Recently, a South African family suffered the death of a beloved uncle. He died at the young age of 46.  The uncle, Sifiso Justice Mhlongo, had not much by way of material wealth to leave his family. But among his meager property, he possessed a burial expense policy worth $2,190 underwritten by the largest insurance company in South Africa – Old Mutual. 

For nine days after his death his nieces sought to recover on the policy so they could bury him properly according to his family’s traditions.  But Old Mutual stalled and rebuffed their repeated attempts to have Old Mutual honor their claim. No amount of supporting documentation proved sufficient to Old Mutual’s claims adjusters that Mr. Mhlongo was, in fact, dead.

As a result, Mr. Mhlongo’s nieces Ntombenhle Mhlongo and Thandara Mitshali resorted to an exceedingly creative solution. They went to the mortuary, grabbed the body bag containing their uncle’s remains, and drove to the local Old Mutual branch office where they then proceeded to provide Old Mutual with incontrovertible proof of their uncle’s demise. Old Mutual suddenly changed its claim denial decision by paying that claim, conditioned only upon the nieces removing the body bag from their branch office. 

Perhaps most Americans would find such insurer misbehavior galling but unlikely to occur in this country.  But as attorneys representing medical providers in payment disputes with health plans, SAC knows all too well that health plans here in America routinely use what can only be referred to as ridiculous excuses to stall and deny paying legitimate claims for medical services rendered to patients.  In fact, it might appear to some that health plans and insurers the world over subscribe to the tactic of “deny first and only pay grudgingly later (if at all)” as a means to pad their bottom line at the expense of others.

The Journal of the American Medical Association (“JAMA”) published a statistical analysis in 2018 regarding emergency room (“ER”) claims submitted to Anthem for the period from 2011 to 2015.  Anthem had initiated a practice of wholesale denial of ER claims it characterized as “inappropriate” – meaning the patient should have sought treatment in a less costly environment (such as at a primary care physician’s office) rather than an expensive ER.  The tool by which Anthem made such denials was a diagnostic-based algorithm (necessarily retrospective in nature) as opposed to a symptoms-based algorithm which far betters the actual decision-making process a patient faces in real time. 

In other words, Anthem engaged in the worst form of Monday morning quarterbacking – a policy which essentially informed the patient that “you better guess correctly if you believe you need to go to the emergency room because if you don’t really need emergency services, Anthem will stick you with the whole ER bill.”  JAMA’s researchers concluded that Anthem’s “heads-I-win-tails-you-lose” claim denial strategy paid off for Anthem by artificially suppressing otherwise valid ER visits such as those where a patient experienced “chest pain.” 

Here at SAC, we see these denials daily. There are even those cases where the payor denies valid claims after requested documentation to validate the claim was submitted. It appears the relevant paperwork just ‘disappears’ during the claims process until the payor is sued and then it reappears during the discovery process. Fortunately, SAC is able to cut through health plan payment denials and shenanigans.  Our firm has recovered well over a billion dollars on behalf of medical providers across the United States by employing creative solutions and aggressive litigation strategies to deter this type of conduct by payors. This is why hospitals retain our law firm when their revenue cycle team has run into a health plan brick wall.

This year we celebrate 30 successful years of reversing health plan payment denials. We are happy that our work helps to ensure that healthcare providers can continue to provide much needed health care without the need to pass that cost on to the patients