Health Claims

The Perez Law Firm Will Represent You

When you need medical care, you want to rely upon your health insurance not only to cover the cost but assure that you have access to the treatment. The proposed treatment may be denied when there is a preauthorization sought by your treating physician or other medical provider. Even if there is preauthorization, and the treatment is obtained your health insurance carrier or the self-insured plan may still deny payment because preauthorization is not a guarantee of payment. We have many years of assisting patients/clients in obtaining payment. We also represented physicians and medical care providers to assure that they get paid as they should under the terms and conditions of the policy or plan.

The Affordable Care Act and other federal legislation and the related regulations expanded your rights after the claim is denied. Now your insurance company is required to tell you specifically why they are paying your claim and to provide you with documentation of their position and you have up to six months to appeal.

To maximize the likelihood of payment you should be aware of the following suggestions. The first is to understand why your claim was denied. You must understand why it was denied. Your explanation of benefits (EOB), a standard and usually confusing form sent by the insurance company whenever your claim is approved or denied, uses codes to explain the basis for the insurance company refusal to pay.  Generally, the EOBs will also have a code with a key to the codes. These keys to the codes are usually vague. It is likely that you still will not be sure why the claim was denied. Now the insurance company or plan must provide you with a document explaining the codes. You have a right to this information, and the insurer has a responsibility to explain it in terms you can understand. Also, when there is a claim denial make sure you have a copy of the appropriate documents. This can be the certificate of coverage, insurance policy or your employer’s health care plan.

Sometimes your claim was denied only because of a data-entry error or other careless mistake such as a misspelled name, wrong insurance ID number, or the wrong date of service. Read through all the documentation from your insurance company carefully. Determine whether there are simple errors. If you find one call the insurance company and ask them to correct it. Explain why it is wrong. Your healthcare provider may have made a mistake and you might call the physician or medical provider and ask that it be corrected and that the claim be resubmitted.

Gather supporting documentation. You may want to obtain a letter from your physician to prove that the treatment was medically necessary. This may require that you obtain the health plan’s criteria with regard to this type of treatment. Under the new regulations, they are required to provide you with that written criteria. Make sure you have all the evidence to show that the services you want covered are medically necessary. Make a request for this information.

Although your doctor has an interest in making sure your payment is made, it is ultimately your responsibility. If the amount involved is great, consider obtaining legal advice from someone who has years of experience in dealing with this type of problem. Calling a friend of your brother-in-law who has legal experience in real estate will not be helpful. If it’s a high dollar claim, you need assistance because the insurance company or self-insured plan will try mightily to deny the claim if it can.

In our experience, health insurance companies and self-insured plans are likely to deny a claim based upon what the computer screen tells the claim adjuster and not care about your own medical condition and need for treatment. Surgical procedures can be denied based upon failure to obtain conservative treatment prior to exercising the surgical option. We have seen these denials without the insurance company obtaining the medical records of the patient/claimant. Do not assume that there has been a thorough investigation of your claim.

Simply writing a letter to your insurance company may be inadequate especially if it’s a high dollar claim. Nonetheless, everything should be in writing and telephoning to try to reverse a claim denial unless it’s a simple error is not only a waste of time but can actually result in hurting your claim and the probability of success later. When you do correspond in writing include your claim number and the number on your health insurance card/plan number. The explanation of benefits you received should tell you how to appeal the decision, but the best thing to do is to get a copy of the certificate of coverage, insurance policy or the health plan. There is also many times a summary plan description that can be helpful but it is not the most important document. Make a request for these documents in writing. There is a penalty provision if there not provided to you within 30 days. Simply calling may not be adequate and it certainly will not be sufficient to invoke the penalty provision later.

You must be and stay organized. If you do telephone make sure you get the name of the person to whom you are talking, that person’s job title and write down what they say with the date and time that it occurs. The insurance company may have a “call reference number” or incident number. Ask for this number.

The insurance company, health care plan administrator or other claims administrator must follow extensive regulation that are set up under federal law. They do not. You can count on them not knowing what their responsibilities are and failing to follow what they are required to do. We know what the requirements are. We know what their responsibilities are. We know what questions to ask. We know the time frames that they have for responses. All these matters are contained within fairly complex regulations in fact, two separate sets of regulations or may be more. This is not a simple area.

If you’ve a right to appeal, you should find out if there is a second appeal required or whether there is a voluntary appeal. This should be in the certificate of coverage, health insurance policy, or in the health plan document itself. Because there are time deadlines for you to act, it is important for you to pay attention to them. Generally, the insurance company will ignore the timelines that they are required to follow. Recent regulations create opportunities for the claimant when the insurance company has failed to administer the claimant a proper timeframe or failed to provide the documents and responses required under the applicable regulations. Do not assume that even if you go through the appeal that you can delay filing suit. The certificate of coverage, health insurance policy or health plan may have a very short limit of time for you to protect your claim and file suit. Do not wait. Seek help.

Do not assume that the insurance company is wrong. Almost no one appeals. If you appeal approximately 40 to 50% of the time the insurance company will reverse its position. Even if it does not, you have the option of going to court and if there is a large dollar claim, it is very wise to consider this and obtain assistance from knowledgeable legal counsel who have extensive experience.

If you are having some major procedure such as surgery that is necessary for your health, and the preapproval, preauthorization does not occur, and the insurance company has denied the procedure you have a difficult decision to make. We can help you make that. If it is necessary surgery, and it will improve your quality of life, maybe enabling you to go back to work and resume your occupation or simply allowing you to perform the activities of daily life are suggestion is to have the treatment and we can help you with the claim and have your doctor paid. To assist you with this decision, we need to see the appropriate documents that are listed above.

Under the Affordable Care Act and previously under Ohio law there is an external review that may be available to you. Although this sounds like a good option, there are many problems with it. With our experience, we can assist you in going through this process. Do not assume that your insurance company is going to be fair and how it handles your claim in the external review. What we have seen is just the opposite. Medical records that are necessary for a fair determination are never sent. Contract language that states what should be paid and what should not be paid is never sent to the external reviewer. Finally, it is the insurance company or healthcare plan that is paying for this external review. Although the rules are structured to assure fairness over the long-term, there are problems with the structure that do not assure that the external reviewer will put your best interest first. Finally, going through an external review can result in you losing your claim and if the insurance company or healthcare plan does not presented in a fair way, something it is probably not going to happen, it may be worse than not going through the review.

8. Take it to the next level

Until now, you’ve been appealing the decision directly with your insurance company. But if your claim is denied a second time, you may have one more chance to change their minds. The Affordable care Act requires that states set up an external review process for denied medical claims. Check the Centers for Medicare and Medicaid Services site to see whether your state has implemented the new guidelines yet.

9. Speed things up

If you need medical care urgently, you may not be able to wait for the company’s internal appeals process to run its course. “You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function,” says In such cases, file internal and external appeals simultaneously. If you’re too sick to take care of this on your own, your doctor can file an external appeal on your behalf.