File: Insurance Binder > Insurance Letters

Date

Attn: Claims Rep

Wausau Benefits

PO BOX 8046

Wausau WI 54402-8046

In Re: Patient Name

Member ID No. 5C

Date of Birth: 081

Dear Claims Rep:

Your request for refund on services rendered to the above referenced patient has been forwarded

to me for review. We are disputing your refund request and would like you to review this based

on the following points:

1) This patient presented for care at our office on 02/24/2004. She is an RN who complained of

ongoing, daily constant pain including burning, stiffness and aching at xxxxxxx. We contacted

your claims department and spoke to a claims rep (Name), who verified to our office that Ms.

xxxxxx had medical coverage with benefits for out patient diagnostic testing and did not require

precertification. Patient history and examination findings have already been forwarded to your

office.

2) Your letter mentions that the services rendered on March 8 and 1 1,2004 were determined to

be "not medically necessary". You are requesting a refund for benefits paid for these dates of

service in the amount of $1495.20. Our contention is that the services were medically necessary

for this patient and for the evaluation of her condition based on the presenting problems and

objective findings in our office.

3) Diagnostic Ultrasound was performed to determine specific joint levels of inflammation and

to determine the extent of inflammation. This is an accepted and more cost effective diagnostic

test for determining soft tissue problems. It is indicated in this particular case to determine soft

tissue irritation or drainage, especially due to the chronic nature of the problem. This test

determines how we will proceed with care and is a component in our treatment plan. Your

concern that it is "experimental" or "investigational" is unsupported and unfounded in a review

of published literature and I can forward peer reviewed, referenced articles if needed.

4) In addition, the electrodiagnostic testing performed on this patient was also denied and

considered "not medically necessary". We disagree with this assessment and feel that the

documentation supplied by our office supports the necessity of ordering these tests.

Electrodiagnostic testing is clinically indicated when there are neurological findings, the

presence of pain, the radiation of pain, and the potential for degeneration of sensory and motor

function. Each of these points were present in this case. Electrodiagnostic testing further allows

us to confirm our diagnosis and add, subtract or confirm our treatment plan for the plan.

In addition, our feeling is that the following court cases concluded that the insurance company is

responsible for knowing their policy limits prior to paying and therefore must bear the

responsibility for their own mistakes.

1. City of Hope National Center vs. Western Life Insurance Company, 92 Daily Journal D.A.R. 10728, Decided July 31, 1992. (In this case the hospital obtained standard assignment of benefits from the patient and submitted claims, which were paid by the carrier. The insurance company later decided the treatment was experimental and requested the money back. The California Court of Appeals stated that if it's your mistake you have to pay for it.)

2. In Federated Mutual Insurance Company vs. Good Samaritan Hospital (Neb. 1974) 214 N.W.2d 493. (The carrier contended that it mistakenly paid claims beyond the policy limits. The court held that the insurance company could not recover the money as it places an undue burden on the providers of service to subject them to r e h d liability.)

3. Lincoln Nat Life Ins vs. Brown Schools (Ct.App. Tex 1988) 757 S.W. 2d 41 1. (In this case the carrier mistakenly paid claims after its policy had expired. The court denied recovery stating "Here the insurer knew it's own policy payment provisions, but failed to notify the health care providers as to these provisions and the insurer alone made the mistake of paying beyond its responsibility . . . in the normal course of such business, the hospital has no responsibility to determine if an insurance carrier is properly tending to its business.")

4. National Ben. Administrators Vs. MMHRC (S.D. Miss. 1990). (Similar case as #3 with same conclusion.)

Lastly, we would also like to know if you have informed Ms. xxxxxxx in writing, that due to the

error on your part she may now potentially be liable for a $1,495.20 medical bill?

Our office made no misrepresentations in filing claims for your insured. We extended valuable

services based on preverification of benefits and assignment of payment by the insured. We were

not unjustly enriched, and simply had no reason to suspect that any of the payments for services

rendered were in error. Refunding the monies at this time would place an undue burden on our

office.

Thank you for your attention to this information.

Respectfully,

Clinic Administrator

Cc: Claim Appeal Unit

P.O. Box 8086

Wausau, WI 54402-8086

Cc: Patient Name

Home Address

City State Zip

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