Managing medical paperwork in a medical crisis – YBA gives clients gets peace of mind and saves them money.
In the same year, Mr. and Mrs. J experienced serious and expensive medical problems. Mr. J hurt his back and his wife was diagnosed with breast cancer. Mr. J underwent intensive physical therapy for his back and his wife underwent extensive chemotherapy and radiation treatment. Neither of them possessed the time, energy or ability to determine whether the insurance company processed and paid 80 claims (over 11 providers) correctly. In a couple of months, I organized the bills, spotted costly errors, corrected the mistakes with the providers and insurance company, removed bills from collection and obtained discounts on the amounts owed. YBA corrected over $15,000 in billing errors and negotiated bills saving Mr. and Mrs. J over $2,000.
Another client, a teacher in New Jersey whose 15-year-old son was being treated for leukemia, lacked the time and expertise to resolve continual billing and payment errors made by the medical group, hospital and insurer. I was hired to manage this one area of concern while she tended to her son, family and students. All she needed to do was email or fax the bills. Over time, I corrected over $3,000 in billing errors.
Negotiation of Medical Bills – YBA saves clients thousands of dollars.
Mr. and Mrs. W have an adult daughter who suffered from a serious mental health disorder and as a result had accumulated several unpaid medical bills that went back over 3-5 years. One was a hospital bill for $17,300. Since the deadline for appealing had long passed, the only thing I could do was negotiate the amount to be paid. I asked the hospital for a copy of the itemized bill which just happened to show the amount expected from insurance had the claim been covered. I wrote the provider and asked them to settle for $5,987 (66% discount), the amount that it would have been paid had insurance covered the claim.
Mrs. P gave birth to twins acting as a gestational carrier for another couple. Her insurance company initially covered all the maternity expenses, but when it discovered that she had acted as a gestational surrogate a few months later, the insurance company reversed all the payments (whether that was proper is a separate issue), leaving unpaid bills of around $30,000. I was able to settle the claims for approximately $11,000.
YBA successfully reinstates coverage under ICHIP after it was terminated for failure to pay the premium on time.
For 20 years Ms. R, who is bipolar, has been covered under ICHIP, the Illinois insurance plan for individuals who cannot purchase coverage because of pre-existing conditions. For 20 years, ICHIP sent premium notices to her mother and for 20 years premiums were paid. However, when ICHIP did not receive a quarterly payment in 2010, it terminated coverage. Ms. R, with her mother’s help, immediately sent in the premium with her appeal stating that no premium notice was ever received. ICHIP refused to reinstate coverage, citing the plan provision: “You are responsible for paying the premium by the Renewal Date even if, for any reason, you do not receive a premium due notice. IMPORTANT: If your CHIP coverage terminates for non-payment of premium, you will have no right of reinstatement.”
Ms. R’s mother then contacted YBA for help. Initially, I was not optimistic, but when we discovered that ICHIP had mailed a late premium notice to Ms. R’s address, not to the mother’s address (the ICHIP address of record), I perked up. Changes of address must be made in writing and ICHIP could not show that the address of record had been changed. Based on this error, YBA convinced ICHIP that it improperly terminated coverage for nonpayment of premium. Note: To avoid the possibility of losing coverage again, payment of premiums is now being made by an automatic deduction from a checking account.
YBA successfully appeals denials based on “medically necessary” criterion
Insurance companies refuse to pay when they determine that the proposed treatment is “not medically necessary”, a charged term if there ever was one. Just because your doctor recommends a particular treatment as medically necessary, does not mean the insurance company will automatically pay for it. For example, if the insurance company determines that the proposed treatment is investigational or unproven for the patient’s particular condition, then it will deny the claim. Typically these involve very expensive treatments. You must enlist the help of your doctor, and maybe even a lawyer, to make the best case for coverage.
Mr. B needed a bone marrow transplant because conventional chemotherapy was no longer working. His insurer twice denied coverage under his individual plan claiming the proposed transplant was an unproven treatment for his type of cancer and therefore not “medically necessary.” Overwhelmed and devastated, Mr. B came to me to handle the last appeal hoping that he could avoid suing the insurance company. Our appeal demonstrated that the insurance company acted in bad faith because a doctor, who was not a transplant specialist, reviewed the case, ignored the medical literature showing the transplant was effective treatment, and disregarded the fact that other major insurers, including Medicare, covered transplants for Mr. B’s type of cancer. Four hours after faxing the appeal to the insurance company, the insurer called to say that it would cover Mr. B’s $300,000 transplant.
Mr. R, a 45-year-old man with a young family, was diagnosed with a terminal illness, an aggressive and rare form of cancer. He consulted with four of the top specialists in the country, all of whom concurred that a stem cell transplant was his only hope for survival. His insurance company refused to pay for the $350,000 treatment because of a lack of scientific evidence showing that the treatment would be effective to treat this rare disease. We filed an emergency appeal arguing that the denial was arbitrary and capricious because the insurance company did not properly consider Mr. R’s individual clinical circumstances. There would never be a clinical trial performed because there are not enough patients with this disease. Moreover all the doctors consulted stated that the cancer behaved very similarly to another type of cancer for which a stem cell transplant is standard of care treatment. Finally, there was one patient with the same disease who was alive and well after undergoing a stem cell transplant. With added pressure from the press, the insurance company approved and paid for the stem cell transplant.
Mr. G, a 45-year-old educator, was diagnosed with Stage IV head and neck cancer in 2009. He chose to be treated with a very aggressive, but a standard of care protocol requiring induction chemotherapy followed by five hospitalizations over a 10-week period for intensive chemo-radiation treatments. He also agreed to participate in a clinical study which administered an FDA approved drug for this kind of cancer in conjunction with the standard of care protocol. The cost of this drug would be paid by the trial, not the insurance company. The plan refused to pre-approve four of the five hospitalizations even though the treatment was identical for all five admissions. The denials were issued because the treatment was considered investigational in nature and because, they said, could have been administered in an out-patient setting. On appeal, we argued that the treatment must be administered on an in-patient basis due to the risk of complications and frequency of treatment, that the approval of one hospital stay meant the approval of the other four because the treatment was identical for all five, and the administration of the additional drug did not render the treatment investigational. The insurance company reversed the denials and paid the $170,000 in unpaid hospital bills.
YBA successfully appeals denial based on an erroneous interpretation of the plan and secures $350,000 in benefits.
Mr. W is in his forties and has lymphoma. He was covered under the State of Wisconsin’s medical plan which provides coverage to individuals who can afford insurance, but who cannot purchase private insurance because of a pre-existing condition. Mr. W was first treated with a bone marrow transplant using his own marrow, but the disease recurred after a few years. His oncologist recommended a second bone marrow transplant using a donor, but the plan denied coverage based on a plan provision stating that the plan will cover only “one transplant per organ.” We appealed arguing that bone marrow is not an organ, and therefore stem cell transplants were not subject to this plan limitation. The plan overturned the denial, acknowledging that the language was problematic even though the intent was to exclude it. Note: shortly after this appeal, the plan was amended to include bone marrow in the definition of an “organ.” No good deed goes undone.
Mrs. D sought coverage for infertility services, but the insurer refused to cover them because she used a gestational carrier to carry her baby. The plan expressly stated that infertility services were covered, and further stated that it would not pay for services rendered to a surrogate. I handled the second level appeal. Through letters from her doctors, we demonstrated that Mrs. D satisfied the definition of “infertile” under the Plan. We further showed that the plan misapplied the facts when it concluded Mrs. D was not entitled to coverage of her infertility services because she used a gestational carrier. The insurer reversed the denial. This was an easy case, but shows that an insurance company will not reverse itself without a formal appeal. It helps to have a lawyer review your plan and write the appeal.
YBA persuades HMOs to approve out-of network services.
Note: HMOs are good health plans for healthy people, but they don’t work well if you get sick and want to receive treatment from a doctor who is not in the HMO network. Here are two cases where YBA persuaded the insurance company to approve out-of-network services.
Mr. H was diagnosed with a Stage IV mouth cancer. He was covered by an HMO thinking that it was an appropriate plan for his healthy family. Although the HMO oncology team was able to treat the cancer with conventional therapy, he sought a second opinion from an oncology team at a large university teaching and research hospital. They recommended a different and more aggressive course of treatment that was could not be performed through the HMO network. The patient and his family believed that the more aggressive, more expensive ($700,000) out-of-network treatment was his best chance for a cure. Mr. H’s primary care doctor initially would not support the client’s request to be treated out-of-network so the HMO refused the request. It was imperative that treatment start immediately. On a Thursday morning I submitted an expedited appeal establishing that he could not get the desired treatment within the HMO network. On the following Monday morning the HMO reversed the denial and approved the expensive out-of-network treatment.
In another case, Mr. F, a man in his 60s, was covered under an HMO when he was diagnosed with a very rare disease. The doctors with special knowledge of this disease numbered few, but fortunately one those doctors was in the HMO network. However, because Mr. F’s disease presented in an unusual way, the HMO specialist wanted Mr. F to obtain a second opinion from a Mayo Clinic doctor to help him choose whether to treat with a stem cell transplant or conventional chemotherapy. The specialist wrote a three-page letter to the HMO explaining why the second opinion was needed, but the HMO summarily rejected the request twice without focusing on the specifics of the case. The notes of the HMO’s internal review process revealed glaring errors and deficiencies, all of which demonstrated that the HMO did not focus on the facts of the case – it just summarily denied the service. The HMO sent my appeal to an independent reviewer who agreed that no other doctor in the HMO network had the special knowledge to determine the best treatment option. The denial was overturned and the HMO paid the $7,000 second opinion at the Mayo Clinic.
YBA successfully appeals denials based on pre-existing conditions.
Insurance companies often refuse to pay medical claims due to a pre-existing condition, leaving it up to the insured to pursue coverage of the denied claim. Here is a sampling of some of the cases I have handled.
Ms. M, a woman approaching age 50, underwent a hysterectomy. She was covered under an individual policy which contained a rider excluding all treatment related to uterine fibroids, a condition in existence when she purchased the policy. The insurance company refused to cover $20,000 of $30,000 treatment claiming that the hysterectomy was performed to treat uterine fibroids. To appeal, I obtained the hospital admission and discharge report, doctors’ notes and reports which revealed that the hysterectomy was performed to treat possible ovarian cancer, not fibroids. The insurance company reversed itself and $20,000 in claims.
Mrs. S is in her 40s and went to the emergency room in 2009 complaining of leg pain. She was diagnosed with deep leg thrombosis which required CT scans. The CT scan revealed the presence of ovarian cancer requiring an immediate hysterectomy. The insurance company refused to pay the $32,000 hospital bill claiming that the hysterectomy was performed for a pre-existing condition, a ridiculous assertion. Yet, the insurance company would not budge without the submission of a formal appeal. Mrs. S had to order her medical records which revealed prior infertility treatment, but no prior medical history of ovarian cancer (had she had prior treatment, she would have already underwent a hysterectomy!) I drafted the appeal, complete with a letter from her doctor stating that the hysterectomy was not for a pre-existing condition. The insurance company paid the claim immediately. It is unfortunate that insurance companies wrongfully deny coverage of services and shift the burden to the patient to fight for their entitled benefits.
Mr. F, a 30-year-old man went to the emergency room, thinking he had dislocated his shoulder. He was treated and released and went back a few days later complaining of headache and dizziness. He was diagnosed with a seizure disorder. He was covered under an individual plan. The insurance company refused to pay for the $6,000 emergency room treatment claiming that the headache and dizziness was related to a pre-existing condition. The patient’s medical records revealed that he had been treated in the emergency room 18 months earlier for a possible concussion after getting into a skirmish in a bar on New Year’s Eve. The insurance company noted that both emergency room treatments showed a diagnosis code for a headache. YBA appealed and demanded that the insurance company show how the concussion headache was the same headache resulting in the seizure disorder. The insurance company paid the claim.
YBA secures thousands of dollars of physical and occupational therapy benefits for stroke victim
Mr. W is a doctor who suffered a serious stroke in 2008, leaving most of his right side, especially his hand, impaired. He underwent intensive rehabilitative therapy with very good success. However, in early 2009, the insurance company decided unilaterally to cut off all further occupational and physical therapy, essentially concluding that his progress was good enough. In the appeal, we showed that the insurance company failed to take into account Mr. W’s specific condition and ignored the medical records showing he continued to make strides toward restoring his pre-stroke function. We also challenged the decision because the insurance company acknowledged that Mr. W would benefit from additional therapy and had the cognitive ability to improve performance of activities of daily living. The insurance company reversed and reimbursed Mr. W for the $15,000 he paid out of his pocket for continued therapy.
YBA corrects Medicare’s mistake in processing claims for disabled Medicare beneficiary as secondary instead of primary.
Mrs. M started receiving Social Security disability benefits in 1999. From 2001 until 2010 Medicare properly paid her claims as primary, and her employer paid as the secondary insurer. After her husband retired in late 2009, Medicare notified Mrs. M that husband’s employer medical plan, under which she was a dependent, was the primary insurer, not Medicare. Medicare, however, got it wrong because the husband’s plan was a retiree medical plan, not a plan for active employees; therefore, under the Medicare coordination of benefit rules Medicare was in fact primary. Mrs. M had no idea how to correct this error. She was relieved when she handed the problem over to someone who understood Medicare’s intricate coordination of benefit rules and knew exactly what information Medicare needed to fix their error.
YBA has counseled several clients on Medicare as they transition from employment to retirement.
Retirement can be challenge especially for individuals who have been with the same employer for most of their working life. One of the big questions is when should I retire? What if I am over 65, but my spouse is under age 65? How does my employer’s retiree medical plan benefits work? Should I take COBRA or Medicare? What Medicare supplement should I choose? How much will my Medicare and Medicare supplement plan cost and what does it cover? Which Medicare prescription drug plan should I pick? YBA has assisted several clients who are on the brink of retirement and want help navigating this small part of this life changing event.
Medicare versus COBRA – YBA convinced Medicare to adjust Part B effective date retroactively and pay $65,000 in claims.
Mr. R was over age 65 and Mrs. R was under age 65. The husband properly enrolled in Medicare Part B during his “initial enrollment period” when he turned age 65. He then dropped his Part B coverage when his wife got a job with health benefits for both of them with the understanding from Medicare that he could re-enroll without delay or penalty when coverage ended under his wife’s plan. (called the “special enrollment” period).
The wife was laid off a year later. She immediately elected COBRA for both of them with the intention of dropping COBRA for her husband once his Medicare Part B coverage became effective again. The couple was shocked when Social Security told him he couldn’t re-enroll until Medicare’s next “general enrollment” period, which was nine months away, because he voluntarily dropped his Part B coverage after age 65.
Shortly thereafter, the husband was diagnosed with a serious medical condition and incurred $65,000 in claims. The COBRA plan paid these claims as if it were the primary insurer until it realized that the husband was Medicare-eligible all along. The COBRA reversed the payments on all of the husband’s claims for a nine-month period. The employer maintained that Medicare should have covered him immediately after his wife lost her job. Medicare maintained that he had to wait nine months to enroll.
Confounded and stressed, the wife asked me to convince the employer that it was wrong to undo coverage, but I was pretty certain that Medicare was wrong. I submitted a written request for reconsideration based on error, citing the Social Security manual and other sources which established her husband’s right to re-enroll in Medicare’s special enrollment period without a coverage gap or penalty. With gentle, but unrelenting prodding, I succeeded in getting Social Security to acknowledge the error and have Medicare pay the claims.
YBA successfully reinstates skilled nursing benefits under Medicare Advantage Plan.
A very frustrated daughter whose mother suffered a serious stroke in December 2009 contacted me because her mom’s coverage under a Medicare Advantage (MA) Plan (a non-government for-profit plan providing benefits to Medicare beneficiaries), cut off coverage for ongoing skilled nursing facility benefits. Her mom had a tracheotomy and a feeding tube, her speech was poor, largely due to the trach, but she was progressing, very slowly, with physical therapy to regain strength. The daughter wanted advice about switching her mom back into traditional Medicare because she believed that under traditional Medicare her mom’s skilled nursing benefits would have continued. While this was true, we determined that from a financial perspective that it was not a good idea to switch until 2011.
The focus, therefore, turned to pursuing coverage under the MA plan. It was unclear to me exactly why the MA Plan cut off coverage – perhaps it didn’t receive the right medical documentation or made a determination that she would not improve. The mother’s doctor was aloof and the nursing home administrators did not make it clear to the family that they could have filed an emergency appeal when the insurance company sent her home. The daughter was at wit’s end – she had already spent hours spinning her wheels trying to get her mom back in the skilled nursing facility while continuing to care for her mother at the same time.
The first and most time consuming hurdle was to find a person at the insurance company who actually understood the situation and had authority to make a decision. The daughter and I were passed from one customer service person to another, each of whom told us we could file an appeal which would be decided in 60 days! When we asked for a copy of the mother’s file, no one knew how to get it. In the meantime, I contacted the mother’s new doctor and in-home therapy providers to build a case for on-going skilled nursing facility benefits. FINALLY, we found the person at the insurance company who understood our story and agreed to reconsider whether the cut off of benefits was proper within 72 hours.
I worked with the doctor, skilled nursing facility and in-home caregiver company to demonstrate that the mother needed skilled care to be weaned off the tracheotomy safely, and to get the skilled speech and physical therapy needed to restore as much of her pre-stroke function as possible. The insurance company overturned the decision and the mother was able to go back to the skilled nursing facility for the care she was entitled to under the plan even though she had already been out for three weeks.
YBA successfully restores benefits, accusing the insurance company of acting in bad faith when it cut off benefits for vague reasons and in contradiction to the insurance company’s own findings.
Mrs. B purchased her long-term care policy in 1992, paying premiums for 18 years before accessing benefits in 2008 after she had undergone neurosurgery, chemotherapy and radiation for treatment of lymphoma. She also suffers from severe osteoarthritis, osteoporosis and severe scoliosis. The insurance company initially approved benefits, but as Mrs. B got stronger after her completion of cancer treatment, the insurance company began to scale back the number of hours of reimbursed care to the point of saying that no further benefits would be paid after a certain date. In the letter notifying Mrs. B that her coverage would end in a couple of months, the insurance company stated she did not meet the “criteria” and that “the documentation indicates that you are not receiving eligible services under the policy.”
What criteria? What documentation? What provision of the plan supported the denial? The only issue was whether Mrs. B was unable to perform two or more “activities of daily living” independently. If yes, then she was entitled to benefits. YBA compared the two most recent insurance company assessments—one done just before it approved on-going benefits and the assessment done just before its decision to cut-off coverage. The assessments showed that Mrs. B remained just as unable bathe and dress herself on her own than when the insurance company approved ongoing benefits!
YBA also argued that the insurance company was impermissibly avoiding its obligation to pay benefits because Mrs. B’s family members frequently stepped into the shoes of the approved in-home health care provider and helped Mrs. B bathe and dress. However, no provision in the policy excused the insurance company from paying benefits to an approved caregiver under an established plan of care when a claimant could not perform two or more activities of daily living. In fact, the family was saving the insurance company money when it didn’t use the approved in-home health care provider. The insurance company changed its mind and began paying benefits again.
YBA convinces insurer to pay $50,000 in retroactive home health care benefits and ongoing benefits for a non-approved provider
Mrs. M purchased her long-term care (LTC) policy in the mid-1990s before the onset of her Alzheimer’s disease. She designated her cousin, Mr. C, to act on her behalf under a power of attorney. Unaware of the existence of her LTC policy, Mr. C contracted with a reputable company of geriatric case managers and caregivers for in-home care. The company, although accredited, was not “licensed” as a home health care provider.
Mr. C discovered the existence of the LTC policy in 2007 and promptly applied for benefits. The insurer issued a perfunctory denial stating that benefits were not payable because the provider was not licensed as required by the LTC contract. Mr. C contacted me for help. I appealed arguing that 1. Mrs. M had every expectation that the LTC contract would cover in-home benefits, 2. benefits were payable under an alternative provision of the LTC contract, and 3. to change caregivers or move Mrs. M to a nursing home just to avail herself of LTC benefits would be detrimental to her health and would violate Mr. B’s fiduciary duties. The insurance company overturned the denial and paid retroactive and prospective home health care provisions of the policy notwithstanding the licensing requirement.
YBA successfully appeals the cut off of home health benefits; insured is paid $13,000 in back benefits.
Mrs. H, an 84-year-old woman, paid premiums for years under a long term care policy. Suffering from a myriad of medical conditions including osteoarthritis, neuropathy from diabetes, vertigo and a heart disorder, she applied for benefits because she needed assistance in her home. The insurance company paid the claims from 2007 until April of 2009 when it unilaterally cut off benefits claiming that she was now able to perform most of her activities of daily living without assistance. Given that her condition had worsened over the years, Mrs. H. wrote the insurance company to fight this decision, but was unable to make any progress on her own for six months. Before submitting a formal appeal, I requested a copy of Mrs. H’s insurance file because I wanted to see how they concluded that she was eligible in 2007 but not in 2009. Upon receipt of my letter, the insurance company immediately contacted me and said that they had made a mistake in not responding to Mrs. H initially. It paid $13,000 in back benefits and even paid my fees.
YBA successfully challenges an improper cut off of benefits.
Ms. R, an account manager and sales representative, went on medical leave in 2007 due to debilitating depression. She was initially approved for short-term disability benefits, but the insurance company cut off them off exactly when her FMLA leave ended and with the intent of avoiding paying long-term disability benefits down the road. The insurance company said that the paperwork submitted by her doctors failed to show that she could not perform the essential functions of her job as an account manager. On appeal, I showed that the insurance company’s review was sloppy and incomplete. I also submitted additional documentation from her therapist and psychiatrist in a form that clearly showed that she was fully disabled from performing her job. The insurance company restored her short-term benefits and later approved long-term benefits without requiring Ms. R to file a new application. I also referred Ms. R to a Social Security disability lawyer who successfully obtained government benefits after two initial denials.
YBA steps in to protect disability benefits and helps secures favorable settlement.
Mr. S, age 57, had purchased a very generous individual disability policy in the 1990s that would pay him $5,700 per month until age 65 (essentially $500,000 in benefits) if he became fully disabled from his job as a telecommunications consultant. He was diagnosed with rheumatoid arthritis in 2005 and it became increasingly difficult for him to do his job. He applied for Social Security Disability benefits and was approved immediately. He also applied for benefits in 2009 under his individual policy. The insurance company paid the benefits under a “reservation of rights” which means the insurance company was not sure that he met the definition of a disabled person under the policy, but paid the benefits while continuing its assessment of the case. Mr. S retained me when it became clear to him that the insurance company was posturing towards a denial. The insurance company claimed that he retired from his “occupation” before he became disabled, and that in any event his disability was not severe enough to prevent him from working. I reviewed the policy and application and realized that Mr. S had made some strategic errors in applying for benefits, including that his failure to apply for partial disability two years earlier. As the matter progressed, I referred Mr. S to a seasoned disability litigator to determine the merits of taking the case to court. Together, we settled the claim through mediation where the client avoided the time and expense of litigation with an acceptable lump sum settlement.
YBA secures $102,000 for beneficiary of person not covered under the Plan
In an unusual case, YBA provided the professional expertise necessary to secure $102,000, the value of the life insurance benefit for the beneficiary of an employee who should have been covered, but was not. Mrs. M worked for a company for over 20 years and had $102,000 worth of life insurance coverage under her employer’s group plan. Shortly before Mrs. M was ready to retire, she was diagnosed with cancer and took a medical leave. While she was an inactive employee, the company switched life insurance companies and continued to pay premiums for Mrs. M even though she was not actively at work on the date the new policy took effect. The old policy provided no benefits and the new life insurance policy contained standard language providing that only active employees are covered, and did not include any provision covering inactive employees like Mrs. M who never came back to work because of disability. Mrs. M died and the insurance company refused to pay benefits. Because the Company intended to cover Mrs. M, YBA was worked with her employer’s lawyers and liability carrier to get the benefit paid.
YBA restores coverage due to an improper cancellation
In another case, the life insurance company cancelled the policy of an insured for non-payment of premiums. YBA intervened and discovered that the policy notices had been sent to the wrong address. The insured paid the premium it would have paid had she received timely notice and the policy was restored as if it had never lapsed.