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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

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SETTLEMENTS OF INJURY CLAIMS: Seven Mistakes Lawyers Can Make

Here are seven mistakes injury lawyers can make when settling injury claims:

  1. NOT DISCERNING THE NEEDS OF THE CLIENT
  2. NOT IDENTIFYING CRITICAL EVIDENCE
  3. NOT UNDERSTANDING THE MECHANISM OF INJURY
  4. NOT GATHERING ALL ICD MEDICAL CODES
  5. NOT PRESENTING AN INJURY CLAIM EARLY
  6. NOT CALCULATING THE RANGE OF CLAIM VALUE
  7. NOT EDUCATING THE INSURANCE ADJUSTER

No. 1: NOT DISCERNING THE NEEDS OF THE CLIENT

Seems simple.  A lawyer should find out what his client needs, right?  But often-times, lawyers mistakenly:
  • delegate the initial client interview to non-lawyers
  • delegate client problems to non-lawyers
From the beginning, Mike Burman listens to each client and takes action based on 25 plus years of personal injury and wrongful death case experience.  Mike’s staff is highly trained, and collaborate with Mike and each other to advance the case.  Mike’s case management system is constantly updated for new technologies and best practices.  The Burman Law Client Portal provide a “personal touch” to every client’s case by allowing rapid access to information and documents as the case advances.   Client phone calls, emails, text messages and portal messages are addressed promptly to give real-world solutions.

No. 2: NOT IDENTIFYING CRITICAL EVIDENCE

Many lawyers fail to recognize that technology has radically altered the collection of evidence.  Closed circuit TV, satellite imaging, social media platforms, camera drones and internet databases provide unprecedented amounts of information and documentation.   Because Mike Burman is an experienced personal injury lawyer in charge at the beginning of every injury case, Burman Law preserves and protects critical evidence early in the case, for a strong foundation later in the case.  Burman Law is a self-funding law firm and does not rely on outside financial sources to pay case expenses.  If a case requires increased financial support, the case gets that support.

No. 3: NOT UNDERSTANDING THE MECHANISM OF INJURY

To understand the mechanism of injury, Burman Law examines how the injury is caused by trauma to the human body.  High school anatomy and physics teaches the body is composed of parts, some of which are fixed and some of which are mobile. Stress produces strain. Strain is a measure of of how much the human body deforms as a result of stress caused by trauma. Many lawyers do not examine the mechanism of injury.  At Burman Law, we work with experts to determine exactly which parts of the human body were affected by the traumatic mechanism of injury.  Understanding this aspect of the case helps predict the present and future affects of injury.  Many lawyers over-look this aspect of a case, especially in the area of permanent impairment of bodily function.  Burman Law works with medical doctors to organize important mechanism of injury considerations for the particular case.  With well organized reports from the doctor and other experts, the value of an injury claim increases.

No. 4: NOT GATHERING ALL ICD MEDICAL CODES

ICD medical codes are used in clinical care and research to define medical conditions, study patterns, manage health care, monitor outcomes and allocate financial resources.  Insurance companies use ICD medical codes to value cases, but most injury lawyers do not, and this creates a major “disconnect” between the lawyer representing an injured client and the adjuster representing an insurance company evaluating a claim based on ICD medical codes.  If the injury lawyer does not provide these ICD medical codes, the insurance adjuster is not going to ask for them, or go out and gather them.  That is why insurance adjusters always say, “Based on the information you have given me, this is the offer of settlement.”

Examine any medical bill and it contains medical codes.  These medical codes determine how much is paid on the bill.  Insurance companies use these codes to pay medical bills, so it makes sense that insurance companies use these codes to pay injury claims.  Burman Law gathers all ICD medical codes to prepare a settlement demand that provides everything needed for a full and complete evaluation by the insurance adjuster.

In many cases, proper ICD medical coding will increase the value of an injury claim by 100% or more.

No. 5: NOT PRESENTING AN INJURY CLAIM EARLY ENOUGH

Every case goes through phases.  The first phase – the acute trauma phase – begins when the injury occurs.  In the acute trauma phase, the patient is rushed to the Emergency Room. But over time, as medical professionals provide quality treatment, an injury case evolves from the acute trauma phase, into the medical plateau phase.  In the medical plateau phase, all injuries are identified and all injuries are relatively stable. Maximum medical improvement, or MMI for short, is an insurance term that insurance adjusters use.  It is not a term favored at Burman Law, because MMI takes too long to reach in most cases.  Many injury lawyers wait for maximum medical improvement rather than medical plateau. For many injured people, MMI means a full recovery with no restrictions.  And so, what does the insurance adjuster say at MMI?  The insurance adjuster says, “The claim is not worth much because the injured person has fully recovered.” Burman Law, on the other hand, does not wait for MMI.  Once medical plateau is reached, we finish gathering information and supporting documentation to establish:
  • diagnostic codes
  • medical bills for past charges
  • prognosis (how the injury will progress over time)
  • impairment (how the injury will affect physical function)
  • lost earning capacity (how the injury will affect future income)
  • future medical expenses (how much future medical services will cost over time)
After gathering the above information and documentation, a settlement demand letter is prepared for the case and all documentation is attached to this demand.  A settlement demand letter outlines the claim for the adjuster in charge.  The settlement demand letter sets forth, in writing, the legal basis for the claim, the medical evidence of injury, and proof of damages resulting from the injury while the injury is still “fresh.”

No. 6: NOT CALCULATING THE RANGE OF CLAIM VALUE

Many injury lawyers have no objective way to determine case value, relying only on experience, or the Jury Verdict Reporter showing jury verdicts for the state where the injury occurred.  But how do jury verdicts and experience provide an objective method for valuing every type of injury claim for every type of injured person? Burman Law’s methodology for determining case value relies on specialized software from a third party vendor to provide an objective range of values for a particular case.  Thus, there is no guessing when the insurance company has offered full and fair compensation.  Burman Law advises each client when the offer is “within the range of reasonable outcomes.”  Further, we prepare our clients to say “no” when the insurance company offer is not full and fair based on the facts of each particular case and the range of reasonable outcomes.

No. 7: NOT EDUCATING THE INSURANCE ADJUSTER

Educating the insurance adjuster is the most crucial part of settling a personal injury claim.  Educating the adjuster requires:
  1. Knowing what the adjuster knows
  2. Making sure the adjuster understands what the adjuster knows
  3. Ensuring the adjuster has properly evaluated the claim
  4. Identifying “new” information for the adjuster to consider
Many lawyers try to educate an insurance adjuster the same way they educate another lawyer, with legal arguments and facts.  This will not result in the highest and best settlement because an insurance adjuster does not think like a lawyer.  An insurance adjuster has a completely different perspective based on the rules set by the insurance company that hires the insurance adjuster. Mike Burman is trained to think like an insurance adjuster, with settlement methods tested over 25+ years.  Mike follows best practices taught by a former insurance company executive with years of experience in adjusting claims.  Mike Burman is  trained to understand how insurance adjusters evaluate cases by applying sophisticated computer programs that run algorithms based on “multipliers” and “value drivers.” An insurance adjuster is never going to explain how to get the highest and best value for a case.   Most adjusters handle between 500 to 700 claims at any one time.  An insurance adjuster will rarely take the time to go out and look for all the evidence that supports a case.  And so, honestly educating the adjuster, with supporting documentation, makes a huge difference in the outcome of a case.
AUTOMOBILE FAIR MARKET VALUE

AUTOMOBILE FAIR MARKET VALUE: Total Loss

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Steps When You Are In a Collision and Your Vehicle Is a Total Loss:

  1. Contact the at-fault party insurance adjuster and establish a claim; demand a rental vehicle; keep good notes
  2. Get at least one estimate to repair your damaged vehicle
  3. Determine the FMV of your damaged vehicle
  4. If the FMV of your damaged vehicle is less than the repair estimate, then your vehicle is a total loss
  5. Negotiate with the insurance adjuster for the full FMV plus tax, title and license
  6. See below for more details

For a Total Loss, You Can Recover Money for:

  • Items of property destroyed by the collision/impact
  • Property damage for the actual cash value (FMV) of your vehicle
  • plus the cost of taxes and title on a vehicle of like value
  • plus reasonable rental (loss of use)

Loss of use is the cost of a rental while you shop for a replacement vehicle.  Property damage includes damage to your vehicle, or its contents, even clothing or glasses you were wearing.  Actual cash value is also commonly called fair market value or FMV.  The law defines fair market value as the amount of money a willing buyer will pay a willing seller for your vehicle before the crash occurred. The determination of FMV includes facts like the year, the make, the odometer mileage, any previous damage and the general condition of your vehicle before the crash.  Dealer service receipts, parts receipts and maintenance records are useful when trying to establish vehicle value.

Sources of Fair Market Value To Prove Total Vehicle Loss Include:

  • Kelly Blue Book
  • NADA Used Car Guide
  • Recent Sales of Similar Vehicles
  • Ads from Newspapers or Auto Trader websites
  • Internet search for “automobile appraisal”
  • Statements from a dealer or car salesman familiar with your vehicle

Tax, Title and License Fees in Kentucky and Tennessee:

For Christian County (and all other counties in Kentucky) the cost of a title is $9.00.  To license a vehicle, you pay a 6% sales tax on what Kentucky says the vehicle is worth.

For Montgomery County, Tennessee the title costs $16.00. To license a vehicle purchased from an individual, the cost is $94.00 for a title and plate plus sales tax, which is usually 9.5%. If there is another lien holder, there is an extra $11.00 charge. If purchased from a dealer in Tennessee, you pay $94.00 without having to pay the sales tax.

In Tennessee, each county has a different “wheel tax”, so you will need to contact the government body where you want to register your vehicle to get a full breakdown.