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  1. WHAT DOCUMENTS MUST I PROVIDE FOR YOU TO APPEAL THE CLAIM?
  2. DO I HAVE ANY OUT OF POCKET EXPENSES?
  3. HOW IS THE MONEY DISBURSED IF THE CLAIM IS PAID?
  4. DO I HAVE COSTS IF THERE IS NO RECOVERY ON THE CLAIM?
  5. HOW DO YOU APPEAL CLAIMS DIFFERENTLY THAN MY OFFICE COULD?
  6. WHAT IS THE TIME FRAME FOR THIS PROCESS?

Q: WHAT DOCUMENTS MUST I PROVIDE FOR YOU TO APPEAL THE CLAIM?

A: The documents we require to appeal an unpaid procedure code are:

  1. A copy of the HCFA claim form
  2. A copy of the explanation of benefits (EOB) for the denied claim
  3. A copy of the operative report or progress note regarding the denied service
  4. A complete copy of the doctor's signed contract with the insurance company

We refer to items 1-3 as a "claim packet". You may have several claim packets for a single insurance company.

Q: DO I HAVE ANY OUT OF POCKET EXPENSES?

A: No. The agreement you sign with us is a contingency fee agreement. There are no up-front costs to the client in a contingency relationship. We pay all costs, up to and including arbitration. "Costs" can include but are not limited to: postage, copying, computer research fees, arbitration filing fees, experts' and consultants' fees, etc. More details on the cost breakdown can be found in our fee agreement that you must read before we agree to represent you.

If you recover money from the insurance company, we receive a portion of that recovery. If we go to arbitration on your behalf and you do not recover, you do not have to pay anything. We only get paid if you do.

Q: HOW IS THE MONEY DISBURSED IF THE CLAIM IS PAID?

A: Generally, the fee agreement between the client and our office states that after case costs are deducted from the payment, we receive a portion of the client's payment from the insurance company. If the insurance company pays you directly, you are responsible for paying us our portion. If the insurance company pays our office, we send a check to you for your portion.

"Case costs" can include but are not limited to: postage, copying, computer research fees, arbitration filing fees, experts' and consultants' fees, etc. More details on the cost breakdown can be found in our fee agreement that you must read before we agree to represent you.

Q: DO I HAVE COSTS IF THERE IS NO RECOVERY ON THE CLAIM?

A: No. If there is no recovery on a claim you are not responsible for paying us for our time or for any costs we advanced in pursuit of the claim payment.

We are interested in the insurance companies paying doctors for procedures they rightfully perform- not making the doctors suffer a double loss of the denied claim in addition to legal expenses.

Q: HOW DO YOU APPEAL CLAIMS DIFFERENTLY THAN MY OFFICE COULD?

A: The Law Office of David D. Mullens has a single focus: to help doctors fight the unfair denials of insurance claim payments. We are dedicated to helping you get paid, and the volume of the claims makes our task worthwhile. We do not help other clients with other legal matters.

To accomplish our goal, we expend great effort in researching a particular denied code and crafting legally sound appeal letters. We use medical research along with state and federal law and regulations, judicial case law, CPS coding definitions, CPS Assistant Guidelines, documents issued by governing medical organizations, Medicare rules, legal treatises, legal analysis, and other sources.

Q: WHAT IS THE TIME FRAME FOR THIS PROCESS?

A: Time is of the essence when it comes to appealing claims. The first step is for you to contact our office to determine that we can help you, and then establish the attorney-client relationship by both signing a fee agreement. This should take only about a week and depends largely upon your time. During this period, you should be compiling the EOBs, claim forms, and chart notes for the denied claims, as well as copies of the insurance contracts. Once we have the fee agreements signed and claim packets in hand, we get to work.

The process for writing an appeal based on a new code denial can take anywhere from 2-6 weeks. In that time, we send a letter to the insurance companies indicating our intent to file an appeal so that the time limit for the filing does not expire.

Once the insurance companies receive the appeal letters, it can take anywhere from a few days to a few months for you to get paid. Although all insurance companies must respond within a reasonable time, some insurance companies have statutory limits on how long they can review a claim without penalty.

If the insurance company overturns the denial, you may get paid within about 4-6 weeks from submitting your claim packets to us. If they decide to uphold the denial, we will exhaust the insurance company's internal appeals process before filing for arbitration. This process can take several months.



Legal Representation for Healthcare Providers
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