Insurance Denial - What to do

Jonathan D'Agostino: And with the pairing for that denial. Dr. Bonnie Glassman: We do that also, we have them fill out a review form, we actually have them time their exam in a state whether they were robed, disrobed or not, what the doctor did because I use it later on to fight for those bills to make sure -- Jonathan D'Agostino: I don't think anybody fights as how as you do for those bills. I mean you have a program that you put together. Dr. Bonnie Glassman: Yes. Jonathan D'Agostino: So what's that about? Dr. Bonnie Glassman: Yes. It's an arbitration program; we make sure that all of our injured patients get the care that they really deserve. What we are finding is that these insurance companies are setting these patients up for these exams in two weeks, three weeks, four weeks; you can't heal a cut on your hand in two to three weeks. And these people have these extensive injuries and then as soon as the insurance company finds out about it, they send them to their doctors, they cut them off, they tell them they are fine. So we make sure that the patient continues to treat as long as it is necessary. We do any diagnostic test that we need to do, objectively demonstrate that the patient really was injured and collect the paperwork and then later on we continue to treat and we don't take any money from the patient and when the care is finished and -- Jonathan D'Agostino: They reach maximum improvement. Dr. Bonnie Glassman: Exactly and we take -- we file for arbitration. Arbitration is a forum which instead of going to the court systems, the court systems are so backlog that it would take two to three years to resolve it in court. So we file with the American Arbitration Association and we bring these big insurance companies to this forum which is in lieu of the court system that we fight those bills. Jonathan D'Agostino: You have already treated the patient and now you are going to get paid? Dr. Bonnie Glassman: Continue to treat them after they have been cut off from their insurance company. Jonathan D'Agostino: What percentage of those arbitrations you would say you win? Dr. Bonnie Glassman: Well, we settle about 50-60% of them for about 75-80% which that in itself says those Insurance companies return the money on and we lose some money. But for the sake of the patient and for my business, that's what we do. And then the rest of them we ends up going to an arbitration. Jonathan D'Agostino: So if I am an insurance company, why not try to curb treatment as early as I can and maybe down the road, I will beat an arbitration or may be I will be paying $0.50 on a $1 to resolve the claim and to win-win. And it is amazing because if you look at the language of the no-fall statue, the insurance company is required to pay for any treatment that is deemed medically necessary, reasonable and is related to the accident. Okay, so that's the really, that three part test where they -- it's very hard for them to say that an injury is not related to the accident if right after the accident you are complaining of neck pain, or back pain or shoulder pain and now you are treating for that. They are going to lose every time. Of course there are always exceptions if you have an extensive history, whatever. But in general, they are going to lose there. The question is what's reasonable and what's medically necessary, right? Well, as long as you are submitting your bills in accordance with the fee schedule, they can argue that it's not reasonable. Medically necessaries is there out, that is what I see. Now and that leads us to these peer reviews and in the more serious injury cases where I have a client with a tear let's say in a knee or a shoulder and needs surgery and now you have an insurance company taking that bill and submitting the records with the bill along to one of their doctors to not examine the client but to review the file and they will pay that doctor probably $500 an hour yes and may be save themselves thousands. Dr. Bonnie Glassman: That is my biggest rife with the system is that they spend millions of dollars not to pay for healthcare. Give it to the providers who want to take care of their patients, give it to the patients who really need the care but we know ultimately that they want to prevent the patient from meeting threshold. Jonathan D'Agostino: I mean that's the inherent problem in this system. The two parts they know for, the first part, you get these benefits. The second part, you have got to reach this burden of proving that your injury is serious. Why you are not entitled to be compensated from some other insurance company for your pain and suffering? So generally across the board, the accident victim is really getting screwed, I mean basically to put it as bluntly as I can. And as the attorney for many of these accident victims, it's very harsh for me to explain to them that it is their own insurance company in many cases because do you know folks coming the car they are in, which very often is their own car and their own insurance company is, even though these people who have paid their premiums, have never had an accident before, been with this company for 20 years, now will be on hold. They need the treatment and the insurance company is trying to deny them. But it used to be that we had 90 days to submit an application for our clients. Dr. Bonnie Glassman: Right! Jonathan D'Agostino: They cut that down to 30 days. You used to have 6 months to submit your bills? Dr. Bonnie Glassman: Yes. Jonathan D'Agostino: Now it's down to 45 days. Dr. Bonnie Glassman: Yes. Yeah. Jonathan D'Agostino: Yeah 45 days. Dr. Bonnie Glassman: 45 days, yeah.