HOME » Settlement Agreement Reached on Retracted Payment Case Study

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This case involved a patient who was admitted for an 18 day inpatient trauma stay. Horizon Blue Cross issued payment on the claim, but subsequently retracted this payment based on a determination that the services were work-related in nature.

Review of the claim indicated that the patient was a pilot who was involved in a plane crash, but that he was not working at the time. Convergent addressed these circumstances with Blue Cross, and they agreed to send the claim back for additional review accordingly. However, Blue Cross upheld its prior denial after completing an additional review.

In light of this, Convergent sought to contact the patient to discuss the circumstances of this claim, if it was work-related or not, and, if so, the pursuit of a workers’ compensation claim regarding it. Concurrently with efforts to contact the patient, Convergent continued to communicate with Horizon Blue Cross, who asserted that the patient had provided information to them confirming that the services were in fact work-related. Convergent made contact with the patient, who advised that his employer did not have workers’ compensation insurance, and that he had retained an attorney to address the workers’ compensation issues. Convergent immediately contacted his attorney directly.

Convergent discussed the matter with the patient’s attorney, including several possible course of action including a products liability case in addition to the workers’ compensation action. After confirming that contested workers’ compensation proceedings had been filed, Convergent worked in conjunction with the patient’s attorney, providing medical record documentation to him in regard to the services rendered by the hospital. Convergent continued to work with the patient’s attorney as the case proceeded through the process of medical evaluation and assessment in the context of the workers’ compensation litigation proceedings.

Convergent additionally made contact with the State Uninsured Employers Trust Fund, and worked with them to verify the full extent of the outstanding charges in preparation for hearing before the workers’ compensation judge. Convergent subsequently confirmed that the Fund had ultimately agreed to accept liability for the patient’s workers’ compensation case. Convergent contacted counsel for the Fund directly to discuss the resolution of the hospital’s substantial medical claim as a result of this. As a result, the Fund presented an offer of settlement in the case. After communication with the hospital, a final settlement agreement was reached, and payment was issued in final resolution of the claim in the amount of $415,058.