Preferred Lifestyle Services - Care Management

Care Management ~ Eldercare Advocacy ~ Dementia Care

Serving families in Palm Beach, Martin and Port St. Lucie counties

How Care Management Recouped $172,000 In Previously Denied Insurance Benefits

Judie Rappaport
November 4, 2021

We are living in a hectic complicated world that changes daily, mandating us to change how we live daily. Major
changes you might be feeling are increasing food costs and continually increasing medical costs. 

Review the Case History below to show how PLS could help reduce out-of-pocket costs.

Client Case History:
Mr. K. received outpatient radiation and chemotherapy at a hospital on the insurance carrier’s in-network provider list. When the hospital filed to recoup its charges of $173,200, the insurance company denied payment of the entire amount. 

  • After reviewing Mr. K.'s policy, PLS called his insurance carrier to verify benefits.
  • PLS obtained a copy of Mr. K.’s hospital bills and coordinated the denials of benefit payments with his hospital bills.
  • With a complete picture of the treatment and billing, PLS contacted the insurance company to verify the exact reason for denial of claims.
  • PLS worked with physicians to obtain letters of medical necessity.
  • PLS started the appeals process.
  • PLS continued to press the carrier every two weeks, using a spreadsheet to track denials, appeals, and sporadic payments.
  • After 17 months, PLS succeeded in reversing 99% of the carrier’s denials. The hospital received $172,000 in previously denied claims; Mr. K. paid the remaining $1,200. 

The Bottom Line: 
Mr. K. received $172,000 in benefits for an investment of $2,300 plus 10% of the total recovered: Net Gain $152,500.

Eldercare FAQ, ,