In a world where insurance companies and HMO’s try to gain any advantage, holding these companies accountable for proper claims handling and claims payment can mean the difference between turning a profit or running at a loss. Most insurance companies and HMO’s have developed well-thought-out methods of ensuring that healthcare providers are not properly paid for their services. These companies routinely deny or reduce claims by asserting reasons such as:
- there was no prior authorization for treatment,
- the billing for treatment was bundled,
- the amount charged exceeds some secret internal fee schedule
Sometimes these companies leave claims “pending” into perpetuity hoping that the claims will be forgotten. Even when proper payments are initially made, these companies have also developed strategies where they wait several months after payment and then turn around and try to recoup the payment for some mysterious reason. To exacerbate the problem, many insurance companies and HMO’s realize that the billing departments at most hospitals and healthcare providers are sometimes overwhelmed by the volume of claims. Therefore, they step up the pressure and continue to bully the billing departments, knowing that many claims will just slip through the cracks.
The healthcare lawyers at Zebersky Payne, LLP have been representing healthcare providers in reimbursement cases for over 15 years. During that time, we and our partners have helped develop computer algorithms which enable our healthcare litigation team to determine quickly and economically evaluate, on a claim-by-claim basis, whether an insurance company has acted properly. Once we are able to determine which claims have not been properly paid, we then are able to file one consolidated lawsuit for all claims and claimants seeking to secure proper reimbursement in an efficient manner. Our team of healthcare lawyers is typically employed on a contingency fee basis and advances the costs of litigation. There is no capital outlay to a hospital or healthcare provider in our handling of any matter and therefore, payment is only made if monies are actually recovered.
Healthcare Litigation Team
Our team handles a variety of matters, including, without limitation:
Insurers are currently obtaining substantial funds each year by offsetting, or recouping, previously paid benefits from providers, including hospitals, based upon untested allegations that the benefits had been paid erroneously.
Verification of Coverage
Healthcare providers lose millions of dollars when insurers provide verification of insurance coverage, frequently followed by pre-authorization of the services at issue, only to be followed by a retroactive denial based on the fact that the patient was not insured at the time of the service.
Many healthcare providers are also subjected to audits of their bills by insurers, or their third party agents. While an in-network provider often has an agreement to be paid a set percentage of billed charges, the insurer frequently bundles a number of procedures and supplies so as to materially reduce the amount of the bill before applying the percentage.
Most insurance plans require healthcare providers to obtain preauthorization before providing hospital services and when this is not done, the insurers will deny coverage.
ONET v. INET Reimbursement
When a healthcare provider is out-of-network (“ONET”), it has not agreed to accept discounted rates from the insurer. As a result, the reimbursement level is determined by the underlying plan documents. Frequently, insurers apply internal policies for making ONET reimbursements, without complying with the plan terms. Thus, the reduction in benefits can be challenged.
Improper Coordination of Benefits
When a patient has two possible insurance policies, including Medicare, the insurer must apply a coordination of benefits provision in the plan documents. We’ve learned that insurers frequently do not comply with these provisions when denying benefits based on such provisions.
Medical Necessity/ Experimental/Investigational
In making medical necessity determinations, insurers often rely on internal policies which are inconsistent with generally accepted standards. These policies could be challenged as being inconsistent with the definition of medical necessity in the plan documents. In addition, ERISA requires that, upon appeal of a medical necessity determination, the insurer must consult with a provider who is trained and qualified in the area of medicine at issue.
Trial Lawyers Representing Healthcare Providers
Over the years, we have been involved with many class action and complex lawsuits where we have represented healthcare providers against insurance companies and HMO’s related to the proper payment of claims. Included in our practice was securing an important decision by the Florida Supreme Court which permits all physicians to maintain actions against HMO’s for failure to promptly pay claims. We have also represented hospitals, surgical facilities and one of the largest physician management groups in the country in complex litigation involving not only reimbursement claims, but also other complex commercial claims. Our lawyers have also written amicus curiae briefs on behalf of the Florida Medical Association related to reimbursement issues. Additionally, our lawyers have actively lobbied in Tallahassee, on a volunteer basis, against the insurance industry with respect to reimbursement and prompt pay issues.