May 23, 2017
Medical Claims If you work as an administrator in a hospital or healthcare facility and are seeking assistance with your collection process using a resource short of litigation or arbitration, visit Healthcare Recovery Services at HRS Online .
\nMedical Claim Denials
\nThe Law Offices of Brian S. King specialize in litigating denied medical claims. These generally fall into one of the following categories.
\nHigh Dollar Claims for Single Patients
- These claims arise in a number of situations. They can be patients with acute, severe conditions such as accident victims, premature babies or stroke victims. Or these claims can arise out of treatment to patients with chronic conditions that involve extended and/or intensive care such as cancer or transplants.
\nPatterns of Denial for the Same Types of Claims Involving Multiple Patients
- These claims arise when the Firm has been retained by Hospitals, other healthcare facilities or physicians groups. The Firm has litigated or arbitrated many cases where insurers or self-funded employer plans reduce or deny payment on a certain type of claim or procedure and that practice violates the language of the insurance policy, self-funded plan, managed care contract or industry standards. The reductions or denials may also violate the requirements of federal or state statutes.
\nUsual, Reasonable & Customary Charge (UR&C) Claim Denials
- One specific category of payment reduction that the Firm has pursued successfully is to prevent the use of “usual, reasonable and customary charge” claim denials by insurers of self-funded employer plans. This tactic to reduce or deny payment is becoming increasingly popular as a way to try to save payors money and, in the process, shortchange health care providers and patients.
\nOften, insurers will retain the services of an outside consultant or company, such as Concentra, to “analyze” the bill and argue that there has been improper billing or overcharging by the provider. The consultant or the payor then unilaterally cuts the reimbursement to the healthcare provider. In our experience, this practice usually violates the terms of the managed care contract, insurance policy or the documents under which the self-funded plan is operated.
\nA variation on this theme is when the consultant contacts the provider and offers to pay a discounted amount, usually 5 – 15% off the billed charges, to be sent within a short time frame, but on the condition that the provider doesn’t balance bill the patient. Sometimes the dollar amount of the reduction in payment is large; however, usually the reduction on any one patient is not so huge that the provider feels that it has many options other than to accept being nickeled and dimed. In fact, there is usually no justification for the request for this type of discount and providers who agree to this improper demand simply give money away and reward bad behavior by payors and their consultants.
\nWith competent legal counsel, hospitals and other healthcare providers can challenge and prevent these abusive practices.
\nThe Law Offices of Brian S. King have successfully challenged and reversed claim denials involving the following issues:
\n• Pre-existing conditions
\n• Timely filing of claim
\n• Experimental or investigational treatment
\n• Coordination of benefits between payors
\n• Improper “leasing” of PPO contracts
\n• Improper bundling of procedure codes
\n• Medical necessity
\n• Coding errors
\n• Claims of patient ineligibility
\n• Inadequate explanation of benefits
\n• Pre-authorization and pre-certification
\n• RTC and SNF claims
\n• Outpatient claims
\n• Claims involving contractual penalty clauses
\n• Claims for interest on late payments
\n• Custodial or maintenance care exclusions
\n• Improper rescission of insurance coverage
\n• COBRA continuation coverage
\n• Conversion conversion
\n• Dual diagnosis
\n• Claims of processing errors
\n• Payor misquotes of what coverage is available
\n• Participating vs. Non-participating provider
\n• Our of Area Providers
\n• Portability of Insurance Coverage (HIPAA)
\nDenials Resulting in Cost Shifting to Medicare and Medicaid
– Often, insurers and self-funded employer plans are tempted to shift costs to Medicare and Medicaid or other government funding resources. Especially when dealing with large claims, these payors present flimsy reasons for denying a claim in hopes that the patient will end up going to a government agency for payment. Indeed, the payor will often direct the patient to the government agency at the same time they deny the claim.
\nShifting the cost of the care to the government agency relieves the insurer or self-funded plan of responsibility to pay. The patient is relieved to not have any personal obligations to pay the medical bills. The losers are the taxpayers who have to pay for medical claims that an insurer or self-funded plan should be paying. In addition, the healthcare provider loses because it is required to accept less for its services than it would have been paid had the insurer or self-funded plan stepped up to the plate. And the provider has no opportunity to balance bill the patient.
\nThis type of cost shifting is becoming more and more common because the government agencies typically do not have the resources or expertise to investigate whether the denial has a solid basis. Even if the agency recognizes that improper cost shifting has occurred, it will often not have the resources or incentive to aggressively pursue the insurer or self-funded plan to obtain payment.
\nThe Firm has worked with patients, healthcare providers and self-funded agencies to prevent cost shifting and place the burden of payment where it belongs: on the insurer or self-funded plan.
Library for Medical Claims:
- EPIC v. Salt Lake County [PDF]
EMTALA, unjust enrichment, prisons, jails, reasonable value, quantum meruit
- Juniper v. M & G Polymers USA [PDF]
ERISA, venipuncture, bundling, abuse of discretion, medical benefits
- Boldon v. Humana [PDF]
experimental, investigational, unresectable hepatocellular carcinoma, liver cancer, TheraSphere
- Whitley v. Carolina Care Plan (part 1) [PDF]
Whitley v. Carolina Care Plan, LVAD, experimental,
- Whitley v. Carolina Care Plan (part 2) [PDF]
Whitley v. Carolina Care Plan, LVAD, experimental
- Via Christ Regional Medical Center v. Blue Cross and Blue Shield of Kansas [PDF]
Via Christi, medical claim for premature baby, fiduciary duty claim, ERISA, contribution by co-fiduciaries, Wesley E. Brown
- Schoedinger v. United HealthCare of the Midwest [PDF]
Schoedinger, United HealthCare of the Midwest, down coding, re-pricing, grouping, prompt payment laws
- Northern Utah Healthcare Corp v. BC Life & Health Ins. Co. [PDF]
ERISA preemption, negligent misrepresentation, estoppel, healthcare provider, insurance verification
- Illinois Insurance Dept. Opposes HIMMA [PDF]
Illinois Insurance Department letter to Senator Obama opposing the Health Insurance Marketplace Modernization and Affordability Act of 2006
- NAGA Opposes HIMMA [PDF]
National Association of Attorneys General Opposes the Health Insurance Marketplace Modernization and Affordability Act
- Illinois Attorney General statement regarding the Health Insurance Marketplace Modernization Act [PDF]
Illinois Attorney General, Lisa Madigan, opposes the Health Insurance Marketplace Modernization Act. This letter outlines her concerns.
- Krodel v. Bayer Corp. [PDF]
- Peay v. BellSouth Medical Assistance Plan opinion [PDF]
ERISA, Nationwide Service of Process, jurisdiction, venue, Brian S. King
- Haymond v. Eighth District Electrical Benefit Fund opinion [PDF]
Haymond, Eighth District Electrical Benefit Fund, ambiguity, ERISA plan documents, Brian S. King
- University of Utah Hospital v. Educators Mutual arbitration award [PDF]
denied medical claim, insurance, notice-prejudice rule, Brian S. King
- Teen Help v. Operating Engineers Health & Welfare Trust Fund opinion [PDF]
ERISA, Brian S. King, denied medical claim, pertinent documents, ERISA claim procedures, relevant documents
- Hernandez v. Prudential opinion [PDF]
ERISA, Brian S. King, relevant documents, pertinent documents, ERISA claim procedures, denied medical claim
- Neurocare, Inc. & Barbara Whitmore Decision [PDF]
rehabilitation claim, ERISA, Brian S. King, Neurocare, Principal Life Insurance Co.
- Memorandum Decision in Toman v. Goldman, Sachs Medical Benefit Plan [PDF]
orthognathic surgery, medical necessity, medically necessary, jaw surgery, ERISA, medical claim denial; United HealthCare, Brian S. King
Frequent Questions for Medical Claims:
Case Results for Medical Claims: