HOME » Denied & Problem Healthcare Claims Case Study




Many hospitals find themselves with unusual claim problems they are not equipped to solve but can ill afford to let go unpaid.

Convergent’s attorney-driven approach has proven time and again to achieve results for these hospitals that they cannot obtain on their own.

A Florida hospital had 29 claims with an average age of 249 days that the insurer refused to pay. When the hospital submitted requests for status on these claims, the insurer advised that these accounts were sent to the corporate office for payment. However, these payments were never received. Immediately after listing, Convergent obtained the company’s profile from the Better Business Bureau and contacted the owner of the insurer. Convergent then demanded the owner’s involvement and immediate payment. Three days later, all 29 claims were paid accordingly.

A New York hospital submitted a 382 day-old claim to Convergent involving a patient whose admission changed from an ER visit to a ten-day inpatient stay, including one medical day and nine psychiatric days. The patient’s behavioral health carrier denied the claim, stating that the bill was not received within the applicable timely filing period. When Convergent resubmitted the bill, the carrier rejected the claim for medical records which were needed for medical necessity review. Convergent submitted the medical records and demanded review and processing of the claim. The carrier then refused to conduct the medical review, because they no longer served the patient’s group and the run-out period had ended. Convergent immediately submitted a complaint to the carrier’s Consumer Affairs Department and demanded that the carrier cover the patient’s hospitalization, since they did receive the medical records prior to the end of the run-out period and should have done the review at that time. Shortly thereafter, the carrier was forced to overturn its original denial and reprocess this claim. Convergent obtained payment for all ten days billed, including the medical day.

A New Jersey hospital submitted an ER claim for $38,843.46 for a patient who was an Indian resident and had insurance coverage abroad. The claim was delayed for an extensive amount of time because the home plan in India had not provided such authorization for payment. In addition, the carrier denied the claim for timely filing, an issue which Convergent fought and won. Subsequently, Convergent obtained names and email addresses of the board of directors of the home plan in India and sent them a HIPAA email blast regarding the mismanagement of this claim. The following day, Convergent received an email advising that the matter was being addressed. Three days later, the payment was approved and ready to issue.

A Texas hospital’s claim was underpaid and processed out of network for no referral by the insurance carrier. Convergent demanded that the carrier look to see if there was a referral to a doctor that could be linked to the claim. The carrier found a referral to a doctor in the same practice and noted other claims processing in network. The claim was sent back and resolved with additional payment issued in the amount of $6,273.76.