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Medical Claim Denials

The Law Offices of Brian S. King specialize in litigating denied medical claims. These generally fall into one of the following categories.

High 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.

Patterns 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.

Usual, 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.

Often, 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.

A 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.

With competent legal counsel, hospitals and other healthcare providers can challenge and prevent these abusive practices.

The Law Offices of Brian S. King have successfully challenged and reversed claim denials involving the following issues:
  • Pre-existing conditions
  • Timely filing of claim
  • Experimental or investigational treatment
  • Coordination of benefits between payors
  • Improper “leasing” of PPO contracts
  • Improper bundling of procedure codes
  • Medical necessity
  • Coding errors
  • Claims of patient ineligibility
  • Inadequate explanation of benefits
  • Pre-authorization and pre-certification
  • RTC and SNF claims
  • Outpatient claims
  • Claims involving contractual penalty clauses
  • Claims for interest on late payments
  • Custodial or maintenance care exclusions
  • Improper rescission of insurance coverage
  • COBRA continuation coverage
  • Conversion conversion
  • Dual diagnosis
  • Claims of processing errors
  • Payor misquotes of what coverage is available
  • Participating vs. Non-participating provider
  • Out of Area Providers
  • Portability of Insurance Coverage (HIPAA)

Denials 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.

Shifting 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.

This 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.

The 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.