Medical Insurance Claims Attorney

Fighting for a favorable decision on a medical claim can be very difficult, and sometimes healthcare consumers need the services of a medical insurance claims attorney. Knowing when to call an attorney in the appeals process and how to choose the best attorney is critical to getting medical claims paid.

Medical insurance claims are denied for a variety of reasons. Some claim denials are valid, such as ones for services the member's plan truly does not cover. For example, if a claim is for dental care and the medical insurance plan does not include dental services, the insurance company could be justified in denying the member's claim. Other reasons for claim denials are not as clear, such as a determination that a certain service is “not medically necessary,” or that a specific treatment is “experimental” and therefore not covered. An attorney can help to more strongly encourage the insurance company to cover the services that are outlined in a member's plan, and also help defend a consumer's rights to fair and adequate coverage.

Most health consumers do not involve an attorney as soon as they receive a notice of denial from their insurance company. The first step is to send the insurance company a written notice of appeal. For some claims, this may be enough to reverse the claim denial if accompanied by adequate medical documentation. However, many cases go through a second or third appeal, and even then, the insurance company may refuse to pay. At this point, the consumer has a few options. One option is to give up and pay the health claim, which many people do, but giving in is not always necessary. Another option is to go to the insurance commission for the state involved. In some states, consumers can file complaints against insurance companies online, but complaints to the state's insurance commission may take a very long time to be resolved. The last option is to consult a medical insurance claims attorney.

Choose an attorney only after careful research and consideration. An attorney needs to have extensive experience with fighting insurance claims denials, both in the courtroom and during the insurance company's internal appeals process. Some attorneys further specialize in specific types of illnesses, such as chronic illness or cancer, and choosing an attorney with this level of specialization can ensure he or she is familiar with the medical information involved in the case. A law firm that has medical professionals available to review and contribute knowledge to cases is even better.

Consumers should not choose an attorney randomly from the phone book. A personal referral from a family member or friend who has used the lawyer's services is the best recommendation, but since that type of referral isn't always available, another good option is to interview a few different lawyers. Many insurance attorneys offer free consultations, either on the phone or in person. Free consultations can be a great opportunity to find out what fees the attorney will charge, how the firm will keep you informed about your case's progress, and the attorney's specific qualifications for medical claim denial cases. It's important to be prepared for a consultation in order to get the most helpful information.

For an initial consultation with an attorney, consumers need to gather information about the case into an organized package. Include written notices from the insurance company, records of any phone contact with the insurance company, letters sent by the consumer or his or her doctor to the insurance company, and any medical records that are relevant to the case. The attorney may request that you fax or mail these documents prior to the initial consultation, but do not send anything to a law firm without asking first, as the attorney may charge for reviewing documents. Always send copies and save your originals.

During the consultation, the attorney will probably express an opinion on the legal merits of the case and give the consumer some idea of how the case would be handled. The consumer needs to evaluate how well he or she is able to communicate with the attorney and if he or she addresses all questions and concerns adequately. It's important to compare the attorney's fees with other attorneys in the area, and to approach how and when fees will be paid.

It is the attorney's job to help consumers get their medical claims paid. Consumers should be able to trust that the attorney will give sound legal advice and make good decisions in their case. Hiring an attorney should only be done after carefully checking qualifications and, if possible, interviewing more than one attorney. Consumers should provide attorneys with all information and documentation relating to a case, and look for an attorney who sees the client as a human being rather than a check. The best insurance attorneys have a passion for advocating for consumer rights, and do their very best to make sure cases are resolved fairly.

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