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Law Educator. Health practitioner in Oklahoma and out of…

Hello Law Educator. Health practitioner in...
Hello Law Educator.
Health practitioner in Oklahoma and out of network with Health Insurance Company ABC. Recently I have been sending claims for a few patients to ABC and in every instance they have requested medical documentation. Now in the past when I was in network with ABC this was not the case.There is a pattern with ABC of automatically requesting patient records for each claim sent, which ABC has a full right to in order to process a claim, but I would like to send a letter to ABC to confirm they are not breaking any rules/statutes, being biased, or prejudice to out of network practitioners and process the claims in a timely matter as they normally would with "In Network Providers or Participating Providers".
When ABC does not process the claim and asks for records, this creates 1. Delay in payment 2. Gives ABC an opportunity to dispute the claim by hiring and Independent Medical Examiner, ie. IME, in my field. 3. Creates additional unnecessary overhead costs with staff, retrieval, copying and delivery of these records that ABC may not normally require for Participating Providers.
Do you have any links to Oklahoma or Federal statutes that are enforceable in court to persuade ABC to not discriminate against "Out of Network Claims"?
Please also send any case law, ie successful cases against Health Insurers in Oklahoma for delay and denial tactics of paying claims for me to cite.What type of letter would be sent?
Please add any type of terminology in bringing awareness of potential practice of "Bad Faith" and "Erisa Act" of ABC Health Insurance.Thanks.
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Answered in 53 minutes by:
4/2/2018
Law Educator, Esq.
Category: Consumer Protection Law
Satisfied Customers: 126,000
Experience: Attorney experienced in commercial litigation.
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Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.

Actually, there is no law saying that it is unlawful discrimination to demand more paperwork from out of network providers. So, they can create the additional paperwork for out of network providers. What they are trying to do is bring you back in for network provider.

There is no state or federal law governing this part though, it is all based on what the provider wants. So, if they want additional paperwork from out of networks because they do not have the same contract with out of network as they do with in network, they can indeed require it and there is no law saying they cannot.

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Customer reply replied 3 months ago
I see your point.
How would the patient pursue any potential denial of the ABC healthcare claims, specifically as mentioned/advertised in the attached screenshots of a law firm advertising to represent patients who pay premiums yet get their claims denied.
Please list any links in Oklahoma that may be helpful if the above does occur particularly to Erisa Act. , Statutes, or Ok rules and regulations of Health insurance companies.
Thanks.

Thank you for your reply.

The doctor has to give them enough information to get the claim processed. This would not be part of ERISA or the healthcare act, because the insurer can demand the proper information. So I agree with you that it is inconvenient and I would have given you the statutes and links if they would exist, but they do not exist to provide you. If you give the proper documentation and claims are denied, then they have the insurance appeals process to pursue.

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Customer reply replied 3 months ago
As previously listed in previous thread......" How would the patient pursue any potential denial... "
Think you may have misunderstood. This is in the future. I am going into this with the worse case scenario.
Please send any links on how to combat the worse case scenario. ie as it would relate to Erisa Act or Oklahoma Statutes and Regulations.
Thanks.

Thank you for your reply.

They can file a complaint with the OK Insurance Department if the insurer improperly is denying their claims. See: https://www.ok.gov/oid/Consumers/Consumer_Assistance/Claims_Process.html

Also see: https://www.healthcare.gov/appeal-insurance-company-decision/appeals/

That is the appeals process for denied health claims.

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Customer reply replied 3 months ago
The other item in the thread was the occur particularly to ie as it would relate to " Erisa Act or Oklahoma Statutes and Regulations."How can the policy holder utilize the Erisa act to enforce an acceptable claim against the health insurance company? Also are you saying there are no "Oklahoma Statutes nor Oklahoma Rules" that help a policy holder pursue an insurance company for denying an otherwise acceptable claim which falls in line within standards set by Medicare and Healthcare.gov. Department of Health and Human Services (HHS) ?

Thank you for your reply.

The party cannot use ERISA to enforce the claims. Claims are based on the terms of the contract in insurance cases. So any failure to pay an insurance claim that should be covered is under BREACH OF CONTRACT. It is not under ERISA or any other statute, it is breach of contract and if the claim is maliciously denied when the insurer knows it should be covered, then it could be bad faith breach of contract that allows the client to get attorney's fees as part of their damages.

Law Educator, Esq.
Category: Consumer Protection Law
Satisfied Customers: 126,000
Experience: Attorney experienced in commercial litigation.
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