Revenue Recovery

In light of the current regulatory landscape and increasing enforcement effort by commercial insurance companies, a qualified attorney well versed in regulatory compliance regarding your specific area of practice can help protect your revenue.

Physicians are finding that they have to argue with insurance companies for proper payment and reimbursement for claims. However, many of those claims are overwhelmingly denied over and over until the appeals process is exhausted and it's one more claim sitting in accounts receivable unpaid.

Why should physicians have to argue for payment they earned?

As of 2008, California Health and Safety Code §1371.4 and California Code of Regulations §1300.71 offer protection to emergency health care providers affected by the passing of Governor Schwarzenegger's ruling on balance billing.

As long as federal or state law requires that emergency services and care be provided without first questioning the patient’s ability to pay, a health care service plan shall not require a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the patient's emergency medical condition.

The law states that a health care service plan, or its contracting medical providers, shall reimburse providers for the reasonable and customary value according to the Gould criteria for emergency services and care provided to its insured members, until the care results in stabilization of the insured member.

What is the "Reasonable and Customary" value?

Known as Gould Criteria, the reasonable and customary payment amounts must be determined using statistically credible information that takes into consideration the following six criteria:

  1. The provider's training, qualifications, and length of time in practice

  2. The nature of the services provided

  3. The fees usually charged by the provider

  4. Prevailing provider rates charged in the general geographic area in which the services were rendered

  5. Other aspects of the economics of the medical provider's practice that are relevant

  6. Any unusual circumstances in the case.

Consulting with a medical reimbursement attorney to challenge unclaimed balances and denied claims as well as your patient intake and appeals process will help you manage the outcome of claims, resulting in improved reimbursements, fewer denials and less time spent managing negative outcomes.

• Maximize earned revenue
• Lower administrative costs
• Focus on medical practice
• Identify regulatory compliance concerns
• Advisory on billing and claims submission

Time is of the essence. Because health organizations are required by law to pay “clean claims” within a certain period of time, physicians should revisit new and old claims while your patient's insurer is liable for the claim.


Start with sharing your story, how you have exhausted appeal options at each level and include any notes of preauthorization or implied contracts. An attorney will contact you if a complaint will be filed against the insurer and litigation begins.


Contact us for a free consultation or send a case inquiry online. To learn more about the recent laws affecting your practice and others, visit our blog.

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Orthopedic Surgeon

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Claims Analysis

Emergency Medicine

Medical Billing Disputes

Healthcare Regulatory and Compliance

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Medical Provider Reimbursement

Litigation and Arbitration

Recovery and Reconciliation Process

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