Medical Billing Claims

By the time you (the medical provider’s in-house or outsourced billing professional) are processing a medical service claim with a health insurance company, the insurance benefits to which the claim relates belong to the patient or belong to the medical provider by way of the patient’s assignment of benefits. Either way, the medical provider is depending on you to obtain payment from the insurance company so that the medical provider does not have to get adversarial with the patient (e.g., direct billing or collections) or morph the bill into a tax write off. The unsavory scenarios that are direct billing, collections, or tax write off arise, of course, only if the health insurance company underpays or denies the claim. So, this begs the question – if the insurance company underpays or denies the claim that you are processing, do you really have to return to the medical provider at that juncture offering only direct billing, collections, or tax write off? No, more should be done before resorting to that – the propriety of the insurance company’s claim decision should be vetted by one of the Merlin Law Group’s well-experienced health insurance attorneys.

It should come as no surprise that there are many different ways in which an insurance company’s claim decision can be erroneous. For example, the claim may have been underpaid or denied because of a simple administrative or clerical error. As another example, the claim may have been underpaid or denied because of the insurance company’s misunderstanding of the factual circumstances surrounding the medical services that were rendered. As another example, the claim may have been underpaid or denied because of a misinterpretation / misapplication of the insurance policy or the law. The Merlin Law Group’s health insurance attorneys have seen it all and are accordingly well-versed in analyzing insurance company claim decisions and unwinding (via letter writing, statutory remedies, appeals, external reviews, mediation, litigation, or et cetera) incorrect claim decisions. Of course, when the Merlin Law Group achieves payment from the appropriate source (the insurance company), you end up the hero for having pointed your client (or perhaps even the patient) in the right direction.

The Merlin Law Group’s initial assessment of the insurance company’s claim decision is a courtesy. The terms of representation will be discussed if it is determined that the insurance company’s claim decision was wrong and that the Merlin Law Group’s services are warranted.