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The payer, Gallagher Bassett, had denied the claim on a technical basis, asserting that the primary diagnosis code billed was invalid. Convergent immediately contested the denial, stressing that there was no basis to contend that the diagnosis code was not valid.

When Gallagher Bassett balked at taking immediate action to redress this erroneous denial, Convergent immediately escalated the matter to the management level at Gallagher Bassett, and obtained agreement for it to be reviewed at an escalated level accordingly.

When payment still was not issued within the following few days, Convergent again escalated matter to the management level. Convergent’s management contact at Gallagher Bassett management agreed to resolve this erroneous denial with the bill review entity directly, and get the payment issued accordingly.

That same management contact then contacted the hospital to request additional medical documentation (operative report documentation) at the request of the bill review entity. Convergent immediately contacted Gallagher Bassett to stress that no additional medical documentation should be required to address any processing needs. Convergent pointed out that liability was not in dispute in this case, and that the condition in question was an accepted condition under the workers compensation case, without any dispute regarding the nature of the treatment, so additional review based on medical documentation would be moot. Convergent demanded that the claim simply be processed without any delay, making clear that, in light of the urgent need for resolution, the matter would be further escalated to the CEO level if not promptly resolved without additional delays.

Gallagher Bassett subsequently confirmed that the claim was processed for payment in the amount of $1,056,147.46. However, Gallagher Bassett then advised that they would need 45 additional days to actually issue the payment. In light of the delay already incurred on this claim, the Convergent Legal Department attorney immediately escalated this matter to the office of the CEO for Old Republic (the insurer underwriting the self-funded employer, for whom Gallagher Bassett administered benefits). Within the next several days, Gallagher Bassett confirmed that three checks totaling $1,056,147.46 had been issued.