Typical Denials and Underpayments
Insurance companies are constantly coming up with new ways to deny or underpay bills. The most common reasons that we have seen to date are as follows:
Often insurance company denials occur when there is a billing error. Even if the error is the fault of medical provider, we can still re-submit or supplement the documentation, and the carrier is required to pay. Insurance companies can be aggressive, using denials as a negotiating tactic or will defame the medical provider to its patients. Insurance carriers have accused providers of fraud, alleged unlicensed medical care and improper billing. In most cases however, the carrier is simply trying to avoid paying legitimate bills.
Insurance carriers often attempt to reduce the payment by a small amount, assuming most medical providers will not bother to file suit. This is precisely why the legislature awards prevailing party attorney’s fees. Multiply a few dollars times thousands, or tens of thousands, of claims, and the carriers are taking advantage of the system.
- Exhaustion of Benefits
One of the most common reasons why a carrier will deny a claim is exhaustion of benefits. In other words, once the carrier pays the full $10,000 in benefits to providers making claims, they close the book on all subsequent claims. However, you may still have a valid claim. The PIP statute contains a hierarchy of who should be paid and in what order, with many exceptions - and exceptions to the exceptions. PIP carriers are required to provide us a payout log upon request. This will often tell us if your bill was misapplied and we can demand payment.
- Fee Schedules
The Florida statute permits insurance carriers, in certain cases, to use fee schedules to pay medical bills. However, there are strict rules as to when a carrier may use a schedule and when they may not use one. If a carrier does not follow the rules precisely, they are responsible to pay the legitimate amount owed.
- Misapplication of the deductible
Most PIP policies contain a $250, $500, or $1,000 deductible. Some carriers chose to apply the deductible in a way to minimize their obligation to pay legitimate bills. These cases often require skilled attorneys with knowledge of appellate law. Lubell Rosen takes all of the risk, and if we prevail, the doctor’s bills are paid and we get our fees.
- Misrepresentations when taking out the policy
Certain insurance carriers deny claims on the basis that there were misrepresentations on the policy application. These are usually fact driven cases and the results vary from case to case. It is is a typical practice of nonstandard auto insurance carriers who sell policies to low income families. The carriers collect millions of premium dollars from these families and then accuse them of misrepresentation when it comes time to pay a claim. Lubell Rosen is not afraid to take these cases to a jury trial for resolution. If we lose, you owe us nothing. But if the jury rules in our favor, your bill and our fees get paid by the insurance carrier.