Arbitration Approach. 

Being available to the parties; enabling the parties to discover relevant information needed to present their respective cases consistent with conducting a fair proceeding that is more streamlined than civil litigation; carefully weighing all relevant evidence and arguments; treating all arbitration participants respectfully; and issuing awards and rulings that are clearly explained and well-reasoned.

Representative Issues at Roth’s Payor-Provider Arbitrations:

• Calculation of fair market value owed by hospital to cardiology group arising out of group operating hospital's cardiac catheterization laboratory.

• Fee schedule dispute arising out of hospital system converting its office-based provision of oncology services to hospital-based outpatient care.

• Dispute between hospital-system and health plan over calculation of payments due under fee schedules; prepayment line-item review by payor related to calculating hospitals' billed charges and stop-loss payments.

• Whether payor entitled to pass along its 2% sequestration payment reduction to hospitals.

• Medical necessity and level of care dispute between hospital and payor.

• Whether claims clean, timely submitted, or submitted late without good cause; and calculating "reasonable fee" for services furnished by out-of-plan group to payor's enrollees.

• Whether payor violated State prompt pay statute and applicability of ERISA preemption.

• Determining patient population and payor mix of medical group to calculate payments due to group from payor.

• Whether payor obligated to pay uncontested portions of line-item denials, pay or process claims, and pay line items on invoices missing correct codes.

• Whether hospital billing non-discounted charges based upon late payment constituted unenforceable penalty.

• Whether pharmacy benefit manager violated Federal/State Any Willing Provider Laws when PBM clawed back payments from pharmacy based upon PBM's application of pay for performance quality metrics to pharmacy.

• Whether health care plan entitled to pay as secondary payor for ESRD patients eligible for but not enrolled in Medicare. 
  

Representative Issues at Roth’s Non-Payor Provider Arbitrations:

• Whether cardiology group or its employed physician breached recruitment agreement with hospital.

• Whether health plan breached its preferred provider agreement with hospital by failing to publicize/promote use of hospital by its members.

• Whether medical group wrongfully terminated physician-employee and violated state whistleblower statutes.

• Whether physician breached agreement with a physician-leasing company when he contracted directly with hospital to which he had previously been leased by company.

• Whether a practice management company breached contract by using medical group's ARs for improper purposes versus whether group breached contract by interfering with AR collections.

• Whether marketing vendor complied with contract terms to conduct direct mail program and make outbound telephone calls on behalf of ESRD supply manufacturer.

• Whether physician group breached contract by altering physician's contract without the physician’s knowledge.

• Whether medical group liable for not timely credentialing its contracted physician with payors.

• Whether a TPA was financially liable for a hospital’s claims for payments arising out of an agreement between the TPA and a PPO, which afforded health plan enrollees access to the PPO’s network of providers.

• Whether compounding pharmacy's membership in pharmacy network was wrongfully terminated.

• Whether teaching hospital underpaid by community health system for its residents and fellows training in system.