Thursday, March 11, 2010

Doctor Collects from Insurance in Small Claims Court

This is straight collections of debt in small bundled amounts in Small Claims. The doctor represented himself, but did his legal homework, in anticipating and finding the rebuttal for the company's arguments.

I would like to see many doctors go beyond debt for services to patients, to charging for filling out pre-authorization forms, spending time on the telephone for approval, for retrieval of medical records. These are for the benefit of the insurance company. They represent contract in law, generating a debt called quantum meruit.

From the article.

Fla. doctor beats insurer -- in small claims court

In the Courts. By Amy Lynn Sorrel, amednews staff. Posted March 1, 2010.

Physicians are not known for taking health insurer payment abuses lying down, having marched big carriers into state and federal courtrooms in a series of successful class-action lawsuits over the years.

But one Florida physician caught an insurance giant from an angle it was not expecting when he launched an attack in small claims court. The dermatologist's strategy: to win back the roughly $130,000 he contends Humana Inc. owed his practice in unpaid bills since at least 2007, even if it took filing a few small claims at a time.

The strategy worked. The doctor has recouped nearly all of the money."If doctors have a legitimate right to be paid based on services they provided, insurance companies should pay. And if they think they can get away with nonpayment, [doctors] should be aggressive in whatever manner it takes," said Steven Rosenberg, MD, president of Palm Beach Dermatology Inc. in West Palm Beach.

Letters to Humana seeking to resolve the claims on behalf of himself and other doctors in his practice brought no recourse. After his lawyer wrote to the insurer, Dr. Rosenberg said he got a promise from Humana that it would expedite the claims.

"But here we were a year and a half later, and we were still doing this process," he said. "We basically kept getting the runaround, and we got frustrated that Humana was not responding to all our efforts."

He explored hiring an attorney to take his case to civil court. But the 40% contingency fee that would have come from whatever judgment the practice collected was not appealing.

At that point, Dr. Rosenberg put his medical research skills to work. He discovered that for the same $350 he paid the attorney to write to Humana he could file a petition against the company in Palm Beach County small claims court, where parties can represent themselves.

Because damages could not exceed $5,000 per claim, Dr. Rosenberg bundled a few bills together worth that amount, filled out a simple claim form, attached a check and, in the fall of 2009, sued the insurer in small claims court for violating Florida's prompt-payment law.

"Palm Beach Dermatology Inc. has worked for the last 29 months to remedy the issue via Humana's claims appeal/special projects process and through their appointed attorney with no resolution," the one-page complaint stated.
Legal maneuvering

Dr. Rosenberg was met in court by an attorney Humana sent to defend the case. But he was familiar with his legal rights, having been a past president of the Florida Society of Dermatology & Dermatologic Surgery and a former state medical board member, so he successfully rebuffed some of the lawyer's legal maneuvers.

When the attorney tried to argue that the dermatology practice did not obtain the requisite prior authorization before treating patients, the doctor countered that state law gave patients direct access to dermatologists without a referral. And to the insurer's contention that Palm Beach Dermatology failed to first collect payment from patients before seeking reimbursement from the insurer, Dr. Rosenberg fired back that state law prohibited such practices.

Then came a settlement offer. Humana agreed to pay the first set of claims and the doctor's filing fees, totaling $5,340, according to a court judgment dated Oct. 6, 2009. Dr. Rosenberg said the case was heard within a month of filing the lawsuit and resolved the same day.

But he warned Humana's lawyer that the case was only the beginning. "I told him this was the first of 25 claims we were going to be filing."

He took the insurer to court a second time and won again in January. Shortly after he filed the second case, Dr. Rosenberg said the practice began receiving checks in the mail from Humana totaling $90,000.

The insurer sent two representatives to the office to go through the remaining outstanding claims. Since then, Humana has restituted nearly all of the $130,000 Palm Beach Dermatology was owed, Dr. Rosenberg said. "We didn't really know if it was going to work but figured it was worth a try. Obviously, Humana got the message this was going to cost them."

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