Commercial/Managed Care Denials

Denials and underpayments by private, for-profit insurance companies have climbed significantly in recent years, a reality that costs hospitals and health systems substantial time, energy, and money. Pursuing recovery of wrongfully denied or underpaid claims from commercial insurers involves more than one strategy or one process. It requires the ability to adapt the basic principles of each kind of denial to the particular rules of each provider-payer relationship. At Fotheringill & Wade, LLC, we have a team of interdisciplinary specialists who focus exclusively on commercial insurance providers and know the ins and outs of each plan. Our depth of clinical, legal, technical and administrative experience enables us to identify and fix errors, draft effective appeals and ultimately hold private insurance companies to their contractual obligations.

Medical Necessity Denials

When denied claims are received by F&W, an Attorney or Senior Reimbursement Analyst will review the claims to determine the appropriate course of action. When a denied claim involves a service the insurer contends was not medically necessary, we follow a number of protocols tracked and managed by our proprietary software, Quantum Appeals. We start by requesting the patient’s medical records and assigning the case to one of our clinicians for review. Our clinical reviewers are expert investigators, combing medical records for facts and documentation that offer the greatest possibility of an overturn. As a group, they are a mix of physicians, physician assistants, and nurses — all with many years of hands-on clinical experience and extensive training in advocacy and appeals writing. Working collaboratively our attorneys and clinicians will draft arguments that demonstrate why the denied service was necessary under the relevant standards, from care guidelines to state law. We view ourselves as advocates for our hospital clients and the patients they serve, and believe most admissions and services are medically necessary. If and when we find the treatment or the level of care unjustified by the circumstances, we provide comprehensive feedback to our clients.

Technical & Administrative Denials

Billing for hospital services presents endless opportunity for insurers to allege technical errors that can prevent payment, even where there is no question the services provided were medically necessary. Was authorization obtained? Should it have been? Did authorization include the service provided? When denied claims involving technical and/or administrative issues are received by F&W, the claim will be reviewed by an Attorney or Senior Reimbursement Analyst to identify the nature of the denial and to determine the appropriate course of action. Our attorneys, reimbursement analysts and recovery specialists will work collaboratively to analyze the denied claims and draft arguments that show the requirement at issue was met or should not apply based on contractual terms and/or applicable State and Federal laws.

Coding Denials

As much as the medical necessity of a hospital visit, how that visit is translated into coding structure shapes how the hospital is reimbursed. When denied claims involving coding issues are received by F&W, the claim will be reviewed by an Attorney or Senior Reimbursement Analyst to identify the nature of the denial and to determine the appropriate course of action. For most coding denials the claim will be referred to one of clinical coders for review. The clinical coder will conduct a thorough analysis of the medical record and write a detailed appeal to defend the billed codes. Since coding denials can hide clinical issues, our attorneys and clinicians will work together to make any clinical arguments that need to be made to demonstrate that the physicians and the coders reached and reported the correct diagnoses.

Linda Fotheringill
Linda Fotheringill

 

Tracy Wade
Tracy Wade

 

Gail Robinson
Gail Robinson