Archive for the ‘Denials’ Category


By Dennis Patouhas

Over the 17 years that we’ve been providing services to the community we have witnessed what a changing landscape Long Term Care Insurance has evolved.

Let me apologize upfront at the length of this article but this is a complicated matter. Without getting into a detailed history of how this segment of the industry has evolved, suffice it to say, the marketplace is not what the insurance companies had anticipated when they launched these products. There have been modifications to the insurance policies sold that tried to keep up with the needs to finance the cost of Home Care for an increasing number of aging adults. While the newer policies have addressed changes in the landscape of Home Care the older policies contained ambiguous language that permitted the insurance company to limit the conditions under which the policy could be used.

We have always advised our clients to review the policy language to determine whether it was accepting of certain providers of Home Care. The problem is in the narrow definitions of who is a qualified provider. Some of the language used include reimbursing only for services provided by a Medicare Certified Home Health agency or a State Licensed Home Health Care Agency. The policies with restrictive language have been and will increasingly be challenged because the terminology used is often not a defined term within the policy or in general legal definitions. These are general descriptions of each;

  • State Licensed Home Health Care Agencies are providers of medical care in the form of wound care, physical therapy, speech and occupational therapy.
  • A Home Health Care Agency is a provider of certified nursing assistants (CNA) or home health aides (HHA) who are qualified to assist with activities of daily living (ADL’s). A home health aide provides assistance monitoring a loved one with medical problems, but the focus of care is actual assisting with everyday tasks, such as bathing, eating, housekeeping and so on.

The problem in a state like Connecticut is that Home Care is registered with the State not licensed by the State. The terminology State Licensed Home Health Care Agency narrowly defines the policyholder’s choice to only use a skilled nursing agency. Skilled nursing agencies which are licensed entities, have typically been for acute care (temporary) as with someone who, by receiving Home Health Care will enjoy an improvement in their condition to the point where they can be discharged from Medicare services, having plateaued in their progress.

This defines a temporary need for that level of care. Home Care is not typically a temporary need but a chronic one that may intensify as a person’s condition worsens with age. There are not many skilled nursing agencies that provide a full menu of non-medically related services (Home Care). Therefore, the number of agencies that fit the definition of the insurance policy is very limited.

You can imagine the surprise by the policyholder and their families when they realize that for all of the money spent to carry this supposed solution to financing care for their elder years, that it has very restrictive covenants that require a uniquely defined service provider with credentials that are not mandated for the vast majority of those agencies whose services are the very thing that the policyholder needs.

An analogy might be that if you bought a car in the 1950s and purchased a lifetime service agreement that specified that you must have it serviced only by a garage that is a “licensed carburetor repair shop”. In 2018 you would be hard-pressed to find someone working in any car repair organization that knows what a carburetor is. So much for your years of paying premiums for long-term care on your 1953 Pontiac. Most repair shops could probably get it fixed but they don’t qualify with the definition in your lifetime service agreement. The bottom line is that Healthcare and care for the aged have evolved. What once may have been a recognized standard has been surpassed and, in some cases, eliminated with new and more effective solutions. In the wake is a policy that can’t be used but cost a whole lot of money.

So, what is a policyholder to do?

  • Start by trying to get an understanding of what the insurance company considers compliance with the language of their policy. In some cases, a mere certificate held by a Home Health Aide (HHA) or Certified Nursing Assistant (CNA) may suffice.
  • If you are working with a Home Care Agency that you prefer to be your provider, grant them permission to discuss matters with the insurance company and see if they can work it out.
  • The interpretation of any policy is subjective based on the language. The insurance company may interpret the policy based on their understanding and that interpretation may not be in sink with what the policy language states. When challenged insurance companies often make provisions to comply with need. All insurance policies are one sided; terms are dictated by the insurer. When problems of non-payments/coverage are elevated to the legal level, the courts almost always side with the insured. Knowing this when disputing coverage details such as licensing agency terms will help influence the insurance to pay for needed care from the provider of your choosing.
  • Insurance policies are regulated on the State level. If negotiations fail, a complaint to the State Insurance Department can be filed.
  • It’s like your 1953 Pontiac service agreement. You have paid for something that cannot be used. The courts are starting to see it and it will become more and more an issue. Pointing out to the insurance company that they have sold you a policy that cannot be used under the law. Licensed Home Health Care agencies that provide custodial Home Care do not exist or are so limited in number as to severely restrict a policyholder’s choice.
  • You are not seeking to use the policy for something other than what it was intended. You are seeking to be able to use it with a broader variety of providers that are better able to meet your needs and at competitive prices. Your policy allows you so much in benefits and your looking to use it as efficiently as possible.

Lastly and before you throw in the towel and stop paying premiums and letting the policy lapse, seek out a reputable insurance consulting firm that works on handling dispute resolution. A situation like what you’re currently dealing with may not work, but the policy may still be totally viable under the right circumstances. To let the policy lapse would make the premiums paid to date become a sunk cost. To replace the policy that you now have at your current age and health condition may be unaffordable. Good consultants can evaluate what you have and what you’re trying to achieve. They can see if, through knowledgeable intervention they can reach an understanding or concessions from the insurance company.

I would like to thank Katalin Goencz for her contributions to this article. Katalin heads up Med Bills Assist which is based in Stamford, CT and are Medical Insurance & Reimbursement Specialists. Katalin can be reached at or 203-569-7610.

Comfort Keepers of Lower Fairfield County has been providing senior care services for over 17 years. As one of the oldest agencies in the area we have helped hundreds of families with elder care for their loved ones. Our service area covers Greenwich to Fairfield and includes such towns as Norwalk and Darien. As part of one of the largest systems for senior care with over 750 offices nationwide we have solutions to senior care issues where you need them. Call us at (203) 266-1227

Long term care insurance: policy provisions in dispute – Lexology


Resolving Long Term Care Insurance Disputes, By Glenn R. Kantor, Esq. and Corinne Chandler, Esq


Long-Term-Care Insurance Gets a Makeover; By Ellen Stark August 31, 2017

PostHeaderIcon Mental Healthcare in Its Worst

Large part of my business is dealing mental health reimbursement problems. People with some problems that can be treated with therapy and medication is manageable.  The real problem is with severe conditions where daily supervision and guidance needed. The two most common issues  are mental health problems, and  or substance abuse.

The Affordable Care Act gave us a false hope that mental health and substance abuse treatment will be covered under the insurance policies. The false hope is arriving from the insurance administration of this care.  While the benefit is available it comes with managed care. Most expensive services require insurance prior approval. Many of the inpatient residential treatment facilities are not in network and have no idea, nor interest, to obtain prior authorization.  So, under the Affordable Care Act we have the coverage, but the law left it to the insurance companies to deny care.

Two parties, the residential treatment facility and the insurance company, supposed to work together are very far away from each other.  Most of these facilities are set up for cash payments and generally don’t participate, nor understand medical insurance.  In the other side insurance companies routinely deny care in out of network residential treatment facilities.

The major factor in treating mental illness is learning to make life changes.  Most insurance company denials state that services could have been provided in an Intensive Outpatient Program. That is almost always a false statement. Major life changes involves the patient relocation and close 24/7 supervision.  It cannot be done while living home and attending a daily sessions.

The usual story is that a parent takes a young adult child to a facility in remote location.  This is an effort from the parent to save that child from further harming him or herself, with a hope for recovery and healing.

In most cases the effort pays off. A few months later this young adult find a new direction is life.  They learn to cope with the illness, or give up illegal drugs. It can be a combined problem; mental illness brought on by drug use.

The  problem is the price tag of  about 40-60 thousand.  Most people expect the insurance company to pay for most of the bill.  Instead it becomes  a tag of war between  the facility’s inability to bill to the insurance company correctly and the insurance company wanting proper billing submission. Once that mess settles the next state is the insurance denial.  The majority of these denials states that the care could have been provided in an Intensive Outpatient Program.  We all know that is not true, but it is a good start to avoid payment as far as the insurance company concerns.

Fighting these denials after-the-services is nearly impossible.  Of course there are a few exceptions where additional considerations may help to overturn those denials.

The best course of action is to be proactive. Bring this person to the psychiatrist.  Do locate an in network Intensive Outpatient Program and enroll.  If it doesn’t work there is a proof, and very good reason for the residential treatment facility. Even so, do call your insurance and ask if there is an in network residential treatment facility.  It is always a good idea to ask and look and check it out prior treatment.  If there is none then ask for a prior approval to the facility of your choice.  By this time there is a psychiatrist and treatment facility on the record, so it would be very hard to deny.


PostHeaderIcon 5 Tips for Handling Medical Claims — guest post by Erin Palmer


It can be upsetting to undergo medical treatment, but when medical bills start to arrive it’s easy to move from upset to completely overwhelmed. For families and patients, understanding how to handle medical claims can make all the difference in dealing with the financial stress and time-consuming nature of medical bills.  Consider these tips when handling medical claims:

1. Don’t wait!  Many families wait until there is an unbearable amount of medical paperwork to wade through before beginning the process.  A better way to handle medical billing is to deal with them when they arrive.  Take time to carefully read the information that is enclosed and determine if action needs to be taken.  If the letter is unclear, then immediately call the physician’s office, medical billing organization or hospital to get clarity.  Keeping up with the process is the best way to decrease the stress of medical billing.

2. It’s OK to ask.  Many patients feel intimidated and confused by paperwork that arrives in the mail.  Medical paperwork may be complex and leave patients with more questions than answers.  It is critical for patients to know that not completely understanding their billing is not a problem. It only becomes a problem when patients and their families don’t take time to ask pertinent questions. Virtually every billing statement has a customer service phone number.  Taking the time to call customer service and have questions answered is another effective practice in handling medical claims.

3. Analyze the EOB.  The EOB – or Explanation of Benefits – is one of the first pieces of information provided to a patient and their family.  Before calling the insurance company or provider, there are certain items to identify on the paperwork that will assist in determining next steps.  First, look for the name of the doctor or hospital and the date of the services provided.  The next item to identify is the total charges, noting the amount paid by insurance and the amount owed by the patient.  There should also be a section that shows contractual adjustments. This section should indicate the amount the doctors write off.

4. Know about insurance benefits.  Understanding insurance coverage will help to determine what needs to be paid and what is covered by insurance. Taking time to read the insurance booklet before medical services can help to answer questions before bills arrive.  Also, it is critical to understand the amount due for deductibles as well as co-payments or co-insurance.  To decrease the amount of bills that have to be sorted through, consider paying co-payments at the time of service and pay all bills by check or credit card so that there is a clear payment trail in case of questions later.

5. Don’t ignore bills.  No matter the situation, simply ignoring bills will not make them go away.  Whether there are unexpected bills or too much financial strain, there are ways to effectively work through the process.  The best place to start is to speak with the medical office and ask questions.  Many times, issues can be cleared up quickly and physicians are often willing to take a lower payment for services rather than receiving no payment at all.  Simply ask if there is a way to work out the billing to resolve the issues. Calling the insurance company also often yields results, either by explanation or a promise of reprocessing a claim. Taking a proactive approach, rather than ignoring the bills, will help to avoid frustrating collections calls.

Clearly, it’s upsetting to get a stack of bills while trying to heal from a major medical episode.  With these practical tips, understanding the paperwork, dealing with billing and communicating with doctors and hospitals should be much easier.

This guest post was provided by Erin Palmer. Erin writes about medical billing training programs and medical assistant degrees for US News University Directory. For more information about healthcare careers please visit


PostHeaderIcon Appeals – what to look for – how to file

Medical claims can be denied for many reasons. In most cases the reason for the denial is listed by codes right next to the service line. At the bottom of each Explanation of Benefits (EOB) there should be a code explanation. If the explanation is not listed or you don’t understand the first thing to do is find out or clarify what is being denied and why.
By calling your insurance customer service you can ask questions about a denial and full explanation should be given. During this phone call you may find out that the insurance made a mistake and your phone call of inquiry can prompt the customer service person to send back the claim for reprocessing. In this case, don’t feel completely relieved just yet. There are many things can go wrong and your denial could stand the same after thins phone call. So, the best thing to do in this situation is to mark your calendar in 30 days, note the date of your phone call, the name of the person you spoke with and if any reference number given. This way in 30 days you can follow up with a second call if the claim has not been paid.
Once the reason for denial is fully understand you can file an appeal. Always be sure to have the correct appeals address for your insurance. Letters and faxes often go to a specific department, so sending a letter to the wrong address can further delay the answer. Some of these companies are big that your letter can be easily misplaced and land in the “black hole”. I have heard insurance company representatives using this term.
The next important part is listing your information before your letter begins. This should include your name, your insurance ID number, the date services were provided, your address and the claim number listed on the denial.
The first sentence should state that this is an appeal and you are disputing the denial.
The body of your letter needs to explain what taken place and why this claim should be paid. Try to be clear and free of emotion. Accusing a person reading this letter will not help your appeal.
The closing sentence is the repeat of your demand for payment.
If you have supporting documentation of any kind you need include that with the letter.
Time: most claims have 180 days appeal limit, from the time a claim was processed. State laws and policies may vary slightly.

Types of denials:
• Coverage based
• Technical
• Medical

Coverage based: these are denial when the insurance company states that your policy does not cover this service.
Example: a client had an oral device made by a dentist to treat his sleep apnea. The claim was denied based on the dental component. I successfully argued that his oral appliance was to treat a medical condition.

Technical: these are claims denials mostly for timely filing or coding problems.
Most claims have to be filed within a 180 days from the time services were provided. Missing this deadline will produce a timely filing denial.
Example: the patient was hospitalized for an extended time period, therefore could not file a timely appeal.
Coding problems: each medical claim have to contain a several numbered codes, such as provider tax ID, place of service, CPT or HCPCS, diagnosis, NPI or license numbers. Missing or using a wrong one will produce a denial. In this case there is no need for an appeal. Simply you need to decipher which code needs a correction and simply can resubmit a claim with correct codes.
I am fully expecting these denials to multiply starting on October 2013. That is when the ICD-10 coding change will be implemented and codes will multiply by nearly 55,000.

Medical: these are services denying by the insurance saying that the service was not medically necessary for your specific condition. The appeal should explain why it was necessary and be paid.
In case the first level of appeal is denied I always file a second level of appeal. The review of this appeal takes place with a different department and there is a chance to overturn the first level of denial.

If a second level of appeal is denied there is always an option to file the next level to the Commissioner of Insurance or the Benefit Administrator. The deciding factor is based on the type of policy the person have. Fully funded insurance policies are appealed at the Commissioner of Insurance level, and self-funded insurance policies are appealed at the Benefit Administrator.

PostHeaderIcon Another bump on the road for Obamacare

Pushing through this monstrous legislation called the Patient Protection and Affordability Care Act (PPACA) was just a beginning of slowly escalating problems with implementation of gradually coming to effect provisions.

We did really well eliminating pre-existing condition limits for children, and everyone liked the young adult coverage extension to age 26, under the parents large group policies.

We are hitting a bump on the road with implementation of the medical loss ratio, which is now in the books and forcing the insurance companies to pay out about 80% of collected premiums on claim expenses. Just like any other business, insurance companies have regular business expenses they have to account for. So the battle was brewing for a while to decide which expenses can be allocated under the general umbrella of claims expense.

The new major outcry is now originating from religious groups. The law added a significant change which makes women health and reproduction along with planned birth control part of a category of preventive care.

In the past religion based institutions were exempted from covering birth control and coverage for reproductive services, other than child birth. The PPACA now requires faith based large organizations, such as hospitals and universities to cover birth control as part of the basic preventive care. (Small churches with only faith based employees are still exempt.)

There is nothing in this law that force women to use birth control, it is only an option to do so. My insurance covers surgery for broken leg, yet I don’t go and break my leg, just because it is covered. This law simply gives women the option to use family planning, fertilization treatments and birth control if they so desire.

Why should this option denied for women who do not agree with the church dogma, or not even catholic, just because their employer has a religious objection to it?

These same religious organizations receive significant federal funding; yet want to be excluded from public healthcare policy. It would seem fair to me to obey federal policy in return for federal funding.

PostHeaderIcon Pre existing conditions

Insurance language defines pre existing condition as a symptom, illness or health condition that was known and existed prior to the writing and signing an insurance contract. Health or life insurance policies will typically not cover pre-existing conditions until a specified period of time has elapsed. Depending on federal and state laws pre-existing conditions may not be covered at all.

The Health Insurance Portability and Accountability Act (HIPAA) provide some protection for people in transition, although it doesn’t go far enough.  The HIPAA law allows a 63 day gap between health insurance coverage.  Once the person is without medical insurance over 63 days, they are vulnerable to insurance company searches in to their medical records.

Unfortunately there are a lot of people affected by this unreasonable rule created by the insurance companies.
In a recent case a young woman was hospitalized and one of her old diagnosis was listed on her medical bill.  This code was put on to represent her historical medical condition and had nothing to do with her recent hospitalization.  Unfortunately, this simple coding oversight prompted her insurance company to deny her hospital and all other relevant medical bills.  The denial brought on disbelief, then frustration and anxiety.  Finally a well drafted letter from the treating physician clarified this new medical care need and all her claims got paid.

Another case involves a man who has been out of work for about two years.  His COBRA had run out and he couldn’t afford medical insurance, therefore his coverage gap went over the 63 day threshold.  One month later he finally got a job with medical insurance. Three month later he found himself in emergency surgery.  Unfortunately the surgery was similar in many ways to his previous condition and anatomical location.  Fortunately, the sudden illness was a newly manifested condition; therefore his insurance cannot deny his medical claim.  With that said it does not mean they don’t try.  Several request letters were sent to the patient.  These letters are originating from a third party company and asking for his signature to give authorization to request all his medical records.  Fortunately he was referred to us at MedBillsAssist, before he had signed any authorizations.  Our first action with the client was to acknowledge the request letters, but did not authorized access to his medical record.  It is always a bad idea to permit third party company to start looking through medical documentations.  The reason is simple:  records aren’t always correct. Hospital and physician records are handled by many and the process is error prone.  It is a very good idea for patient to request medical records and review them for accuracy.   According to HIPPA regulations, a patient can request their own medical records simply by signing and dating a request to release.       Once a person satisfied that the documentation is what he/she understands to be true, then it can be forwarded to the third party for review.  If there is an error the patient has a legal right to request correction of that error.  A simple letter to the hospital or physician to modify the medical record should be sufficient.

The Patient Protection and Affordability Care Act prohibited insurers to deny claims for children, except in grandfathered individual health insurance plans, based on pre-existing condition starting last fall.  The same law will apply to adults in 2014; provided the law will not be modified.

PostHeaderIcon Health Reform – Implementation 2011

Below are some highlights in phase two of the Health Care Reform Bill.

This is the year when our tax codes are going through significant changes driven by the health care law.  Overall, health care is getting more regulated, therefore it is forcing businesses, health care providers and insurance companies to spend more money on administration.  There are a lot of plans that are studying and “advising” on how to make health care better.  Sadly, those groups and advisory bodies should have been created prior to the enactment of this law.

  • Minimum Medical Loss Ratio

Health plans, including grandfathered plans, must report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

  • Consumer Protection

Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage as well as rescinding coverage except in cases of fraud.  Annual limits are still in effect until 2014.  The provision also prohibits plans from denying children coverage based on pre-existing medical conditions.

  • Standardizing the Definition of Qualified Medical Expense

Match the definition of qualified medical expenses for HSAs, FSAs and HRAs to the definition used by the IRS itemized deduction.  Over-the-counter medicine will now only be considered as medical expense of accompanied by a doctor’s prescription.

  • Reporting Health Coverage Costs on Form W-2

Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2.

  • Creating Simple Cafeteria Plans

Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax‐free benefits to their employees.

  • Appealing Health Plan Decisions

Appoints the right to appeal medical claim and/or policy decisions made by any health plan and the right to appeal decisions made by the health plan to an outside, independent decision-maker, no matter what state a person lives in or what type of health coverage a person may have. This includes, for the first time, new self-funded plans.

Read the rest of this entry »

PostHeaderIcon Pre-authorization denied for routine medical service

It is truly amazing what patients have to go through to receive covered medical services.

One large insurance company managed to cross all lines yesterday.

A client called to ask me to look into a pre-authorization denial for medical services that has been ordered by her doctor a few days before. She told me that in the morning of her test the physician’s office called to let her know that her test was denied; therefore she doesn’t need to keep her appointment.

The medical procedure in question is common for people over 40 years old; therefore I was surprised about the denial. Naturally, I called the doctor’s office to find the reason for the rejection.  I was told that they don’t know. Seemed odd, so I took the next step and called her insurance company. As you would expect I wanted to know the reason for the denial, so we can have it corrected, and get this test approved. At first the customer service person didn’t know, so she asked me to wait on the line. It took her some time to get back on the call, and to tell me that no one knows why the test was denied. Their third party administrator (a company who is hired by the medical insurance company to manage certain tests) made this decision without giving any reason.  She suggested that I appeal the decision. Although I have no reservations on writing appeals, as I had done several hundred ever the years, I always have solid reasoning.  Sending an appeal based on nothing seems foolish, so I asked “what should I base this appeal on?”  She had no answer.

This type of insurance behavior is not only unfair to patients, but it is unlawful. State insurance law requires insurance companies to explain, in plain language, why is a service being denied. They are also required to provide information about the appeals process.

In a few days this test will be pre-approved and paid by the insurance company in question, whether they like it or not!

PostHeaderIcon Mistakes and confusions – part two

About two weeks after filing the appeal I received a call from the insurance company with an offer to attend the appeals hearing.  My response was a quick yes; I am planning to be on the conference call. One week before the scheduled call, I receive, yet another message, asking if we could change the date. We move the appeals conference call up a few days. The day of the new date, I receive another call. In this conversation, I am told, “there is no need for the hearing; the denial has been overturned and payment will be made in 30 days”. 

 30 days later we are still waiting for payment.

Naturally, I call the insurance company.  I am advised that there was an error and please excuse the delay. The insurance company is correcting this error and promise to move this, now approved medical bill, along for processing. This will take another 30-45 days.

PostHeaderIcon Mistakes and confusions…

A claim for a diagnostic imaging of a broken bone  has been submitted to an insurance company. The claim was denied by the insurance company, citing the lack of reason for medical necessity. One would think that presistenent pain should deserve proper  diagnoses and treatment .

In the world of the insurance companies that’s not always the case!

Soon after the denying the claim, an appeal had been filed. The response to the appeal should have been a simple overturn of a denial, but the response was denial of the appeal.  Following regular appeals procedure, a second level of appeal had been filed to have the claim paid.  That is when things got interesting….

The second level was denied based for the reason of “no first level of appeal on file”.  Having the first level of denial in hand, I call the insurance company to say “I have the first level of denial in my hand, where do I fax it?” To my surprise the insurance company isn’t interested on my documentation; they rely on CareCore for information and they are going with that!  They need to investigate and will give me a call back.  There isn’t a way for me for moving forward, so I wait.  A few days later I  receive a call back.  I am told that the appeal was filed as a “provider appeal”, therefore I have to re-file the first level. At this point I call the billing department of the hospital at 7 AM and to my surprise a billing supervisor picks up the phone. She verifies  that the hospital has not filed any appeal.

Just to keep things in motion I re-send all the papers to CareCore.  In return I get a call back from a confused nurse, who wants to start an approval process for a new service. No more broken bones please…

By this time, I have made a new friend at the insurance company who is telling me that “this is very frustrating”. You don’t say… Following many more phone calls, it turns out that CareCore,  and the radiology management subcontractor made couple of mistakes during the filing process.  The entire mess is elevated to management level for correcting the mistake, but unfortunately, it requires more paperwork.  After two weeks of trading phone calls, and admission of mistakes, I get to file my second level of appeal for the diagnostic image of a broken bone claim. The insurance company will evaluate the second level of appeal and they’ll let me know within 30 days. By no means the second level of appeal is a slam dunk, it still could be denied for the reason of medical necessity. In that case my new friend at the insurance company will get more calls and be even more frustrated.

Stay tuned for more…