We have nearly a quarter century of successful outcomes for our clients.

Pre-existing Condition — $100K+: This patient had a very serious, complicated medical condition which involved a multitude of diagnoses. For the first couple of months, the insurance carrier was ducking and dodging, always making requests for new information and then finally denying the claim for a pre-existing condition. The claim was referred to us for further handling. After our nurse reviewed the medical records and wrote her summation, our paralegal wrapped a legal demand letter around it and sent it to the insurance carrier demanding payment. The patient did have a serious illness, but it didn’t fit the policy parameters for a pre-existing condition — it was just a very large bill with a very high payout due. At the same time, we filed complaints with the state insurance board — magically, the hospital and physicians and other ancillary services were paid as if that had been their plan all along. If we hadn’t gotten involved, the patient would have been stuck for this large bill.

Pre-existing Condition: The patient had her policy for years and had always made her premium payments on time. She received a postcard advising that as an excellent, long-term client, she was entitled to a new, better policy at a slightly lower cost than her existing one. She immediately signed up.Then she had cataract surgery and her medical claim was denied as a pre-existing condition and the bill was turned to her to pay. The patient contacted our office for help. When we advised she had a policy with them for 20 years — they said it made no difference because this was a new policy. We were able to convince the insurance carrier otherwise, and the claim was paid.

On-Site Visit: After many attempts to contact a patient via phone and mail, we finally set up an on-site visit. At the patient’s address, our staffer was dismayed to see a “For Sale” sign and a vacant house. “I went next door,” she says, “to see if the neighbor could tell me where the patient had moved, and was happy to discover I was talking with her: she had moved next door! I told her I was there to help, no charge. I only needed a single form completed in order to get her medical claim processed.” After 30 minutes, which included completion of the form, faxing it to the carrier on our portable fax, contacting three other providers to let them know their claims would now process, our staffer asked if there was anything else we could do. “This lovely lady left the room and returned with two 33-gallon trash bags, filled with billing statements and correspondence from collection agencies. She hadn’t known what to do, so she saved them all.” Five hours later, we‘d gone through all the mail, called various providers and sent the patient’s claims back for processing, and in the bargain lifted a huge burden from the patient. As promised, there was no charge to her. (A number of bills were from providers we didn’t represent, and thus had no contract to collect a fee, but Patient Advocacy didn’t resolve this case for payment from the providers, we did it for the patient.)

Worker’s Comp Case: This patient had been injured at work and his legitimate claim had been denied — wrongfully. Crippled, unable to work, denied worker’s comp benefits, the man had turned to petty theft to support himself and his family. Our research had determined that this was a valid worker’s claim, but we had to find the patient in order to get everything back on track. We finally found him in a small town jail. Hopeless and helpless, he’d given up. We explained why we were there and assured him there was no cost to him for our services. After a few calls and a legal demand letter, we not only got him the help he needed, but saw that he received back pay. He is now on disability and getting the medical care he deserved all along and is in a position to straighten out his life.

Medical Case: A teenager had come to a hospital after suffering convulsions. The young man had been treated by a local physician. The insurance carrier had denied for medical necessity and the file was turned over to us for handling. We requested medical records for our in-house nurse and she quickly noted that the particular drug that was being prescribed was actually not appropriate for his age or condition and had been banned in Canada. This drug actually induced the convulsions. (We also learned this drug was under investigation in the U.S, but there was not at that time an order to ban it.) This case history is representative of our medical perusal capabilities — getting the facts and providing them to our clients along with our recommendations for a remedy.

Tracking Trends, Hospital Chain A: In working medical claims we track trends within hospitals, medical practices, patients and insurance carriers. In this instance, we were working a high number of back-surgery claims that were consistently being denied. Different patients, different hospitals, different insurance carriers, but all denied for medical necessity. During our research, it became apparent that the common denominator was the physician and the similarity of the patients. Seeking out poorly educated patients, the doctor convinced them that their work injury was actually back related. (Higher fees for the physician!) This was the main reason for the medical necessity denials — the injuries were rarely related to the back. But whatever the injury: ankle, knee, even the hand, the physician performed back surgery. We turned our findings over to legal counsel for the hospitals and the doctor was effectively removed.

Tracking Trends, Hospital Chain B: In work-related claims, we see three common types of problems. One is where a patient doesn’t identify upfront that they have suffered a work-related claim. The second is where patients don’t provide correct contact information (while it is still fresh in their minds). The third is where the work-related claim is bogus. By preparing a simple questionnaire for admissions that obliged patients to state they had suffered a work-related injury, to complete this form and to sign it, stating that the facts were true and correct to the best of their knowledge, invalid and inaccurate work-related claims plummeted.

Litigation, Hospital Chain C: During the course of an extensive patient account review, we determined that a certain insurance carrier had been invalidly denying and underpaying claims for years. We compiled the data for a three-year period and presented it to our client. With their permission, we met with the Vice President of Claims with this carrier and presented our well-documented findings. The Vice President was loud and aggressive and ended his tirade with “I have the ability to put every hospital in the State of ********* out of business if I choose to — you don’t know who you are dealing with!” Obviously he didn’t know who he was dealing with: we provided the documentation to our client’s legal counsel and a multi-million dollar settlement was reached.

Contracts, Hospital Chain D: In working a group of claims we felt were underpaid, we questioned the insurance carrier as to their reimbursement. Finally, the insurance carrier said the hospital was at fault because the contract had not been updated in over 10 years. When we contacted our client to verify this audacious statement, we were advised that it was unfortunately true and somehow it had slipped through the cracks. A new contract was immediately put in place and the hospital is being paid at current market rates.

Tracking Trends, Extended Care Facility: A local podiatrist offered to perform "free foot checkups" for elderly patients and often included free nail cutting for ingrown nails. Of course, a “consent to treat” form had to be on file so these procedures could be performed on an ongoing basis. As it happened, the podiatrist often found “other reasons to treat” patients and these charges were forwarded to Medicare for payment. Not all the charges were legitimate and in the course of tracking trends for this client, the doctor's less-than-honest ploys were revealed and stopped.

Tracking Trends, Health Insurance Carrier A: This carrier offered a Medicare HMO replacement policy but advised patients to tell their providers they were covered by Medicare, keep their Medicare cards on them at all times, and that, even though the insureds had a new Medicare HMO replacement policy, they should always refer to their Medicare number. For providers in this small community, who weren’t verifying Medicare eligibility, it came out too late that these patients were not covered by Medicare. As well, many services required an authorization under this Medicare HMO replacement, but none was sought because the provider didn’t know the patient was covered by a non-Medicare policy.

Tracking Trends, Health Insurance Carrier B: Offering a Medicare HMO replacement policy to elderly patients, but not advising them that their local hospital, the only hospital within 100 miles, did not have a contract with this insurance carrier. This meant that patients were paying premiums for a policy that was in effect worthless.


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