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What to do When Your Health Insurance Refuses to Pay

Health insurance companies often deny pre-authorization requests for testing or medical treatment. Sometimes, the company refuses to pay the medical bill after you have already received the services. You feel punched in the gut when you receive a bill, sometimes for hundreds of dollars, with a note from the care provider that your insurance denied your claim.

Many times, the denial seems unfair. You may feel trapped and assume there is nothing you can do, but if this has happened to you, you do have some options. You can appeal the denial, but the first step is to understand why the claim was denied.

Reasons the Insurance Company May Give for Denying Your Claim

  • The claim was not covered under your health insurance plan. Read your policy carefully. You may be interpreting a clause differently than the insurer is interpreting it. Contact your insurance company and ask for a detailed explanation of its denial. You need to understand this in order to pursue an appeal.
  • The service was not “Medically Necessary.” You will need to get your health care provider to explain, in writing, to the insurance company why the service was medically necessary if already performed, or is medically necessary so that your insurer will commit to covering the procedure.
  • The service is, or was at the time it was performed, experimental or investigative.
  • You failed to get preauthorization for the service. Most insurance plans now require healthcare providers to get preauthorization before they provide certain medical or surgical services. Discuss this with your physician.
  • Another insurance policy is responsible for the claim. If you have two insurance plans, for example, you and your spouse are both covered through your work, one plan may be expected to pay first. This is also true if the healthcare services provided to you were the result of a car accident, the insurer for the at-fault driver may be expected to pay your bill.
  • You received care from an out-of-network provider. If this was due to an emergency, you need to provide this information to your insurance company.
  • There is an error somewhere in the process. For example, a billing error may have occurred, such as the wrong code used by the medical biller.

If your claim was denied for any of these reasons, or because you were told simply the service was not covered, you have the right to an internal appeal.

How to File an Appeal

Call your insurance company. Have them explain to you in detail why your claim was denied. Also, ask them to explain to you how to file an appeal. Follow the appeal instructions precisely.

Write an appeal letter. This is the most important part of your appeal. The purpose is to convince the company that it should pay your claim. Your letter should include:

  • A brief description of your medical condition including why the service was, or needs to be, performed.
  • Reference the portion of the insurance policy that you believe says the service is covered. Use specific language from the policy indicating the service should be paid for.
  • Attach a statement from your healthcare provider who performed or ordered the service that explains why the procedure is medically necessary, or if it was already performed, why there was no time for preauthorization.
  • Wait a few days, then call and verify the company received your appeal documents.
  • Follow up as much as necessary.

Be sure you keep a file documenting everything you have done. Any time you have a conversation with an insurance representative, document the date and time of the call, who you spoke with, and a summary of your conversation. If you are told to call back because the person you need to talk to is away, note the date and time of your call and the reason you were given to call back.

If your internal appeal is denied, you can then contact your state’s insurance commissioner and request an external appeal. The National Association of Insurance Commissioners maintains a list of all state commissioners and information about how to contact them.

Contact us for Help

Depending on the amount of money involved, you may decide to do this appeal yourself. If a large amount of money is involved, or you just feel you need help with the process, contact us at Burman Law. Our slogan is “Mike Will Fight to Make it Right.”

 

Sources

https://yourgpsdoc.com/2017/06/11/how-to-file-appeal-insurance/
https://www.verywellhealth.com/health-insurance-company-wont-pay-323174
https://www.medicalbillingandcodingonline.com/medical-billing-errors/
https://www.naic.org/documents/members_membershiplist.pdf

Liens: Why Is There a Lien in My Case?

LIENS: What, Who and How Liens Affect an Injury Case

THIS ARTICLE DISCUSSES:

  • What Is a Lien?
  • Who Can Take a Lien?
  • How Is My Case Affected by a Lien?
  • How Can Burman Law Help Reduce or Eliminate a Lien?

What is a Lien?

In a personal injury case, a lien is defined as “any official claim or charge against property or funds for payment of a debt or an amount owed for services rendered.”  A “lien” is like a debt you owe, but instead of paying the debt with your own money, you pay that debt using your personal injury settlement money.

To help understand, here is a common example.  Let’s say a careless semi-truck driver runs into your vehicle, sending you to the hospital.  You have no idea who insures the semi-truck driver, so your health insurance pays the hospital bills caused by the truck driver’s negligence.   The hospital submits a bill to your health insurance carrier and your health insurance carrier pays it, less any deductible, etc.  Now, here is how the lien arises: when your health insurance carrier pays the hospital bill, your health insurance carrier has a legal right to obtain reimbursement for the money it paid to the hospital for your medical bills.  This legal right to collect money creates a “lien” in favor of your health insurance carrier.  The lien goes against the settlement you eventually receive from the trucking company’s insurance carrier.  The dollar amount of this lien is equal to the dollar amount paid by your health insurance carrier on the hospital bills associated with your wreck injuries.

There are other legal terms you may hear when a lien is discussed.  “Subrogation” means “stand in the shoes of.”  “Reimbursement” means to “collect what has already been paid.”  When another party, such as the health insurance carrier in our example, has subrogation or reimbursement rights against your personal injury case, then the health insurance carrier stands in your shoes and holds the right to place a lien against the compensation you receive from your personal injury case.  The health insurance carrier holds certain legal rights to reimbursement for what it paid.  When the health insurance carrier has a lien, it is commonly called a “lienholder.”

Who Can Take a Lien?

We used health insurance in the above example.   A health insurance carrier is probably the most common entity to assert a lien, but there are many other types of liens in a personal injury case.  Let’s discuss a few other common types of liens.

One type of lien occurs when there is a Letter of Protection (LOP).  Although emergency departments must legally provide you treatment, other non-emergency health care providers may refuse treatment unless you provide an (LOP) from your attorney. An LOP is a signed agreement between you and your health care provider which guarantees payment when your personal injury case is concluded, either by settlement or jury award.

Federal law allows Medicare and Medicaid to place a lien on your settlement. These types of liens are administered by the Centers for Medicare and Medicaid Services (CMS) and under contracts with some private administrators. Federal law gives Medicare and Medicaid liens precedence over any other lien.  This means that federal law allows Medicare and Medicaid Services to jump in front of everybody, including the injured party, and get paid before any other lienholder receives payment.

In some states, including Tennessee, a common lien we see is called a “med-pay” lien.  It arises when you contracted for medical payment coverage with your automobile insurance carrier and you submitted medical bills to your insurance company for payment. When your automobile insurance carrier pays, it will frequently inform you that it will be asserting a  lien against your settlement seeking reimbursement for the bills it paid.

In Tennessee, hospitals can hold a lien under Tennesse law.  This type of lien is called a “hospital lien.”

So, you can see that various types of liens can arise under the facts of a particular case and the federal or state law that applies to the lien.

How Is My Personal Injury Case Affected by a Lien?

Let’s recap the types of liens we have discussed:

  • Health insurance liens
  • LOP liens
  • Medicare liens
  • Medicaid liens
  • Med-Pay liens
  • Hospital liens

Liens and lienholders can affect a case in a number of important ways.  First, a lien can significantly reduce the amount of compensation available to you for your injuries.  Secondly, a lienholder can intervene in a case and create delays and uncertainty when you want to resolve your case.  Thirdly, a lien placed on your personal injury settlement can affect your ability to maintain control over the settlement funds.  And lastly, in extreme cases, a lien can affect your ability to secure future medical treatment under your health insurance coverage.

How Can Burman Law Help Reduce or Eliminate a Lien

The number one thing we do at Burman Law to help reduce or eliminate a lien, is to start early and be “pro-active” with liens and lienholders.  At the beginning of each case, we gather the facts relevant to each lien and lienholder.  We establish contacts with decison-makers.  We read the contracts that discuss the lien, identifying weaknesses and developing legal strategies to reduce the lien.  We communicate with lienholders and take a stand on your behalf.

In every case, we can reduce the lien.  In most cases, the reduction is significant.  In some cases, we obtain a very substantial reduction or eliminate the lien entirely.

For years, we have studied liens and lienholders.  We understand where weaknesses can be found, and where the law is on your side.   We keep you informed about any existing liens and make sure you are not surprised at settlement time by suddenly discovering there is a lien.

We also make sure to document the full dollar amount of all your losses in any settlement demand or closing argument.   When we resolve your case, we are always careful to take into account liens and lienholders so you are protected from future claims by the lienholder.  We are pro-active to ensure your settlement or award is not delayed by “last-minute” snafus.

If you have questions about how liens work in personal injury cases, or any question about your personal injury claim, contact Mike Burman for a free consultation.   In addition, Mike Burman never charges to consult with lawyers in other cases about how to reduce or eliminate liens.

Sources

https://dictionary.law.com/Default.aspx?selected=1160
https://www.law.cornell.edu/uscode/text/42/1395y
https://www.bizfilings.com/toolkit/research-topics/running-your-business/asset-strategies/different-lien-types-provide-creditors-with-different-rights
https://www.injuryclaimcoach.com/bodily-injury-claim-settlement.html

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PERSONAL INJURY PROTECTION INSURANCE: A Short Guide

PERSONAL INJURY PROTECTION INSURANCE IS COMMONLY CALLED “PIP.”

THIS ARTICLE DISCUSSES:

  • PIP in General
  • Main Types of PIP
  • Maximizing PIP Benefits
  • Special Situations

PIP IN GENERAL

Under Kentucky law, auto insurance is mandatory.  Personal Injury Protection insurance (commonly called PIP insurance) is a part of the mandatory auto insurance Kentucky requires.  A typical Kentucky auto insurance policy provides no less than $10,000 per person for PIP insurance to pay medical expenses, lost income and similar “out of pocket” costs due to a motor vehicle injury.  PIP is paid by the insurer of the vehicle the injured person is using at the time of a motor vehicle injury, regardless of fault.  Additional PIP coverage above the basic amount of $10,000 is optional.  PIP can be purchased with a deductible up to $1000.  Burman Law does not recommend purchasing PIP with a deductible.

TYPES OF PIP INSURANCE

There are four main types of PIP insurance:
  1. PIP MEDICAL LOSS is used to pay medical bills.  The medical bill must be for reasonable charges incurred for reasonably needed medical services, products, accommodations, rehabilitation, licensed ambulance services, and other remedial treatment and care.
  2. PIP WORK LOSS is used to replace income lost because the injured person cannot work.  It is also used to pay for expenses reasonably incurred by the injured person in obtaining services to replace those the injured person would have performed for income.  Unfortunately, unless additional PIP is purchased, the basic PIP work loss claim is limited by law to $200 per week.
  3. PIP REPLACEMENT SERVICES LOSS is used to pay for “in-kind” expenses reasonably incurred in obtaining ordinary and necessary services the injured person would have performed, not for income, but for the benefit of the injured person or the injured person’s family.  The $200 weekly maximum applies.
  4. PIP SURVIVOR’S REPLACEMENT SERVICES LOSS is used to pay expenses reasonably incurred by survivors after a person’s death to cover ordinary and necessary services the person would have performed if the person had not died from a fatal motor vehicle injury.  The $200 weekly maximum applies but can be prospectively applied to exhaust the entire $10,000 in basic PIP.

MAXIMIZING PIP

Maximize PIP MEDICAL LOSS by directing that certain medical providers be paid first.  In some cases, it may be advantageous to send the PIP carrier $10,000 worth of unpaid medical bills and direct the PIP carrier to pay the $10,000 in basic PIP to an escrow  account. This is a highly technical area of law, so consult Mike Burman. Maximize PIP WORK LOSS by reserving and directing, in writing to the PIP adjuster, that all PIP wage loss be paid before any medical providers are paid.  Always get a work excuse from the doctor showing it is necessary to be off work due to the motor vehicle injury and the period of time off work.  Again, this is a highly technical area of law, so consult Mike Burman. Maximize PIP REPLACEMENT SERVICES LOSS by saving written invoices to prove these expenses were actually incurred.  Take photographs of the work performed. Maximize PIP SURVIVORS REPLACEMENT SERVICES LOSS by completing an affidavit to detail the services and expenses reasonably incurred by survivors for valuable services that would have been provided had the injured person survived the motor vehicle injury.  Again, this is a highly technical area of law, so consult Mike Burman.

SPECIAL SITUATIONS

Assigned Claims Plan:  When a vehicle owner does not have PIP insurance, the people injured in the owner’s vehicle are entitled to file a claim for basic PIP insurance through the Kentucky Assigned Claims Plan.  Contact Mike Burman for assistance with the Kentucky Assigned Claims Plan. Coordination of PIP Insurance:  In some cases, the payment of PIP insurance can be directed and coordinated with health insurance to process all medical bills.  In some case, PIP can be used to pay co-pays, deductibles, and non-covered items. Motorcycles:  Basic PIP insurance is optional for motorcycles. Unless basic PIP insurance is purchased for the motorcycle, neither the operator nor the passenger of the motorcycle is entitled to collect basic PIP benefits from any source.  Other insurance may be available, so consult with Mike Burman to determine available coverage. Out of State Owners:  Non-residents of Kentucky driving through the state may be “deemed” to have PIP insurance but this is dependent on the whether the underlying auto insurance carrier is licensed to sell auto insurance in Kentucky.  Contact Mike Burman for assistance. Workers’ Compensation Situations:  Employment at the time of a motor vehicle injury, may provide under Kentucky Workers’ Compensation law:
  • Primary coverage for related medical expenses
  • 2/3 wage replacement for time off work
PIP wage loss insurance can be coordinated to pay the remaining 1/3 wage loss. This is a highly technical area of law, so consult Mike Burman.