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How Lawyers Defend Against Healthcare Claim Denials & Audits

How Lawyers Defend Against Healthcare Claim Denials & Audits

Dealing with insurance claim denials and audits can be extremely frustrating. As a patient, you did everything right—you saw an in-network provider, made sure the treatment was preauthorized, and felt confident that your claim would be covered. So when you get that denial letter in the mail, it can feel like a punch in the gut.

Luckily, there are options. Hiring an experienced healthcare lawyer to appeal the decision on your behalf is often the best way to get the outcome you deserve. But how exactly do they do it? Let’s break down the most common strategies lawyers use to fight back against unfair claim denials and audits.

Thoroughly Reviewing the Denial Letter

The first thing your attorney will do is carefully analyze the denial letter from your insurance company. These letters are notorious for being vague, but there are always clues about the specific reason for the denial. Common reasons include:

  • The service wasn’t medically necessary
  • It was experimental/investigational
  • It was not preauthorized
  • An in-network provider wasn’t used
  • There was lack of clinical information to support the claim

Understanding the exact basis for the denial is crucial, because it allows your lawyer to target the appeal arguments effectively. They’ll also look for any internal inconsistencies or ambiguities in the insurer’s reasoning that can be used to challenge the decision.

Analyzing the Plan Documents

In tandem with the denial letter, your attorney will also carefully review your plan documents – things like the summary plan description, benefits handbook, and clinical guidelines. These materials outline what services should be covered and the criteria for medical necessity. If the denial contradicts the terms of the plan or established processes weren’t followed, that’s useful ammunition for an appeal.

Gathering Supporting Medical Records

Your lawyer will reach out to your healthcare providers to collect medical records, doctors’ notes, lab results, and any other documentation related to your treatment. The goal is to paint a complete picture showing that the services were appropriate and necessary. This evidence is key to refuting some common denial reasons like “lack of medical necessity.”

Obtaining Independent Medical Reviews

In some cases, your attorney may seek an independent medical review from an outside expert. These reviews assess the medical evidence and provide an objective opinion on whether treatment was necessary and appropriate. Independent analyses like this can carry a lot of weight in the appeal process and make denials more difficult for the insurance company to defend.

Checking Provider Contracts

If a claim was denied because an out-of-network provider was used, your lawyer will review the provider’s contract with the insurer. There may be clauses that still require coverage in certain situations – for example, if an in-network provider was unavailable. Any contractual nuances like this can be used to challenge the denial.

Identifying Coverage Mandates

Your attorney will determine whether any state or federal laws apply that require coverage in your situation. Some common examples include mandates for certain types of cancer treatment, mental health services, or emergency care. If a legal coverage mandate exists, denials can often be overturned quickly.

Crafting a Persuasive Appeal Letter

With all the supporting facts and evidence in hand, your lawyer will draft a formal letter appealing the denial. This letter will methodically walk through the reasoning behind the denial and explain point-by-point why it was improper. Things like highlighting inconsistencies, citing relevant plan documents/laws, and including excerpts from medical records help build a rock-solid case.

Negotiating with the Insurance Company

Before filing a formal appeal, your attorney may first attempt to negotiate a resolution with the insurer. Having a lawyer involved shows the company you mean business and may make them more likely to overturn the denial without further dispute. Negotiated settlements can save significant time and expense compared to prolonged appeals.

Filing Internal Plan Appeals

If negotiation fails, your lawyer will start the formal appeals process outlined in your plan’s documents. There are usually two levels of internal appeal within the insurer before an external review option becomes available. Strong appeal letters combined with your attorney’s persistence result in many denials being overturned at the internal appeal stage.

Pursuing External Review

If the internal appeals are unsuccessful, your case can proceed to external review by an independent organization. The reviewer will look at all the facts and make a binding coverage determination. Having a quality appeal built by a legal expert enhances your chances in external review. And if even that fails, filing a lawsuit is still an option.

Knowing When to Take “No” for an Answer

As much as it pains them to do so, ethical attorneys also know when to advise a client to accept a denial and move on. If appeals are unsuccessful and the prospects of winning a lawsuit are slim, they will have an honest conversation about the best path forward to avoid wasting time and money.

While it can be intimidating to stand up to large insurance companies, appealing denials is your right. And having a knowledgeable lawyer on your side levels the playing field. Don’t take “no” for an answer until you’ve explored every option.

References

Here are some references used in this article:

Appealing Health Insurance Decisions | healthcare.gov

How to Appeal a Health Insurance Denial | Nolo

Appealing a Health Insurance Denial | Lawyers.com

Appealing a Health Insurance Claim Denial

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