Disability Insurance Claims
Health Insurance Claims

Many different kinds of health insurance policies exist, and there are many different ways in which insurance companies attempt to deny health insurance claims. Of course, not every kind of policy or claim denial can be discussed on this website, so we encourage you to give us a call to discuss anything and everything pertaining to health insurance. That said, however, here are a few examples of the many things one must keep in mind when it comes to health insurance.

In the health insurance arena, the most common basis for claim denial was arguably pre-existing condition. “Was” because the Patient Protection and Affordable Care Act (“Obamacare”) is supposedly doing away with the pre-existing condition denial. It would be surprising, however, if insurance companies did not try to devise functional equivalents to the pre-existing condition denial and / or manipulate Obamacare language regarding same. The Merlin Law Group will ensure that your claims are resolved in compliance with applicable laws.

Confusion (and, thus, lackluster benefit payments) can arise out of the treatment pre-authorization (sometimes called pre-approval or pre-certification) process. And insurance companies are sometimes responsible for a botched pre-authorization. The Merlin Law Group can assess who is responsible for a pre-authorization gone awry and assist with remedying same.

Oftentimes, health insurance claim denials are the product of administrative or clerical mistake. Typically, such denials are easily remedied if one knows what to look for and how to go about things. The Merlin Law Group can help unravel denials based on administrative or clerical blunders.

Another common basis for health insurance claim denial is an insurance company’s contention that your treatment was not medically necessary or was experimental in nature. Perhaps the insurance company guidelines simply do not recognize your novel treatment and legal letter writing or appeal is likely to resolve the situation. Or perhaps the insurance company’s medical director needs to receive expert and / or legal explanation as to the necessity of treatment provided by your attending physician. The Merlin Law Group has the experience and resources required to assist in these (and other similar) regards.

 

 

Health Insurance Claim Articles

Air Ambulance Insurance Coverage, Insurance Claim

By Jeffrey L. Greyber, Esq.

 
Health Insurance Claim Appeal Process

By Jeffrey L. Greyber, Esq.

 
Childbirth Insurance Claims, Pregnancy Bills

By Jeffrey L. Greyber, Esq.

Insurance claims in general tend to be complicated, but it appears as of late that healthcare insurance claims, specifically those related to pregnancy and childbirth, have increased in complication. One prediction for the increase in pregnancy and childbirth insurance claim denials and delays is this: the science behind pre-birth child and mother care and post-birth child and mother care is ever-evolving. Some health insurance companies are having trouble keeping up with the evolution of pregnancy and childbirth healthcare and are unable to always fulfill full and proper coverage for mother and child.

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Physician Billing

By Jeffrey L. Greyber, Esq.

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Whether you are a physician who handles billing on your own or you have in-house personnel dedicated to billing and insurance claims or you outsource your billing and insurance claims to a billing agent, the attorneys at Merlin Law Group are here to assist you. When an insurance company delays, denies, or underpays the insurance claim, Merlin Law Group is here to help you, the physician.

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Health Insurance Explanation of Benefits

By Jeffrey L. Greyber, Esq.

An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. The EOB is commonly attached to a check or statement of electronic payment.

Do you ever have difficulty determining how a certain amount has been deemed as patient responsibility? Have you ever had trouble figuring what is applied to your annual out of pocket max? Have you ever asked yourself what is a deductible? What is a co-pay? What is the difference between in and out of network?

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Health Insurance Denied Medications

By Jeffrey L. Greyber, Esq.

Medical prescriptions can cost some patients thousands and thousands of dollars. Medical prescriptions are more frequently being denied insurance coverage. A possible example includes: a health insurance company attempting to force generic prescriptions on their policyholders, when in fact their medical provider is insisting on name brand prescriptions.

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Health Insurance Denied Paying For Surgery

By Jeffrey L. Greyber, Esq.

When surgery is needed, it is typically at a high cost. Whether or not your health insurance policy requires you to have a pre-approval, sometimes referred to as pre-certification, for surgery, you should always get a pre-approval. Most likely, your health insurance policy will dictate, in very fine print, that pre-approval does not constitute a coverage decision.

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Medical Providers And Billing Agencies: There Are Things That Should Be Done Before Sending The Patient To Collections Or Writing Off The Medical Bill

By Jeffrey L. Greyber, Esq.

This follows up on the Merlin Law Group’s attendance at an April 2015 conference put on by the Healthcare Billing and Management Association (HBMA). As I discussed with several folks at the HBMA conference kind enough to stop by the Merlin Law Group’s exhibitor hall booth, medical providers and / or billing agencies should consider looking into the contractual, legal, and / or factual (im)propriety of the health insurance company’s claim denial or partial payment before sending patients into collections or writing off the medical bill.

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Paying The Bills: April 22-24, 2015, Healthcare Billing and Management Association
Spring Educational Executive Symposium (Orlando, FL)

By Jeffrey L. Greyber, Esq.

It is not uncommon for patients to assign their insurance benefits to medical providers. And, regardless of a possible assignment, it is not uncommon for medical providers to handle the processing of claims with the patient’s insurance company. From the medical provider’s perspective, what happens if the patient’s insurance company denies claim payment?

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Getting The Claim Decision In Writing

By Jeffrey L. Greyber, Esq.

Sometimes, insurance companies will verbally convey a claim decision to a policyholder.  If this happens to you, it is imperative that you ask the carrier to memorialize its claim decision in writing.  Why is it important to have the carrier reduce its claim decision to writing?  Well, there are several different reasons, but here are a few examples. 

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What Law Governs? ERISA Or Not?

By Jeffrey L. Greyber, Esq.

Generally, if you are part of a group health insurance plan, disability insurance plan, or life insurance plan, your claim (and related litigation) will be governed by the federal body of law called ERISA (Employee Retirement Income Security Act).  In my opinion, ERISA is pro-carrier in most jurisdictions.  So, in my opinion, you should try to avoid ERISA like the plague.

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Don’t Blindly Trust Your Health Insurer’s In-Network Medical Provider List

By Jeffrey L. Greyber, Esq.

Most health insurance companies make their in-network medical providers list available to policyholders, oftentimes via the carrier’s website or a printed directory. And most health insurance policies place the burden (or at least the initial burden) of locating in-network medical providers squarely on the shoulders of the policyholder. Well, actually, this should not be too much of a “burden” equipped with the carrier’s medical provider list, right? Hum, not so fast…

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Don’t Blindly Trust Your Health Insurer’s In-Network Medical Provider List

By Jeffrey L. Greyber, Esq.

Most health insurance companies make their in-network medical providers list available to policyholders, oftentimes via the carrier’s website or a printed directory. And most health insurance policies place the burden (or at least the initial burden) of locating in-network medical providers squarely on the shoulders of the policyholder. Well, actually, this should not be too much of a “burden” equipped with the carrier’s medical provider list, right? Hum, not so fast…

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Is Your Treatment or Care Medically Necessary?

By Jeffrey L. Greyber, Esq.

In the health insurance and long-term care insurance arenas, an all-too-common basis for claim denial is that the subject treatment or care was not medically necessary. “Medical necessity” is an amorphous concept, for several reasons. Perhaps the most obvious reason is that treatment plans often account for the individual just as much (if not more) than the diagnosis; i.e., a particular kind of treatment may be necessary for one of two patients presenting with the same condition, but not for the other.

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Post-Treatment Follow Up With Health Insurance Companies

By Jeffrey L. Greyber, Esq.

So, I have written about the importance of seeking your health insurance company’s pre-authorization / pre-certification of a medical procedure that you will subsequently be claiming with your carrier. But what about following up with your health insurance company after you have received medical services and sought coverage for same? Is it a good idea to stay on top of your health insurance company in the wake of medical treatment and claim submission? Absolutely, in my opinion.

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Are Stem Cell Treatments Covered In My Health Insurance?

By Jeffrey L. Greyber, Esq.

This article (which is precautionary in nature) hits close to home, as I have a friend who is undergoing stem cell transplants for the treatment of scleroderma and is doing so “out-of-pocket.” The “out-of-pocket” aspect of that is a travesty, in my opinion – the current lay of the medical land (stem cell treatments gaining traction throughout the worldwide medical community and meeting with significant success) simply does not square with the current lay of the insurance land (most insurance companies still considering such treatments “experimental”). 1

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2014 Florida Conference On Aging

By Jeffrey L. Greyber, Esq.

Last week, my colleague and I attended the 2014 Florida Conference On Aging in Weston, Florida. We were there, with our booth and handouts, representing the Merlin Law Group’s disability, life, health, and long-term care insurances practice.

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Health Insurance Claim Denied Due To Waiting Period Provisions

By Jeffrey L. Greyber, Esq.

I would like to deliberate on the health insurance arena, particularly, on what I have noticed recently on the rise, health insurance claim denials based on waiting period provisions. According to the United States Department of Labor, Affordable Care Act Implementation Part XVI Section 2704(b) (4) of the PHS Act, section 701(b) (4) of ERISA, and section 9801(b) (4) of the Code, a waiting period can be defined as the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.1

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Health Insurance Claim Denied, Pre-Approved Medical Procedure

By Jeffrey L. Greyber, Esq.

Pre-approval for a medical procedure is an imperative precaution when your health insurance policy is concerned. Pre-approval or pre-certification, is an authorization that can be required by your health insurance company to ensure that said medical procedure is necessary and ultimately appropriate for your condition. Always remember that every insurance policy differs, so it is crucial to know exactly what is covered in yours.

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Beware of the Ongoing Disparity Between Mental and Physical Insurance Coverages

By Jeffrey L. Greyber, Esq.

This article is largely geared toward promoting consumer awareness. The awareness being that those requiring mental health services and / or those who are mentally disabled are still (inexplicably, in my opinion) not treated equally with those requiring physical health services and / or those who are physically disabled. You should keep this unfortunate reality in mind when securing health or disability insurance.

Regarding disability insurance and for example, it is still all too common for disability insurance policies to limit the mentally disabled to a shorter period of benefits (e.g., 24 months). Compare this to the physically disabled, who are, under most disability insurance policies, entitled to receive benefits until age 65 or through their lifetime.

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Is A Surviving Spouse Liable For The Deceased Spouse's
"Uninsured" Medical Bills?

By Jeffrey L. Greyber, Esq.

In my health insurance, life insurance, and long-term care insurance practice, I sometimes encounter the tangential issue of keeping the deceased insured’s creditors, such as hospitals and doctors, at bay from the deceased’s spouse until it is determined whether the creditors’ bills should have been paid by the insurance company. This begs the question: notwithstanding any contractual obligation the insurance company may have to pay a deceased spouse’s medical bills, is the deceased’s surviving spouse legally on the hook for such bills?

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Post-Application Manifestation Of A "Pre-Existing" Health Condition: No, You
Are Not Necessarily Up The Creek Without A Paddle As The Carrier
May Be Suggesting

By Jeffrey L. Greyber, Esq.

Here is the hypothetical, yet all-too-common real life, scenario around which this blog revolves: you represent to a disability or life insurance company during the insurance application process that you do not have any noteworthy pre-existing conditions, but you find out for the first time after inception of your coverage that you had a malignant tumor growing in you at the time of application. What, then, if your once unknown condition renders you unable to work or, God forbid, results in your passing away? Are you (or your beneficiary) precluded from receiving indemnification under your disability or life insurance policy because your condition technically “pre-existed” policy inception?

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Long-Term Care Insurance: The Pre-Existing Condition Dilemma

By Jeffrey L. Greyber, Esq.

A reader of last week’s blog, Get Back To School - Long-Term Care Insurance 101, asked me if the Affordable Care Act removes insurance company pre-existing condition discrimination from Long-Term Care (“LTC”) insurance policy underwriting as it has from health insurance underwriting. Regrettably, the answer is “no,” as the government felt it was going to be too expensive to do so.1 That said, let’s talk about what LTC policy applicants or LTC claimants can do about the pre-existing condition disparity in the application process and exclusion in the claim process.

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Obamacare and Pets

By Jeffrey L. Greyber, Esq.

While recently chatting with a colleague about how my pup, Bowser, was recovering from this year’s knee surgeries, we got to wondering whether the pre-existing condition facet of Obamacare applies to pet health insurance as well as human health insurance.

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