Denial Based on Medical Review Companies

More and more insurance companies are submitting their insured's medical bills to a medical review company to determine whether the charges are reasonable and necessary.

Unfortunately, insurance companies continue to unilaterally reduce properly submitted medical claims based on medical review company’s opinion. Some of these companies software programs do not take into account the experience of the board certified medical providers, specialties of medical providers, severity of injury and other factors in determining a reasonable fee to charge a patient.

Further, there is no assurance that the peer review done on paper is subject to any standards at all. The way some insurance companies use medical review companies vests total discretion in the medical review company. However, the medical review company often disclaims any responsibility for any decision made with regard to whether or not to deny payment of any insurance.

To succeed in a lawsuit against the insurance company for reduction or non-payment of properly submitted claims based on a medical review company's opinion is similar to that of succeeding in an improper compulsory medical examination cut-off. The medical provider should continue to submit the claims of bills to the insurance company for consideration. If the properly submitted bill or claim is reduced or not paid within the 30 days time period, a lawsuit is appropriate. Again, it is strongly recommended that a detailed office procedure be used to document when the bill was submitted, who submitted it, any telephone calls or correspondence relating to the submitted bill, and documentation of non-payment or reduction after 30 days. The medical provider should supply this information to the attorney representing it or its patient. Also, documentation to support the reasonableness of the medical provider's charges should be forwarded to the attorney.