Overturned denial for jaw surgery

A school-aged child needed medically necessary jaw surgery which Blue Shield of California had denied. We worked with the client to file an appeal and then submitted a request for Independent Medical Review which resulted in the insurance denial being overturned and the child received surgery as a covered benefit under the plan.

Overturned denial for Skilled Nursing Facility stay

Health Net denied extended Skilled Nursing Facility coverage for a client who had undergone brain surgery. We wrote appeals and a request for Independent Medical Review which resulted in the insurance denial being overturned. The client had been presented with a bill for $125,000 from Beachwood Post-Acute and Rehab for which we successfully obtained insurance coverage.

Obtained policy reinstatement and coverage for surgery

Anthem Blue Cross terminated a client’s policy the last month prior to Anthem Blue Cross withdrawing from the market which resulted in a lapse of coverage precisely when the client had surgery. One year after the policy lapse and surgery, the client suddenly received a provider bill in the amount of $45,000 which Anthem Blue Cross had denied due to policy lapse. We wrote an appeal for reinstatement and successfully obtained coverage for the surgery.

Full reimbursement under a Long-Term Care policy

A client requested a policy review of her Long-Term Care coverage. We identified an error in benefit calculation which resulted in underpayment of the claims. We successfully obtained an additional $80,000 payable to the client.

HIPAA Access Complaint

We filed a HIPAA Access complaint on behalf of a client in order to obtain medical records which had been withheld from the client. Through the assistance of the Office for Civil Rights (OCR) which has HIPAA enforcement authority, we successfully obtained medical records.