Health Care Program Disputes

The growth of managed care in recent years has added high levels of complexity to the business of caring for patients. Health insurance plans now often take an active role in evaluating treatment options and access to specialized personnel and services. The same insurance programs also sometimes refuse to pay medical providers after services are rendered.

When doctors, hospitals, and other healthcare providers have difficulty obtaining payment or reimbursement for services rendered, they turn to the experienced attorneys of Davis Levin Livingston. With significant experience in litigating health care program disputes, our team is dedicated to ensuring a favorable resolution for medical providers.

Consumer Disputes

  • Disagreements between consumers and health insurers also have become more common as a provision of health care has grown increasingly complex in recent years. Disputes can occur for a number of reasons, including:
  • Denial of coverage for medical services that have been rendered.
  • Denial of authorization to see a specialist.
  • Denial of authorization for a hospital stay or medical procedure.
  • Erroneous charges for health care services.
  • Cancelation of health insurance without prior notice.
  • Failure to continue a policy when an insured individual has a change in employment.

Disputes surrounding health care plans can include a variety of different parties, such as individual consumers, medical providers, employers and insurers. Because disputes have become increasingly common, both consumers and medical providers should understand their rights and options for resolving a disagreement with a health care program or entity.

Role of the Affordable Care Act

Passage of the Affordable Care Act in 2010 added new complexity to health care program dispute law. Significant changes from the massive insurance reform measure included:

  • Requiring insurers to include certain benefits, including birth control, as part of health care programs.
  • Prohibiting denial of health care services based on existing conditions.
  • Requiring certain employers to provide health insurance to workers.
  • Allowing children to remain on parents’ health care plans until age 26.

Initiating Health Care Program Disputes

Understanding exactly what a health plan covers and does not cover is important before initiating a formal dispute. Working with an attorney experienced in health care program disputes, consumers, and medical providers can determine whether a complaint is valid and likely to result in adequate compensation. Before initiating litigation, parties can attempt to resolve a dispute using the following procedures:

  • Speaking with customer service. An entity’s agents may be authorized to reverse incorrect charges or approve medical services that were denied originally. If an agent is unable to help, request a supervisor. In some cases, an agent may request additional documentation or ask that original documents be resubmitted.
  • Obtaining a notice of denial. In an instance of denial of coverage or a refused authorization of services, the complaining party should request a letter giving formal notice of the decision and details about the entity’s decision.
  • Requesting an internal review. When the complaining party is unable to resolve the situation through customer service, the entity’s internal review or appeal procedure is the next step. A formal request should be made that the entity reverse its decision about payment or services to be provided. Health insurance entities and programs must have rules and procedures in place for handling customer appeals, which may be referred to as consumer complaints or grievances. The entity’s “evidence of coverage” document should provide details on initiating an internal review and any applicable deadlines. The entity must respond to an appeal in the time period specified in the evidence of coverage document.
  • Seeking arbitration. In some cases, health plan entities include voluntary or involuntary arbitration clauses in their agreements. In arbitration, the complaining party submits the details of the dispute to a neutral arbiter, who considers both sides and renders a decision.
  • Seeking an external review. In most states, consumers may appeal a health plan entity’s decision through an external review program following an unsuccessful internal review. Availability of an external review may be determined by the specific type of health plan.
  • Filing a complaint with the state department of insurance. Aggrieved parties also can file complaints with their state’s department of insurance regarding an action by a health plan entity.

Work with Attorneys Experienced in Health Care

In some cases, resolving a health care program dispute may require litigation in the civil courts. Winning a case involves the presentation of complex evidence and may require the testimony of expert witnesses. Davis Levin Livingston has extensive experience in resolving health care program disputes in a favorable manner for our clients. For more information, please contact Davis Levin Livingston at (866) 806-4349.