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Don't Give Up on Dead Claims

Greg Freeman for HealthLeaders Media, February 3, 2012

"At that point, there are some very good arguments that their rights are waived completely and the claim just has to be paid," he says. "But 99 out of 100 providers don't realize that the lateness even matters, and instead they start trying to jump through all the hoops that the insurers want them to go through. They don't realize that they actually have leverage to get the claims paid."

If the claim response is late, you are not even obligated to provide more information when requested, Quadrino says.

Even so, don't expect the payer to respond well when you say no.

"Legally you should be able to politely refuse the request for more information and just tell them that the claim is payable. But if you do that, they're not always going to just say okay and send you the money, especi-ally if it is a large amount," Quadrino says. "Some of these requests will need to be made by your lawyer, and it would only be someone up the food chain at the insurer that would realize they have a problem and have to pay you."

Quadrino once represented a solo practitioner chiropractor who had $1.6 million in unpaid claims-all of the claims came from one insurance company because the chiropractor had treated a patient population whose members were all covered by the same plan. The insurer effectively cut the chiropractor off because it decided that he was getting too much money from that patient population, Quadrino says. The insurer delayed payment by repeatedly requesting more information and denying claims.

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