by Gustavo Matheus | Jun 13, 2022 | Insurance Coverage Disputes
On April 27, 2022, the Office of the Inspector General for the U.S. Department of Health and Human Services (“OIG”) released a report finding that Medicare Advantage Organizations (“MAOs”) are issuing unnecessary denials resulting in delayed care for patients and...
by Gustavo Matheus | May 6, 2020 | Appeals and Denials, COVID-19 Updates, Healthcare Appeals, Healthcare Reimbursement, Managed Care Reimbursement
Healthcare Providers Must Insist HMOs Accept Electronic Filings An appeal recently filed with a health maintenance organizations (HMO) on behalf of a hospital was rejected because medical records were provided on a CD-ROM rather than on paper. That case involved 3,647...
by Gustavo Matheus | Aug 1, 2019 | Appeals and Denials, Denied Claim Appeals, Denied Claims Litigation, Healthcare Appeals, Healthcare Reimbursement, Hospital Reimbursement, Managed Care - General, Managed Care Reimbursement, Payer Reimbursement, Provider Denials
Utilization management requirements often run counter to the medical standard of care When representing providers, I have noticed an unfortunate trend in recent years. Utilization management (UM) is encroaching upon the profession of medicine. With utilization...
by Gustavo Matheus | Jul 2, 2018 | Healthcare Appeals, Healthcare Reimbursement, Insurance Coverage Disputes
When Healthcare Services that are not Medically Necessary can be Reimbursed. Providers that know this one exception to the rule are less likely to leave money on the table. A mainstay of managed care is that coverage applies only to medically necessary services....
by Gustavo Matheus | May 24, 2018 | Healthcare Appeals, Insurance Coverage Disputes
How healthcare providers can avoid getting tripped up by the medical necessity requirement. The world of medical claims is littered with booby traps that can catch providers off guard. Our law practice has found that healthcare service providers often get tripped up...
