Health Insurance Rights Increasingly, health insurance companies are denying claims.

The reasons given are many, including that coverage is not provided in the policy, that the services were not medically necessary or were not authorized, or perhaps the insurer will characterize the treatments as experimental. We have seen all of these reasons advanced to deny coverage, as well as dozens of other reasons. Sometimes the insurance companies are correct in their decisions, but quite often, they are not, and the result is that deserving people are denied their insurance benefits. This might not be a huge problem when the treatments are simply for the routine maintenance of good health, but when treatments or medications are critical to treat dangerous or even life threatening conditions, challenging the insurance company decision becomes an absolute necessity. For over 20 years, we have been helping people deal with the roadblocks put up by insurance companies, and more important, helping them obtain the insurance benefits they are entitled to. If you find yourself in a dispute with Anthem Blue Cross, Blue Shield, Aetna, Health Net, Kaiser, Met Life, or other insurance companies, call us for a free consultation. ------What Our Health Insurance Lawyers Can Do For You There are two main areas in which Quadrino Schwartz is providing industry-leading services for medical providers. The first area is combatting claim denials and forcing health insurers to pay valid claims. The second area is successfully defending medical providers when health insurers pursue refunds of monies they have already paid to the providers, such as in post payment reviews or health insurance audits. As to claim denials, there are numerous issues that revolve around the proper procedures that the health insurers must follow under both the federal ERISA regulations and state law. Using our extensive knowledge of the law in this field, we seize upon the use of improper procedures, protect the rights of the medical providers, and obtain payment on valid claims that had been denied. Quadrino Schwartz is becoming a leader in this field and is using its extensive ERISA experience to collect thousands of dollars for medical providers. On the health insurance audit front, there is a national trend in which health insurers are pursuing medical providers for refunds of monies that the insurers previously paid to the providers on past claims. The insurers begin their efforts with audits or post payment reviews of the medical providers prior billing on previously closed and paid claims. The medical providers have more defenses available to them than they realize, and they should employ counsel to either resist such audit requests or have qualified counsel manage the process. In the vast majority of situations, the health insurers have no entitlement to a refund whatsoever and are using the process to intimidate the medical provider. These providers need the help of experienced health insurance lawyers to identify their defenses so that they have the greatest chance of success in these circumstances. Quadrino Schwartz is also on the cutting edge in this area of health insurance law and has a track record of success in defending medical providers.

If you are a medical provider facing an audit or want to pursue payment for denied health insurance claims, contact Quadrino Schwartz. Our experienced and dedicated team of health insurance attorneys is ready to fight for you.

========================================================== Health Insurance Lawyers Representing Health Insurance Policyholders throughout Florida Imagine being diagnosed with cancer, heart disease, or another serious condition and having your insurance company refuse to pay for your treatment. Imagine having your health insurance coverage cancelled by the insurance company after you make a claim. It happens every day. The Nation Law Firm Legal Help with Insurance Claims 1-800-NATION-LAW (1-800-628-4665) Se habla espaol In an effort to cut cots and increase profits, health insurance companies frequently deny treatment or refuse to pay valid health insurance claims made by policyholders. They also engage in a tactic known as rescission retroactively cancelling your coverage for supposed misstatements on an application form. At The Nation Law Firm, our attorneys stand up for the rights of policyholders and help them get health coverage they are entitled to receive. For more than a decade, we have taken on large health insurance companies, and forced them to live up to the terms of their policies. Justice Denied All too often, we see insurance companies making healthcare decisions, rather than doctors making these critical decisions. The insurers may refuse coverage for treatments they call experimental even though medical professionals disagree. These disputes often result in a delay of potentially lifesaving treatment for the patient. Thats just not right. At The Nation Law Firm, we fight for justice on behalf of sick and injured people who have been mistreated by their own insurance companies. Regardless of the size of the claim, if you have had an insurance company deny a claim, delay payment of benefits, or cancel your policy after you make a valid claim, you should call and speak to one of our attorneys for a free consultation. In most cases, the insurance company will be required to pay our fees and costs. To schedule a free consultation, please contact Mark Nations law firm toll free at 1-800-Nation-Law (1-800628-4665) today. With offices in the Orlando area, our lawyers represent people with health insurance disputes throughout Florida. Remember, there are never any fees or costs unless we win, and if we lose, I work for free.-Attorney Mark Nations promise to you.

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Medical claims can be denied for any number of reasons:

Your insurer does not have enough information to process your claim You've reached your lifetime maximum limit with your insurance provider, so they can no longer pay for your claims You've received services not covered under your plan

You've received experimental medical treatment You have a pre-existing condition that prevents you from being covered for certain services The provider put the wrong code for the service on your claim

After you've determined the insurance provider's reasons for denying your claim, do your research to make the most solid appeal you can. This means talking to your doctor to better understand your illness or injury, getting copies of letters between your doctor and insurance provider, examining the coverage of your insurance policy, and finding out how to appeal a claim denial under your specific plan. (There might be different appeals processes based on the type of dispute you have). Call your insurance company to find out more about your claim denial so that you can better address their concerns in your resubmitted claim. Sometimes all that is needed is more information about the services you received, and your resubmitted claim can be accepted. To appeal your claim, send an Insurance Claim Denial Information letter to provide additional information and request that your claim be reconsidered. If your insurance company continues to deny your claim and not cover your medical expenses, and you think they are wrong, you can contact your state insurance department or Find a Lawyer. ==============================

What Happens During the Investigation Of My Disability Claim? Yes, they can interview your neighbor, follow your Facebook postings, and a lot more...

Have you ever wondered what happens during the investigation of your long-term disability (LTD) claim? Be aware that surveillance techniques can be utilized at any time by a Claims Administrator during the initial claims administration, and even after benefits have been approved. We frequently see surveillance applied by the Claims Administer the day of a clients IME (independent medical examination) or FCE (functional capacity examination). In addition to surveillance during medical exams, you may be followed in everyday situations- walking to your car, taking the trashcans out, running errands, or participating in an activity. Your Facebook postings/pictures that describe you engaging in an activity will also be copied if they are public. You should understand that the Claims Administrator can use this information against you to argue that you are not disabled. --HEALTH INSURANCE LAW IN AUSTRALIA The Australian Government provides a basic universal health insurance, Medicare. Private health insurance in Australia is limited to those services not covered by Medicare or to services provided in private hospitals. The Australian Taxation system encourages middle to high income earners to take out Private Health Insurance. While most taxpayers pay a 1.5% Medicare levy, an additional 1% Medicare Levy Surcharge is payable by those taxpayers who earn more than $76,000 and do not have Private Health Insurance. Policy Coverage Your circumstances may change from time to time, so its important to review your health insurance policy regularly to make sure it still meets your health needs. For example, if you chose a hospital policy with restricted or excluded hospital services, you may want to increase your hospital cover as you reach certain life stages.

I have just received a letter about Lifetime Health Cover. What do I need to do? Lifetime Health Cover is a set of rules that determines how much you pay for private hospital cover. If you turned or are turning 31 during the 2012-13 financial year, then you need to purchase hospital cover by 30 June 2013 if you want to avoid paying LHC loading later in life. If you dont purchase cover, then you will pay the Lifetime Health Cover loading on top of the premium of any hospital cover you may later purchase. I've just turned 30; do I have to purchase private health insurance? Private health insurance is optional - however if you don't purchase hospital cover by the 1st of July following your 31st birthday, you will pay the Lifetime Health Cover loading on top of the premium of any hospital cover you later purchase. See Lifetime Health Cover for further information. Lifetime Health Cover Lifetime Health Cover (LHC) is a Government initiative designed to encourage people to take out hospital insurance earlier in life and to maintain their cover. Who pays LHC? If you do not have hospital cover with an Australian registered health fund on the 1st of July following your 31st birthday and then decide to take out hospital cover later in life, you will pay a 2% loading on top of your premium for every year you are aged over 30. What is covered? In Australia, Medicare provides universal health insurance that delivers affordable, accessible and high-quality health care for citizens and permanent residents. However you can also choose to take out private health insurance to give you more health care options and to cover items which aren't covered on Medicare. Below is a side by side summary of what is covered by private health insurance and what Medicare covers forhospital, medical services and general treatment, pharmaceutical benefits and ambulance. Since 2007 funds have also been able to cover a variety of alternatives to hospital treatment, known asBroader Health Cover. HOSPITAL COVERAGE You can choose to be treated as a private patient in either a public OR a private hospital. You can choose your own doctor, and decide whether you will go to a public or a private hospital that your doctor attends. You may also have more choice as to when you are admitted to hospital. If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the Medicare Benefits Schedule (MBS) fee for associated medical costs.

The remaining hospital and medical costs will be charged to you - some or all of these costs may be covered on your private health insurance, depending on your policy. The remaining costs include 25% of the MBS fee for doctors' services and any amount the doctors charge above the MBS fee, plus some or all the costs of:

hospital accommodation, theatre fees, intensive care, drugs, dressings and other consumables, prostheses (surgically implanted), diagnostic tests, pharmaceuticals, and any additional doctor's fees. . Medical Services and General Treatment Medicare does not provide benefits for the following:

most dental examinations and treatment, most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services, acupuncture (unless part of a doctor's consultation), glasses and contact lenses, hearing aids and other appliances home nursing. You can arrange private health insurance to cover many of these services. ============================================================================ ========================= What is covered by private health insurance? Private health insurance cover is generally divided into hospital cover, general treatment cover (also known as ancillary or extras cover) and ambulance cover. Ambulance cover may be available separately, combined with other policies, or in some cases is covered by your state government. There are different types of cover that offer different benefits. Check with your health fund to be sure of exactly what you are covered for. Hospital Cover With hospital cover you have the right to choose your own doctor, and decide whether you will be treated at a public or a private hospital that your doctor attends. You may also have more choice as to when you are admitted to hospital. When you are admitted to hospital, you can choose to be treated under either the public Medicare system or in the private system: Accommodation Type Choice of hospital Choice of doctor

Public patient, public hospital Private patient, public hospital Private patient, private hospital

No No Yes

No Yes Yes

Private health hospital cover insures you against some or all of the additional costs of being a private patient in either a public or private hospital. Medicare will cover 75% of the Medicare Benefits Schedule (MBS) fee for associated medical costs. Provided you have the appropriate private health insurance policy, your health fund will cover the remaining 25% of the MBS fee. You will be charged any amount above the MBS fee the doctors have chosen to charge. Depending on the extent of your private cover, you may also be charged for some or all the costs of hospital accommodation, theatre fees, intensive care, drugs, dressings and other consumables, prostheses (surgically implanted), diagnostic tests, pharmaceuticals, and any additional doctor's fees. Some funds also offer 'gap cover' to cover some or all of the difference between the doctor's fee for services provided in hospital and the combined Medicare benefit and health insurance benefit. Some also provide cover for alternatives to hospital treatment known as Broader Health Cover. As with any other insurance policy, you can manage your cover by choosing comprehensive cover with higher premiums, or pay lower premiums for reduced cover. You can also reduce your premiums by opting to pay some of the costs through an excess or co-payment. What may not be covered? The health insurance policy you buy will have some limitations on hospital treatment, which might include:

Exclusions - specific services that are not covered at all. Restrictions - services that are covered to a limited extent, which means you will have greater out-ofpocket expenses. Benefit limitation periods - which pay reduced benefits on one or more services for a set period of time after the waiting period, then pay full benefits after this period. Surgery or hospital treatment that Medicare does not pay a benefit for - Medicare pays a benefit on all medical services necessary to maintain your health, but does not cover optional treatments such as elective cosmetic surgery. Long stay patients - If you are in hospital for more than 35 days in succession, you will be regarded as a long stay or nursing home type patient, unless your doctor specifies otherwise. This means you will have to pay more for the cost of hospital accommodation after the initial period. The Health InsuranceAct 1973 does not allow health funds to insure for this cost. General Treatment Cover General treatment cover (also called ancillary cover or extras cover) provides insurance against some or all costs of treatment by ancillary health service providers. The extent of your cover depends on the type of policy you select and may include services such as:

dental treatment, chiropractic treatment, home nursing, podiatry, physiotherapy, occupational, speech and eye therapy,

glasses and contact lenses, prostheses (e.g. hearing aids). What may not be covered? Nearly all services covered under general treatment are only covered to a limited extent. There are various limits that may apply, for example a limit per service, per year, or lifetime limits. Some services may not be covered at all. Ambulance Medicare does not cover the cost of emergency or other ambulance services. You can organise cover for this service as part of your hospital or general treatment plan, or as a stand-alone cover. The options for ambulance cover vary depending on what State you live in. For further information please see the Ambulance section of the website. ============================================================================ ========================= What is covered by Medicare? Medicare is the basis of Australia's health care system and covers many health care costs. You can choose whether to have Medicare cover only, or a combination of Medicare and private health insurance. Citizens and most permanent Australian residents are eligible for Medicare. The Medicare system has three parts: hospital, medical and pharmaceutical. Hospital Under Medicare you can be treated as a public patient in a public hospital, at no charge, by a doctor appointed by the hospital. You can choose to be treated as a public patient, even if you are privately insured. As a public patient, you cannot choose your own doctor and you may not have a choice about when you are admitted to hospital. Medicare does not cover: private patient hospital costs (for example, theatre fees or accommodation), medical and hospital costs incurred overseas, medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons, ambulance services. Medical When you visit a doctor outside a hospital, Medicare will reimburse 100% of the Medicare Benefits Schedule (MBS) fee for a general practitioner and 85% of the MBS fee for a specialist. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything. Medicare provides benefits for:

consultation fees for doctors, including specialists, tests and examinations by doctors needed to treat illnesses, such as x-rays and pathology tests, eye tests performed by optometrists, most surgical and other therapeutic procedures performed by doctors,

some surgical procedures performed by approved dentists, specific items under the Cleft Lip and Palate Scheme, specific items under the Enhanced Primary Care (EPC) program, specified items for allied health services as part of the Chronic Disease Management Plan. Medicare does not cover: examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer or government authority), ambulance services; most dental examinations and treatment, most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services, acupuncture (unless part of a doctor's consultation), glasses and contact lenses, hearing aids and other appliances. home nursing. Pharmaceutical Under the Pharmaceutical Benefits Scheme (PBS) you pay only part of the cost of most prescription medicines purchased at pharmacies. The rest of the cost is covered by the PBS. You must present your Medicare card to obtain this benefit. The amount you pay varies with the medicine, up to a standard maximum. People with concession cards have a lower maximum payment. ========== MANAGING HEALTH INSURANCE POLICY Exclusions If your policy has an exclusion for a particular condition, you are not covered for treatment as a private patient in a public or private hospital for that condition. For example, if your policy excludes obstetric services, hip replacements and knee replacements, and you go into hospital as a private patient for one of these conditions, your health insurer will not pay any benefits towards your hospital and medical costs. If you need treatment for an excluded service, your options would be to seek treatment as a public patient or to cover the full cost of the treatment yourself. Restricted Benefits If your policy has restricted benefits for some conditions, you will be covered for treatment for those conditions but only to a limited extent. You will face considerable out-of-pocket costs if you have this treatment as a private patient. If you need treatment for an restricted service, your options would be to seek treatment as a public patient, or as a private patient in a public hospital or to cover some or most of the cost of the treatment yourself.

Excess An excess is an amount of money you agree to pay for a hospital stay, before health insurer benefits are payable. This is sometimes referred to as a front-end deductible. For example, if your policy has an excess of $200, you will be required to pay the first $200 of your hospital costs should you go to hospital as a private patient. An excess may apply every time you go to hospital in a year, or may be capped at a total amount that you will have to pay in a year. Co-payment With a co-payment, you agree to pay a set amount each day you are in hospital. This can also be referred to as an overnight excess, daily excess or patient moiety. For example, a policy may have a co-payment clause that requires you to pay the first $50 for each day of hospital accommodation. If your policy has such a co-payment and you were in hospital for five days, you would have to pay $250 ($50 x 5). The total amount of co-payment you pay per hospital stay is often limited to a set maximum amount. Exclusions, restrictions, excess and co-payments are listed on the Standard Information Statements. Discounts Health funds may offer discounts on premiums for people who:

pay their premiums at least three months in advance, pay by payroll deduction, pay by pre-arranged automatic transfer from an account, have agreed to communicate with the private health insurer, and make claims under the policy, by electronic means, belong to a contribution group under the rules of the fund, eg your health insurance product is organised through your workplace or an organisation you belong to, and where the insurer is not required to pay a state or territory levy (e.g. if you are a pensioner or a low income earner in New South Wales or the Australian Capital Territory, your premium may be reduced because you are entitled to free ambulance cover). Check with your health fund to see if you are eligible for any of these discounts. Rate protection If you can pay your premiums 12 months in advance, some funds will offer a rate protection policy. With a rate protection policy, if the rates are increased within the 12 months you have already paid you will not have to pay the increased rate until your 12 months of cover ends. If you do not have a 'rate protection' policy, the fund will ask you to pay the balance owing on the new rates, or reduce the length of time your payment covers. Failure to pay If you fall more than two months behind in paying your contributions, your private insurance will lapse and you will not be insured.

Some funds may not accept payment of arrears in excess of two months. When you resume your payment, the insurer may impose further waiting periods before you can claim benefits again. Suspending your membership Health funds may grant suspensions for an agreed period of time, at their own discretion, for circumstances such as working or studying overseas, financial hardship or temporary unemployment. During the suspension you will not be able to claim and if you are over the income threshold you will be required to pay the Medicare Levy Surcharge for that period. Suspension rules differ between funds so you should check to see if you will need to serve any waiting periods again. Suspending your membership with the agreement of your health fund will not affect your Lifetime Health Cover entitlements. ============================================================================ ===================== What is the Private Health Insurance Ombudsman? The Private Health Insurance Ombudsman is an Australian Government agency but acts independently of the Government in dealing with complaints and reporting. The role and functions of the Private Health Insurance Ombudsman are set out in Sections 230256 of the Private Health Insurance Act 2007. The office deals with inquiries and complaints about any aspect of private health insurance. The Ombudsman provides advice to the health insurance industry, the government and consumers and also publishes independent information about private health insurance and the performance of health funds. The Private Health Insurance Ombudsman is independent of the private health insurers, private and public hospitals and health service providers. Who is the The Private Health Insurance Ombudsman? Ms Samantha Gavel is the Private Health Insurance Ombudsman. Statements of Expectation and Intent In January 2013, the Minister for Health & Ageing issued the Ombudsman with a Statement of Expectations. The Ombudsman responded with a Statement of Intent. Both of these documents are available below.

These documents outline the PHIO's role and its relationship with the Minister and Department of Health & Ageing, and explain how the PHIO will be working to protect the interests of people covered by private health insurance. PRE-EXISTING CONDITION RULE What is the Role of the Private Health Insurance Ombudsman? The Private Health Insurance Ombudsman (PHIO) acts as an independent third party in dealing with complaints about the application of the pre-existing condition waiting period. When PHIO receives a complaint from a member about the pre-existing condition waiting period, our process is to request a copy of the health insurers medical report and a copy of the certificates completed by the members treating doctor and specialist. This information is only requested once the member has provided written consent for PHIO to seek this information from the insurer.