Case Summaries

Wrongfully Delay Due to Pre-Existing Condition Review


The third party administrator (TPA) was pending a claim for information from the patient and medical records from various providers in order to complete a pre-existing condition review. I reviewed the medical records and discovered that the patient was treated for an abscess of the lung caused by a fungal infection, coccidioidomycosis.  I researched the epidemiology of the particular fungus infecting the patient, coccidioides immitis and found that coccidioides immitis occurs in arid and semi arid areas.  I further found that this condition had an incubation period of one to four weeks but could develop insidiously and that the symptoms resemble to common cold and influenza.  I reviewed the patient’s medical records in connection with the information gathered about the patient’s condition and his policy information.  I found that there was no indication that the patient was treated within his policy’s look back period and due to the nature of coccidioidomycosis it was likely that the patient did not even know he had this condition until just prior to his admission. Therefore, I submitted a demand for payment to the TPA arguing that the patient’s condition could not be considered pre-existing in nature.  The TPA initially rejected the demand.  However, while preparing to submit an additional demand letter, I found that the TPA was not licensed as a third party administrator in Oklahoma (the patient’s work place and domicile), Missouri (the patient’s previous work place) or Georgia (the employer’s state of incorporation).  With this information I was able to place pressure on the TPA and force them to pay the claim.

Contractual Under Payment


FCCI, the patient’s workers compensation carrier, paid $15,330.54 on this claim asserting that the payment was made in accordance with the hospital’s contract with First Health. I obtained the hospital’s contract with First Health.  I reviewed the First Health contract and determined that there was a provision for payment of workers compensation claims.  The contract provided that workers compensation claims would be paid at the Florida Workers Compensation Fee Schedule Rate with an additional seven percent discount.  In this case, I determined that the claim should have paid $63,670.19.  I then reviewed the contract’s attachments and determined that FCCI was entitled to the First Health contractual discount.  I then submitted a demand for payment to First Health and FCCI.  First Health agreed with my reading of the contract and they advised FCCI to process the claim for additional payment.  FCCI issued a check for an additional payment of $45,138.62.  I reviewed the payment amount and determined that the claim was still under paid.  I obtained the pricing sheet from First Health and submitted it to FCCI with a demand for payment of the remaining balance, $3,200.00.  FCCI processed the claim to pay the additional $3,200.00. 


Within about two weeks, I obtained the hospital’s contract; determined that the contract contained a provision for payment of workers compensation claims; verified that the payer was entitled to access the contractual discount; submitted a written demand for payment; followed up with several telephone conferences demanding payment; obtained payment on the bulk of the balance due; determined that the amount paid continued to be below the contractual payment; submitted a demand for payment of the balance, and collected on the additional amount owed.

Misverification of Benefits


Allmerica denied the claim because the patient, a newborn, was not added to the insured’s policy and because the insured’s policy terminated in the middle of her in-patient admission.  I submitted a demand letter restating that the patient, as a newborn, was automatically added to the insurance policy at birth under Colorado law.  See, Colo. Rev. Stat. sec. 10-16-104(c)(I).  I further argued that Allmerica was, in fact, liable for this entire in-patient admission under Colorado law.  See, Colo. Rev. Stat. sec. 10-16-705 (4) (c).  Allmerica responded that they were the third party administrators for a self-funded plan sponsored by Tesco Drilling Industry, Inc. (Tesco), and that Tesco denied liability.  I determined that because the patient was covered by self-funded plan these claims were likely exempt from most state laws regulating insurers.  However, Allmerica and Tesco were subject to state laws concerning negligent misrepresentation.  I reviewed the hospital collector notes and verification of benefits forms.  I found that Allmerica verified prior that the patient had coverage prior to admission.  Therefore, I submitted a misverification of benefits appeal arguing that hospital relied to their detriment on incorrect information provided by Allmerica and should be compensated for services rendered.  I collected $238,549.27 from Allmerica.  I also collected $147,786.56 from the patient’s secondary insurance company, CIGNA HealthCare.