Case Studies

A patient was struck by a car while crossing the street. He was covered by an ERISA plan. The plan denied payment of nearly $100,000.00 in claims, relying on a provision that barred payment when the injuries are caused by a “violation of the law.” The violation? The patient had a small amount of illegal drugs in his pocket, which resulted in a charge of possession. He had no drugs in his system, but the claims were denied anyway. When the matter was referred to ALO, the first thing we did was obtain the Summary Plan Description. The exclusion language was very clear: it excluded payment only when the illegal act was the cause of the injuries. Here, there was no causal connection between the injury and the illegal act. This argument was presented to the Plan, along with the promise of litigation if they continued to improperly deny the claim. The claim was paid shortly after our involvement without the need to resort to litigation.

A patient covered by an ERISA plan suffered horrendous injuries in a motorcycle accident. The ERISA plan was part of a PPO and entitled to a discount upon prompt payment. The plan had stop-loss insurance to pay claims over a hospital was able to recover this money. certain amount. The plan had stop-loss insurance to pay claims which were over a designated amount.  The hospital’s claim exceeded that amount and the plan made its partial payment and turned the matter over to its stop-loss carrier. They eventually resolved the dispute, but the resulting payment was beyond the deadline for the prompt payment discount. We sought full payment and, when the ERISA plan refused, filed suit against the Plan, the responsible stop-loss carrier and the PPO. The case was settled before trial with the hospital being paid what it was owed.

Bad debt in Hospitals and Healthcare systems continue to grow for various reasons. The timely placement of your problematic claims will allow hospitals and healthcare systems to focus on resolving claims which offer the highest and fastest value of receivables. In turn, we will work your problematic claims to recover and ensure that you are not writing off accounts that could otherwise be collected on.