At Stotler Hayes, we know that securing payment from private insurance can be an uphill battle – full of red tape, unforeseen barriers, and multiple appeals. Our clients have sought our assistance to tackle these issues, including erroneously denied claims, delays in processing and payment, and pursuing claims the insurance company deems untimely or uncovered. The most important thing to remember with private insurance is to read and follow your contract—especially the prior authorization requirements and the claim submission deadlines.
Private insurance will almost always require a prior authorization for skilled or long-term care. We often see denials due to lack of pre-authorization. Be on the lookout for of any pre-existing condition clauses, as well, and make sure the resident’s diagnosis does not fall into that category. Many protections for pre-existing conditions provided by the Affordable Care Act have been eliminated in the past few years and, consequently, excluded by certain policies. Stotler Hayes recently handled such a case where a provider received prior authorization indicating the resident’s treatment was medically necessary, but the claim was denied due to a pre-existing condition clause.
Always get confirmation of your claim submission through a fax confirmation, email read receipt, or electronic proof of submission, and retain these confirmations where they can be easily located. We often see claims that linger unpaid and the provider will subsequently resubmit the claim only to have it denied as untimely. Without proof of the initial timely submission it can be difficult to recover on these claims. If proof of timely submission can be provided, the insurance company must process and pay the claim as the contract requires.
Many states also have prompt payment laws requiring the insurance company to pay interest on delayed payments.
If you are experiencing delays in payment or claim denials by private insurance companies, please reach out to any of our SHG attorneys for assistance.
SHG Attorney Peggy Ferraro earned her Juris Doctorate from Cleveland Marshall College of Law– Cleveland State University with a Certificate in Healthcare law. She graduated summa cum laude and was awarded Health Law student of the Year. She earned her Bachelor’s degree from Kent State University with a major in Social Work. Peggy is licensed to practice law in Ohio & Pennsylvania and is a lifetime resident of Northeast, Ohio.
