I took an insurance company to court for not paying me and won!

Ever get upset when a insurance company nickels and dimes you or says they paid their claims but didn’t?  Ever wish there was a way to take them to court?

For one of my state’s Medicaid programs, they never paid me up to their allowed amount for cataract surgery. The patient was dual eligible and had a replacement plan as primary. Here in AZ the Medicaid plan is secondary to the replacement plan and pays the remaining balance, the difference between the Medicaid allowed amount and what the primary plan paid.

After sending in my appeals (at this point I have form letters for most situations so I only need to change the patient name, EOB, date of service and a few other details) they continued to deny my claims. So I faxed in a request for a hearing.

No billing company, or the billers for my HMO mill, would ever go to this much trouble. The balance would simply written off, and the insurance company would simply but unjustly keep the profit- so their CEO can buy a yacht for their second vacation home (read the article on this link- the true parasites of health care).

I have requested these hearings before, but usually a few weeks before the insurance company capitulates and pays me. This time they never contacted me. So the hearing was done over the telephone (no need to travel to court) and lasted a half hour. They said they paid me the remaining balance- but when I cross examined the plan representative, they were unable to give any evidence of payment: no EOB, no check number, no date of payment.

I also stated they paid me the wrong amount because they took out sequestration. That’s BS- when Medicare is the primary (in this instance it was a dual eligible replacement plan that was primary), they pay me the difference between what Medicare paid me and the Medicaid allowed amount- without taking out sequestration. I told the judge that there was no federal or state statute, or no contractual stipulation allowing them to do this. The judge agreed with me.

Several times the judge said “these are for such small amounts.”  I said every time- “yes your honor, but if the plan pays me in a accurate and timely fashion like it is contractually obligated to, we would all be doing something else right now”.

So I was awarded a total of $66- but I doubt that this plan will ever try to underpay me again. Think about it- $66 unnoticed becomes $660, $66,000 then $660,000 and finally $6.6 million if no one bothers to complain. If every doc or their office did what I did would they try to get away with these schenanigans?!?!  

Most importantly, the decision goes to AHCCCS, the state agency that administers these plans. If they don’t know that the companies are trying to pull this crap on us, who else will tell them?

$66 isn’t worth a half hour of time for most docs- so train your employee or office manager what to say at the hearing and stick around while they’re on the telephone for the hearing, if they need any help. If you’re like me who looks at this as a form of entertainment, participate in the hearing yourself.

Ironically, I filed a hearing for another plan. They sent me a letter stating they would pay me and ask me to dismiss the hearing. I told them I wouldn’t unless they settled ALL by back claims against the company; or I would request hearings for all of these claims. Just got EOB for $400 this week 🙂

When I posted this in our google group, it stirred a lot of interest. Many other folks wanted to know how to sue a underperforming insurance company. The problem is usually you have to follow what’s in your contract regarding disputes and appeals, and only after these avenues are exhausted would you take them to court. For traditional Medicare, disputed claims go under internal review and then external review and if still appealed to a federal court. It just so happens for my state’s Medicaid plans, if disputes are not settled internally, they go to an administrative law judge.

Here’s what the judge had to say:

Pretty good stuff, yes?