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Reduced and Denied Health Insurance Claims

Insurance Company Tactics Rob Doctors And Patients Of Millions 

Last year, New York State Attorney General Andrew Cuomo shook up the health care industry with his investigation of Ingenix and United Healthcare for "usual, customary and reasonable" reductions on out-of network reimbursements.  The results of the New York AG probe were shocking: health care billing database vendor Ingenix, a subsidiary of United Health Group, was accused of a conflict of interest and rigging its database to reduce medical reimbursements on out-of-network services based on artificially low UCR rates derived from bad data.  Based on the report, hundreds of insurers used the Ingenix database to reduce claims.  


Medical Providers and Consumers Are Owed Millions from UCR Reductions, Silent PPOs and Other Denials and Underpayments

Consumers and medical providers may be entitled to millions of dollars in reimbursements from the hundreds of insurers who used Ingenix to reduce medical expense claims.  However, the Ingenix problem is just the tip of a big iceberg.  Insurance companies have an entire arsenal of cost containment tactics designed to reduce your bills:  Silent PPOs, Prompt-Pay violations, UCR reductions, improper contract interpretation, retroactive denials, outdated fee schedules, and other forms of managed care contract abuse.  It is so prevalent that we gave it a name - Managed Care Contract Abuse.  

In the wake of the Ingenix scandal, health care providers across the country are now taking a much closer look at how these unfair denials and reductions have damaged their businesses and hurt their bottom lines.

How Can Health Care Providers Recover Money Lost To Wrongful Denial and Reduction Practices? 

Seemingly small insurance company cost containment reductions add up to hundreds, if not millions, of dollars in the aggregate.  A UCR or Silent PPO scheme can and will hurt a medical provider's bottom line. Many health care businesses have pinpointed the scams with the help of their billing managers and medical auditing and denial management firms and have requested payment from the insurance companies only to be ignored, blown-off, or provided a low-ball settlement.  Sound familiar? 

Phillips & Garcia is one of very few law firms that concentrate their practice on healthcare revenue recovery litigation against insurance companies. Almost ten years before Attorney General Cuomo exposed Ingenix, we were representing medical providers in class action lawsuits involving UCR reductions and Silent PPOs. Pioneers of medical bill reimbursement litigation, we have handled a variety of cases dealing with healthcare insurance denials and reductions and related instances in which insurers breach the terms of their contracts in order to underpay medical providers. 

While other law firms struggle to learn about these relatively new concepts, we have a decade of frontline experience fighting these practices and winning multi-million dollar class action settlements in court.  From years of taking depositions and going to Court in insurance cases, we understand the terminology as well as the insurance tactics used.


Contact Us Today To Discuss How You Have Been Affected By Reduced Reimbursement and Managed Care Contract Abuse


Many of the medical provider billing managers, CFOs, medical auditing firms, and medical provider lawyers that we speak to have already identified and pinpointed the illegal reductions and wrongful discounts taken by insurers - they simply don't handle the complex federal and state court litigation needed to make the insurance companies pay what medical provider's are owed. That is where we like to step in.  

We do not handle all health care reimbursement cases, but instead focus on a select number of big cases primarily where a particular reduction scheme has caused a medical provider big losses.  We are not a collection firm, and do not handle small claims.  We prefer cases where your medical auditing company or lawyer has identified the problem, estimated your potential losses and already demanded payment without success.  We work as part of a team with your lawyer and medical auditing or denial management firm to get results.  

If you would like to discuss your reduced or denied claim for reimbursement, please call us toll-free at (877) 892-5620 or by filling out the electronic contact form located on the right hand side of this page.

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Blog for Reduced and Denied Health Insurance Claims

• UCR Rate Problems: Health Insurers Covering Up Their Mistakes
• Silent PPOs in CA Workers Comp?
• Mega Life and Health $17M Settlement with MA AG
• Mega Life and Health Fined $20 Million for Market Conduct Issues
• Will the Silent PPO Model Law Help Medical Providers?
• All Types of Medical Providers Fall Victim To Ingenix UCR Rate Reductions

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Web Resources for Reduced and Denied Health Insurance Claims:

• Law Offices of Brian S. King

  Description:

  Brian KIng is a lawyer based in Utah who frequently discusses ERISA issues in his blog and handles denied disability, life and health insurance claims.

• U.S. Senate Committee on Commerce, Science and Transportation, Report of UCR Investigation

  Description:

  After hearings in March of 2009, the U.S. Senate Committee investigating the UCR rate practices of the insurance industry issued its report on June 24, 2009 entitled, "Underpayments to Consumers by the Health Insurance Industry."  The report discusses the "usual and customary" rates in the health care industry, Ingenix's close ties with the health care industry and the challenges to the reliability of the Ingenix databases.

• NAIC Hearing on UCR Practices

  Description:

  On September 24, 2009, the National Association of Insurance Commissioners held a public hearing on UCR practices within the insurance industry.  The report from the hearing describes the presentations made at the hearing which primarily discuss how UCR practices are applied to out-of-network claims and the impact that UCR reductions have on consumers.

• PPO Check,

  Description:

  PPO Check provides retrospective auditing and consulting services to hospital and other healthcare clients to identify and recover non-compliant managed care discounts, contractual underpayments, unreasonable U&C reductions and various other forms of underpayments. 

• American Hospital Association

  Description: The article "Provider's Beware: Guarding Against Silent PPOs Reselling Contract Rate Discounts Through 'Silent' or Non-Directed PPOs and Discounted Indemnity Plans" highlights the concerns about Silent PPO discounts and recommends that medical providers scrutinize their PPO contracts and their dealings with payers.

• Healthcare Financial Management Association

  Description: The HFMA is the nation's leading membership organizaton for healthcare financial management executives and leaders.  The HFMA website and magazine are good sources for valuable information on Silent PPO practices and underpayments.

• Medical Economics Magazine, The Secret World of Silent PPOs

  Description: Medical Economics Magazine highlights the discount practices of Silent PPOs and quotes Phillips & Garcia on the Silent PPO danger signs to watch for when reviewing EOBs and EORs.

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