Healthcare Law

Healthcare Law

At no time in history has healthcare become important to so many individuals. This includes: understanding such things as the benefits being purchased, the basis for denial of claims and/or benefits, the appeal process in the event of denial and whether a particular procedure, medication or treatment is covered.

Healthcare Litigation involves administrative procedures as well as state and federal court actions. This includes: issues involving breach of contract and bad faith and, if self-insured, ERISA claims. Each of the categories discussed below has a significant effect on coverage. Ms. Maw has extensive personal and professional experience in these areas.

Denial of Claims/Benefits: Many individuals have unknowingly purchased health insurance which has minimal benefits and isn’t what the individual requested or is paying premium for. Many have experienced denial of coverage, that is, the company is not paying benefits for multiple reasons. For example: from billing or coding errors on the part of the provider to an assumption by the patient that a treatment is a covered benefit. Each insurance plan is different and because of the differences and the complexity, an attorney experienced in the interpretation and application of Health Insurance Policies can significantly assist the individual in obtaining coverage.

Policy Interpretation & Coverage Issues: Coverage issues include problems obtaining coverage for procedures, treatment and prescription drugs. For example, denying a treatment or procedure claiming it’s experimental and/or investigational, denying coverage for a drug prescribed for an “off brand” use, denying coverage based on inconsistent and ambiguous policy provisions and policy interpretation in general. These issues are often unfamiliar to the patient and require assistance.

Informed Consent: Informed consent is when a patient is asked to consent to a particular procedure after being informed about all the potential dangers and side effects. Informed consent can and should include the cost of a particular treatment and/or procedure and whether it is a covered benefit. For example, informed consent is prescribing a drug that is $60,000 a year and informing the patient of the cost, whether it is a covered benefit and if there are any alternatives.

Healthcare Litigation: Most, if not all, Health Insurance Policies have a mandatory appeals process before a lawsuit can be filed. Usually there are two mandatory appeals and one voluntary appeal. After the mandatory appeals process is exhausted, then an action can be filed in state or federal court. If coverage is under a self-insured plan, then ERISA applies. Statutes of limitation and the policy time limits are a consideration as well.

Small Business and Corporate Consulting: Acting as a resource to the employees of small businesses and corporations in the handling of denials, obtaining informed consent, interpreting policy language, providing an understanding of the Explanation of Benefits (“EOBs”), benefits that are covered, those that are not, but should be, those that are clearly excluded and understanding the appeals process in the event of a denial.

Barbara L. Maw P.C.
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Phone: (435) 655-3818 Fax: (435) 655-3575