- Out of Network
- International insurers / health schemes
- Denied Workers’ Compensation
- Third-party liability (slip and fall, etc.) with Attorney Involvement
- Uninsured Motor Vehicle Accident Claims
- Lack of Medical Necessity
- Allegations that you lack proper authorization
- Coverage Exclusion or Exhaustion
- Pre-existing conditions on Travel Accident Insurance
Denied vs Rejected
A denied claim is one that an insurance company alleges is not payable. Sometimes they are 100% wrong. A rejected claim has been rejected because of alleged errors. Sometimes they reject claims several times before determining that you have the knowledge and tenacity to challenge them.
While many healthcare providers have internal staff to verify, correct and appeal rejected claims, the internal staff may lack the time or know how to overturn wrongfully denied or rejected claims.
How I can help you
- I offer “as needed” assistance. First, we’ll chat briefly about your situation. A 15-20 minute call is all it takes to get started. If you decide to give it a try, I will sign a HIPAA BAA and my staff will begin the new client onboarding process.
- Then, once you are officially a client of my firm, any time you need help send me an email that you need to discuss a possible assignment. Send me your toughest and most high-value denied and rejected claims at no obligation or cost and let me analyze their potential for recovery and propose how I can help.
- I’ll provide proposal based on my assessment and indicate if I believe I can overturn the rejection or denial. My assessment leverages nearly 40 years of managed care appeals success and training and experience as a health law paralegal and revenue manager for a 400-bed hospital and large medical group administrator.
- You’ll pay me on a percentage of recovery basis as indicated in the proposal. If I don’t succeed, you don’t pay.
Get the cash you are rightfully owed into your bank account
Small hospitals in rural communities need specialists with the training and experience to collect on complicated denials and appeals, but often, there’s no available pool of skilled applicants locally. Your community may not be attractive to potential recruits who have these skills. Or, you may believe you are unable to afford to hire them as full-time employees.
Hospitals outside the USA frequently encounter problems with emergency services and inpatient admission bills because their staff doesn’t work during the hours that the insurers are open for business in the USA, and they don’t know the complex U.S. health insurance tactics and strategies to fight on a level playing field. I solve this problem because I can work the claims on local time zones that the insurers are open and I know the complex rules and the games they play. I know what to say and to whom to get action and get you your money.
There are few places or training courses that teach these skills, and sending staff to them represents time and travel expense you may not have in your budget. Besides, for every day they are gone, their other work piles up and they fall further behind. It isn’t like they can sign up for a distance learning course at the local vocational or technical training center or community college to learn these skills from their desk.
In 2018, a former medical director of Aetna said during a videotaped deposition that he had not personally perused the patient’s medical records before deciding whether to approve or deny these insurance claims. Instead, he said, he relied on recommendations from nurses—and added that this practice was not unusual at Aetna. I have worked at HMOs and PPOs and I concur. Denials are often made according to someone’s personal decision or worse, according to a decision-tree formula. The health plan where I worked in provider contracting and provider relations had 268 reason codes to deny or pend a claim and see if the provider fought back effectively, and within the timely response limits. If not, we sang the Hallelujah song all the way to the bank, with wheelbarrows full of cash that should have been rightfully paid to providers. That situation was what gave rise to my resignation. I couldn’t sell out. I’m a provider advocate through and through.
I also watched them shred claims and disavow they ever received them. They would then tell the provider that the claim was “never received”, not “in the system” or that they just “don’t know why it wasn’t paid” and to refile. When the refiled claim arrived beyond the timely filing limits, the plan denied payment because of its timely filing policy. I know how to fight these denials using their own policies and loopholes and state and federal laws to protect your interests and get you paid.
And in addition to timely filing limits, many contracts and health insurance policies have a time limit to pursue appeals. After that window closes, you may be forced to write off the entire claim or pursue the patient as a self-pay account.
If the claim was the result of a third-party liability and an attorney has been retained, the attorney may settle and discharge the proceeds of the settlement without paying your bills, first. In that case, you’ll need to pursue the patient before they pay off their other bills, buy a new boat, or take a whirlwind trip around the world with their windfall.
If the patient was an international traveler that had travel insurance or their national health insurance and/or private supplemental insurance and has left the country your staff may not know how to pursue payment.
Stop writing off money that’s collectible because it languished for too long in a pile of claims that needed follow up that no one had time (or skills) to pursue.
Let me help you tackle that pile of claims that should be appealed right away.
You’ve got nothing to lose and everything to gain.
Start with a simple, toll free call to discuss your situation. (800) 727.4160.