Case Studies

Improper Denials

Case A:

Patient admitted to hospital after a car accident, having been hit by an uninsured motorist. Patient had only liability coverage under his car insurance. He had an individual health insurance plan and received six different courses of care totaling over $63,000. Patient’s health insurance plan denied all six treatment dates as as not covered under the Patient’s plan because they said it was “…sustained while under the influence of or due wholly or part to the effects of intoxicating liquor or drugs…” We argued that a review of the records showed that Patient had only trace alcohol only (15 mg/dl) and therefore was not possibly under the influence of intoxicating liquors as defined by law or the insurance policy, and therefore the accident could not be considered a result of the effects of intoxicating liquors or drugs. We pointed to state law intoxification guidelines in successfully overturning the denial and recovering full policy benefits to the provider.

 Case B:

Patient received services after a soccer injury to her mouth. She was a minor covered under the school’s plan for extracurricular activities (a policy her parents elected and paid for) and her parent’s health insurance plan. She required replacement of both front teeth with implants. Benefits were quoted under both plans, the extra plan being primary due to the soccer injury. The school insurance would pick up all damages up to $7,500 and thereafter the patient’s health insurance through her parent’s plan would kick in. She received ongoing services from a dental surgeon to replace her two front teeth. Several claims were paid by the extra policy. However, the main claim for the implant was denied as services were to be rendered within one year of the date of injury. We appealed, asked for the plan documents and found that claims needed to be submitted within 2 TWO years of the date of accident or injury. We appealed the claim again and it paid full dollars. One subsequent claim after that denied erroneously for the same reason, but after one phone call that claim paid as well.

 Case C:

Patient was authorized to receive inpatient substance abuse treatment. Insurance, a union benefit fund, denied coverage, stating that the services provided were “residential” in nature. After appealing, we discovered that the insurance policy did not exclude “residential” treatment. In fact, the word “residential” never appeared anywhere in the policy. After we appeared in person at an administrative hearing, the case resolved for full dollars of approximately $20,000.00.

COBRA Denials

Patient received services at a facility for detox. When he came to the facility, benefits were quoted and services were authorized. After claim was billed, claim was denied for no coverage as patient was termed allegedly 4 days before services were rendered. We demanded proof of the proper COBRA notices from the employer to the employee. The employer had no such notice due to an error administratively. Subsequently, the employer paid full dollars to the facility for the claim.

Coordination of Benefits Issues

Case A:

Patient, a minor, received services at facility. Mom brought the child in for services and gave hospital ex-husband’s insurance information. Insurance coverage was verified and services were rendered. Dad (ex-husband) does not know of the admission to facility or of the claim. Services totaling over $12,000 were rendered. Dad’s insurance, denies claim for minor stating that other coverage is primary. Mom won’t respond to calls or letters from the facility to update any coordination of benefit information for the minor child. Dad does not know if child has other coverage along with his, only knows that he is ordered to carry insurance for the child. After reviewing the plan with insurance and with dad, along with medical records and admission papers signed by mom in the medical records, appeal to insurance to process and release the claims for the facility recouped full insurance benefits.

Case B:

Insurance company retracted over $30,000 in payments over two years after services provided to a minor, claiming that father’s policy is actually primary, not mother’s. Provider bills father’s policy and all are denied as services not covered and timely filing. After months of appeals, account placed. Resolved in one week – there was a gap in father’s policy during $25,000 worth of services, so the insurance company that retracted agreed to pay that back, and father’s policy agreed that timely filing was an inappropriate denial and the services were covered for the remainder of charges.

 Late Pays

One hospital client had contract with one PPO Network where discounts were reversed if clean claims were not paid within thirty days. Resolved twenty-eight (28) accounts for $226,000 in inappropriate discounts. Another hospital client had a similar contractual agreement regarding claims not paid on a timely basis, resulting in over $78,000 in recoveries on ten (10) late-paid accounts.

VA Appeal

Patient came to the facility through the emergency room and was in the ICU for his stay. He subsequently passed away after receiving services at the facility totaling over $313,500. Patient had Medicare Part A (which was exhausted), Medicare Part B and VA benefits. Medicare Part A denied the claim as the patient’s coverage was exhausted. The VA denied the claim stating that the patient was covered under some other health insurance plan. However, the only coverage in effect at the time of service was Medicare Part B which paid approximately $6,000.

We filed a Notice of Disagreement with the VA. We obtained customized documents from CMS which showed that the patient’s coverage through Medicare Part A was exhausted, along with medical records showing the urgency and necessity of the care. The VA subsequently overturned the denial and paid the FULL MEDICARE RATE for the services to the facility, leaving a zero balance due.