standing of providers to bring reimbursement actions...

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