How a Success Fee Works for a Network Dispute

A dispute with a health plan has an uncertain outcome. The plan decides, not us and not you, and no one can promise what it will do. Our pricing reflects that: a modest upfront fee for the work, and a flat fee only if the work produces a win. Here is how it fits together.

What do you pay, and when?

So a provider disputing one payer pays $249 for the review, then the $799 dispute with the $249 credited toward it, and $1,500 only if that payer offers a contract or approves credentialing. Fees charged by others, such as a plan's application fee, certified mail or an attorney you hire, are separate and paid to them. See pricing.

What counts as a win?

A win is a payer offering you a contract, or approving your credentialing, after the dispute. That is the point at which the closed door has opened. Enrollment and loading then pass to our sister company, White Glove Credentialing.

Some outcomes are not wins and carry no win fee:

• a plan's statement that it may reopen the panel later, or an invitation to reapply in a year;
• a request for more information;
• a plan's decision to stand by its denial.

A single-case agreement is priced on its own, as Single-Case Agreement Support at $350 per agreement, not as a win fee. See single-case agreements.

Why a flat fee and not a percentage?

Two reasons.

It is predictable. You know the number before you start, and it does not grow with your success with that plan. A percentage of collections would keep charging you for months or years after the work was done.

It avoids fee-splitting problems. Licensing rules in some states restrict sharing professional fees. New York's professional misconduct law for physicians, for example, includes "any arrangement or agreement whereby the amount received in payment for furnishing space, facilities, equipment or personnel services used by a licensee constitutes a percentage of, or is otherwise dependent upon, the income or receipts of the licensee" (N.Y. Educ. Law 6530(19)). A fee calculated as a share of your payer revenue could raise exactly that question. A flat fee per win does not depend on your income from the plan. If you have questions about how your own state's rules apply to any vendor arrangement, ask a healthcare attorney.

What does the upfront fee pay for?

The work that has to happen whether or not the plan says yes: reading the plan's letters and policies, identifying the plan type and the rules that apply, calendaring deadlines, requesting the written reason and your file, auditing the plan's directory, measuring distances and wait times, and preparing the reconsideration request, network adequacy letter and any regulator complaint draft. You review, sign and send each document; we track the plan's responses and prepare the follow-ups.

What if the review finds no lever?

Then we say so. The review exists to tell you whether a dispute has a realistic basis before you pay for one. Sometimes the honest answer is that the network is genuinely saturated, the plan is a self-funded employer plan outside state law, and the best path is to apply elsewhere and reapply later. That answer is worth having for $249. Panel Watch ($199 per year) can then track reapplication dates and reopenings. See reapplying after a network denial.

What do we never charge for?

We never charge a share of your billing, and we do not sell legal services. We are not a law firm and do not represent you; if a matter needs a lawyer, you hire a healthcare attorney directly and pay the attorney yourself. See when a dispute needs a healthcare attorney.