Health insurance coverage usually provides people with a feeling of security that in the event of an emergency you will be able to seek the necessary treatment and not accumulate large medical bills. As such, when reviewing health insurance benefits provided by a Health Management Organization (HMO), most people would not consider the possibility of denied payments or interference with their medical treatment which could have negative outcomes. So it must come as a surprise to discover that many HMOs are doing just that and are actually working against your best interests. It’s time to look at the fine print.
There are several ways HMOs are denying coverage.
- Some of the simplest denials are the result of mistakes such as incorrect coding or typos and can be reversed quite easily if caught in time.
- Other claims are denied due to treatment that is received out of network or treatment that is considered experimental. These claims may require additional efforts, including your doctor writing a letter of explanation and in support of your claim being paid.
- Strict and/or not clearly defined notice requirements that often go unfulfilled may cause a claim to be denied.
- Many HMOs use third party companies to review and make determinations on their insureds’ claims. These third party companies can have different, undisclosed requirements of their own, or arbitrary rules which allow them to deny the claims.
Now that we have taken a look at some of the more common denials, it is important to remember that HMOs are looking for any way to cut costs and by denying coverage or delaying payments they are able to do just that. Although these denials may seem absurd and not likely to be upheld, let’s look at a couple extreme examples of denied coverage to see the extent these HMOs will go to in order to save some money.
- Monroe Bird III: A 21 year old man, who became paralyzed from the neck down after being shot at by a security guard, was denied coverage by his HMO and later died due to the lack of appropriate medical care. His HMO based the denial on their determination that his injuries resulted from “illegal activity.” However, Mr. Bird was never convicted of any crimes or even charged and the details of the events leading up to the shooting are not exactly known. And yet, the insurance company upheld their decision to deny his claim based on his involvement in illegal, later changed to “hazardous,” activity leading up to his injury.
- Robert Mendoza: A gentleman who was diagnosed with a rare and likely fatal form of prostate cancer underwent a life-saving procedure at the recommendation of his doctor. Robert’s HMO denied coverage for the procedure and he was stuck with a $30,000 bill. The HMO claimed that the procedure was not “medically necessary,” with little more explanation.
Ok, so your claim has been denied, now what? Insurance companies have an obligation to provide a denial within a certain time frame which is likely defined in a member handbook. These denials often come in the form of an Explanation of Benefits (EOB) which will have a description of what was or was not paid. However, an initial denial does not have to be the final answer. Once an EOB is received, action should be taken right away to ensure timely review of your appeal.
You will need to first request an internal appeal with the insurance company. Be sure to inquire about the specific requirements as it may need to be requested in writing or separate forms may need to be completed. Once your insurance company receives the request, they must review the claim and provide a determination explaining whether they are upholding or reversing their decision.
If they are upholding their decision, the next step is to request an external appeal in which a third party company reviews the claim and makes a determination. The decision rendered by this third party becomes final and must be honored by the insurance company.
Still Denied and Need Help?
If your HMO has denied payment for medical treatment or in any way prevented you from receiving necessary medical care you must act immediately. Remember that many HMOs have a limited time frame in which you can file an appeal. At the Dolman Law Group, our team of experienced attorneys and staff are familiar with these situations and want to help stop HMOs from making their insureds suffer while they profit. If you would like to learn more about your legal rights, please contact the Dolman Law Group. Call today: 727-451-6900.
Dolman Law Group
800 North Belcher Road
Clearwater, FL 33765