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Don't Give Up on Dead Claims

Greg Freeman for HealthLeaders Media, February 3, 2012

"He had something like a thousand appeals, and soon he had sold his house and was almost out of business," Quadrino says. "I showed that on all of these claims he didn't need to provide more information and he didn't even have to appeal."

Quadrino demonstrated how the insurer had violated multiple rules regarding claim denial, such as missing deadlines or failing to provide a scientific reason for saying there was no medical necessity. The attorneys for the insurer realized Quadrino was right and worried that a decision by the judge could affect class action lawsuits pending against the insurer, so they decided to settle the case for "an enormous amount of money," Quadrino says.

Many providers are reluctant to hire an attorney to fight for denied claims because they fear that insurers will find a way to punish them in the long run, says Quadrino.

"The insurers can act like bullies with their denials, but the way to fight a bully isn't just to take it. If you stand up and punch them in the nose they'll leave you alone," he says. "And if they do get vindictive, they're just digging their own graves. That's what physicians fear, but you really see the opposite. They're afraid to bully you again."

As part of the chiropractor's settlement, the insurer wanted the physician to join the network. He said no, and then the insurer negotiated how it would pay for services in the future.

"That's leverage. We negotiated how the insurer would pay for various procedures and actually put the CPT codes in the settlement agreement," Quadrino says. "Doctors have a lot more clout and a lot more power than they realize."

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