DENIALS MANAGEMENT AND APPEALS
A Hospital's Challenge
Denials and appeals can be some of the most challenging collections situations facing a hospital business office. Many require legal knowledge to effectively dispute and overturn. Most hospitals do not have enough personnel or adequately trained staff to effectively turn these accounts into cash.
Our Revenue Solution
- Our attorneys and staff's level of knowledge and expertise in handling insurance denials puts a provider in a position to properly evaluate each denial and to overturn the denials that are unlawful and unjust.
- We maintain a professional and ethical demeanor in our representation of each hospital to ensure the relationships with payors and the community are never tarnished.
- We can initiate state and federal court litigation through the Turek DeVore law firm to compel recovery of wrongfully denied accounts.
EXAMPLES OF COMMON DENIAL/APPEAL ISSUES
- Prompt Payment Violations
If claims are not being paid “promptly” as defined by state or federal statute or in an applicable managed care contract, the payor may be responsible for penalties including loss and discount, interest, and attorney fees. - Failure To Honor Assignment of Benefits
An insurance company may be in violation of the law if it pays a patient benefits directly without putting the hospital’s name on the check if a proper assignment of benefits is provided prior to settlement. If the insurance company “paid over” the assignment, then it may be responsible for payment of the hospital’s bill. - Usual And Customary Reductions
Payors improperly reduce benefits payable based on “usual and customary” reductions. Many times the payors use improper comparisons from other areas or discounted rates such as Medicare. If a hospital can show its charges are reasonable and customary for its service area, its rates should be upheld. - Policy Exclusions
Payors deny payment based on exclusions such as pre-existing condition, non-covered benefit, experimental, and intoxication. Depending on the particular fact situation, these denials can be successfully challenged. - Pending Receipt
Payors assert that the claim has not been received even though it has been sent one or more times. If proof of delivery can be established according to legal standards, the payor should then pay the claim and may be subject to prompt pay penalties. - Precertification/Preauthorization Disputes
If the hospital is complying with the statutory requirements regarding precertification and preauthorization, a payor may be prohibited from denying benefit payments. Depending on the situation, a retroactive precertication can be obtained with competent medical evidence. - Medical Necessity Disputes
Payors will deny benefits based on the reason that the services were not medically necessary. If competent medical evidence can be submitted to the contrary, these denials may be overturned. - Contract Disputes
Disputes as to reimbursement and coverage will arise under a hospital’s managed care contracts. A thorough legal review of the contract by attorneys will provide a valuable evaluation of the hospital’s position and likelihood of success on a particular issue. - Pending Additional Information
Payors will often stall claims requesting additional information from the hospital or patient. Many times, such tactic is a direct violation of prompt pay laws or contractual provisions. - ERISA Plan Disputes
Many employers are now self-insured and their health benefit plans are be governed by ERISA (Employee Income Retirement and Security Act of 1974). Disputes with these plans can be challenging since most state laws do not apply to these plans. Cooperation with the patient and compliance with plan terms is of the utmost importance in these claims. These can be some of the most complex and challenging claims to dispute and legal knowledge is of utmost importance.
OTHER DIFFICULT THIRD PARTY ACCOUNTS
- Estate And Probate Matters
If a patient is deceased, there may be an estate that is responsible for payment of a hospital’s unpaid bill. A hospital’s claim must meet statutory requirements and be timely filed to perfect the claim for payment. We can help investigate the existence and evaluation of these claims and make the proper filings and necessary follow-up. - Government Payor Disputes
Hospitals sometimes receive unjust denials for reimbursement from such government payors as Medicaid, Medicare, CHAMPUS, and Veterans Administration. We can help evaluate and appeal unjust denials. - Forged And Missing Checks
Many times a payor makes a check out jointly payable to the hospital and the patient. We can help in obtaining necessary endorsements. We also pursue payment of checks that are forged and cashed without the proper endorsements. - County Or Hospital District Responsibility For Indigents
Indigents from other counties or hospital districts are treated at a hospital outside their county of residence. Some state law provides procedures for reimbursement of that treatment from the indigent’s county or hospital district, in which he/she resides. - Prisoner Bill Responsibility
Many state statutes provide rules regarding entities responsible for the payment of the prisoner’s hospital treatment. - On-The-Job Injuries (Non-Subscriber To Worker’s Compensation)
Patients injured on the job with employers that do not subscribe to a particular state’s Worker’s Compensation Act may still have a claim against the employer for damages, including medical bills.