A FL Managed Care Claims Lawyer in Delray Beach at Eric H. Luckman, P.A. has represented many clients who are dealing with wrongful healthcare claim denials from their HMO. In most instances, the words used in these denial letters include statements like: coverage not provided in policy, not authorized, not medically necessary, or experimental.
Unfortunately, many people assume that there is nothing that can be done about this claim denial, and then have to take funds out of their own pocket when they really shouldn’t be the one paying for it. Or, they don’t have the money to continue getting the care they require. Rest assured, that our team sees these denials and intentional delays in approval for what they are, and can be strategic in fixing these wrongs.
What HMOs Do
A Health Maintenance Organization (or “HMO”) is a type of health care plan that has become very popular in the U.S. in the last 25 years. Our law firm can decipher the policy language with these plans. The primary reason why HMO’s have become popular is cost. HMO coverage is typically cheaper to buy than traditional health insurance coverage. Like many things in life, however, cheaper isn’t usually better.
In exchange for a less costly premium, an HMO subscriber gives up some of the decisions regarding their care and treatment to the HMO. For example, in many HMOs the primary care physician – and not the patient – decides whether a visit to a specialist is needed. Without pre-approval from the primary care physician, the HMO will refuse to pay for the cost of care obtained from a specialist.
In the past, many HMOs provided financial incentives to primary care physicians to limit patients’ access to medical specialists. We cannot emphasize enough the importance of speaking with a Delray Beach Managed Care Claims Lawyer if this has happened to you.
How HMOs Cut Costs
Many HMO plans also exclude coverage for the cost of treatment received by a patient outside of the “network.” A “network” is a group of medical providers who have agreed to accept certain terms of treatment and reimbursement specified by the HMO. These medical providers are often referred to as “participating providers.” Under these HMO plans, if you receive treatment from a medical provider (not “in-network”), then the HMO can deny payment for the services received from that provider.
Another way HMOs cut costs, to the detriment of the patient, is to claim that the treatment for care sought is not “medically necessary.” Often the individual making this determination for the HMO has never even seen the patient. In one case that we were involved in, the medical director of the HMO who made the decision to deny care was not even licensed to practice medicine in Florida.
If an HMO denies care to a subscriber, or fails to honor a claim in full, Florida law allows the subscriber to recover attorney’s fees if a lawsuit is successfully brought against the HMO. Thus, even if the amount in dispute is rather modest, a lawyer who is successful in helping a subscriber can recover their fee from the HMO for the time spent assisting the subscriber.
Claim Disputes Can Be Confusing
Insurance disputes, like insurance policies, can be complicated and difficult for most people to understand. An experienced Delray Beach, FL Lawyer for Managed Care Claims can help you determine whether you have a valid claim. Please feel free to call me to discuss your case. The initial consultation is free, and you will speak directly with me, Eric Luckman, about your claim and your rights.
Eric Luckman is a Florida Board Certified Civil Trial lawyer. Less than 2% of lawyers in the state of Florida are recognized with this prestigious certification. Board certification recognizes attorneys’ special knowledge, skills and proficiency in various areas of law and professionalism and ethics in practice.
How Patients Suffer From Claim Denials
Unfortunately, HMOs are often for-profit driven and may make decisions based on not what is best for the patient, but what will save the company money instead. When health insurance claims are denied, this may mean that the patient suffers a prolonged illness, pain, or even death. If your loved one passed away because of a healthcare claim denial, then we urge you to meet with us right away about how you can take action in the honor of your family member.
A Managed Care Claims Lawyer in Delray Beach understands that sometimes the outcome of a claim may mean life or death for some patients. We don’t take this lightly. We can aggressively fight for your behalf and will do whatever is within our legal power to see that you get what you need in regards to your health. We know how to challenge claim denials by using state consumer protection and insurance laws. We are well-versed in legal issues that surround healthcare claims.
The 3 Claim Outcomes
When a person files a healthcare insurance claim, there are three outcomes that the HMO has to choose from. They may decide to pay the claim, deny the claim, or cancel the policy. If the policy is rescinded, the coverage that the patient may have had for many, many years has suddenly become null and void. If this happened to you or a loved one, please contact us immediately so a Florida Managed Care Claims Lawyer at Eric H. Luckman, P.A. can begin working on your claim.
It isn’t unlike insurance companies to deny claims for concealed reasons. Sometimes, the denial could have been due to a simple mistake, oversight, or unintentional error when completing your application. So, we may ask to see the claim you originally submitted too just in case.
If you are dealing with a healthcare claim denial, we can evaluate your circumstances in hopes of creating a strategy to fight the denial. Feel free to call our office to discuss your case. The initial consultation is free, and you will speak directly with Eric Luckman, about your claim and your rights. For help, you can contact a Managed Care Claims Lawyer in Delray Beach, Florida at Eric H. Luckman, P.A. as soon as possible for prompt legal intervention.
Do Some Insurance Companies Issue Insurance Claim Denials More Often than Others?
There is nothing quite like receiving a notice that your insurance company is denying a legitimate claim. Whether a policyholder submits a claim because they had emergency surgery or were involved in a car accident, experienced property damage due to an Act of God or lost a loved one, that policyholder trusts that their legitimate claims will be honored according to the terms of their policy. Unfortunately, insurance companies do not always behave with integrity when trying to protect their bottom line. Certainly, legitimate insurance claims are sometimes denied due to human or machine-related error. Mistakes are always going to happen in the insurance business and many are easily rectified. However, it certainly seems as though some insurers either “make mistakes” in denying legitimate claims too often for anyone’s comfort or intentionally deny legitimate claims in the hopes that few policyholders will push back against their unacceptable claims-related approaches.
Some insurance companies are indeed “repeat offenders” when it comes to denying legitimate claims either in bad faith or due to internal processes that lead to unacceptable claims-related error rates. If you have recently had a claim denied by your insurance provider and you believe that your claim should have been covered by your policy, please connect with an experienced managed care claims lawyer in Delray Beach, Florida today. You may have the right to have your claim paid in-full and the right to receive damages for the harm the insurance company has caused you.
Identifying Insurance Companies at High Risk for Behaving in Bad Faith
It is not always easy to predict which insurance companies may deny legitimate claims at one point or another. However, government reporting, journalists, academic institutions and nonprofit organizations have made it increasingly easy to identify which companies are habitual offenders when it comes to denying legitimate insurance claims. An experienced Delray Beach, FL managed care claims lawyer will likely be able to tell you whether or not your insurer fits into this category of offenders, simply because professionals who handle bad faith cases tend to deal regularly with these offending insurance companies. However, you can also do some research on your own to see whether your recent insurance claim denial was likely a mistake or just another in a long line of legitimate claim denials. It is worth noting that an experienced Delray Beach, FL managed care claims lawyer can help you with your situation no matter what your research reveals. But it can be helpful to know what you are likely dealing with before you meet with your insurance claims denials lawyer for the first time. If you are interested in doing some research on your own, you may want to start by looking up the report published by the American Association for Justice (AAJ) in regard to the worst insurance companies for denying policyholder claims.
Legal Guidance Is Available
Whether your claim was denied due to error or bad faith, a Delray Beach, FL managed care claims lawyer from The Law Offices of Eric H. Luckman, P.A. can help you to obtain the compensation you are entitled to. If your claim was denied and it seems like your policy should have covered your costs, you do have legal options available to you. Sometimes, a call from an experienced attorney is all it takes to get an insurer to fix a mistake and sometimes it takes more effort than that. Either way, you have every right to pursue the coverage you paid for in good faith.