Insurance Denial Fraud “bad faith practices”

Please note that noTRACH can ONLY assist with denials of treatment that directly relate to tracheostomies, or may result in one being required.

Because of the nature and consequences of required tracheostomies, breathing equipment, and other such items, noTRACH can assist in resolving disputes with insurance companies where claims are denied for reasons of medical necessity.

noTRACH can provide expert evidence and review of cases by experts in the field of respiratory care, and legal liability. Few insurance companies employ any acknowledged experts in respiratory care, and it is not uncommon for Medical Directors to deny claims without ever reviewing patient records. This is not only a violation of law, but malpractice on the part of the Medical Director Physician. A recent example of this is a Medical Director Physician formerly in the employ of Aetna whom openly admitted that he denied claims without ever looking at any patient records.

Whilst it is a common belief that insurance fraud is only committed against insurance companies, sometimes it is the insurer that is committing fraud.

Commonly referred to as “bad faith insurance practices”, fraudulent activities on the part of insurers include actions such as denying valid insurance claims, denying coverage to individuals for certain conditions that should be covered, failing to properly investigate claims, and deliberately underpaying claims.

noTRACH does not itself engage in any civil disputes, but can act as an expert witness or provide other opinion or evidence where it believes that an individual has or will suffer harm in support of a civil claim.

noTRACH can review cases where disagreements arise on medical necessity and provide an objective and medically conclusive opinion. With consent, noTRACH can also act as an independent external reviewer, but noTRACH cannot compel any insurance company to comply with our findings –

However:

Where noTRACH believes that a denial constitutes bad faith practices, or where a Medical Director has been negligent in review of a patient’s case, or has denied a claim where a claim is clearly justified and should be approved – noTRACH can – and does – take appropriate action.

 

Some of the remedies open to noTRACH are:

  • Report that an insurer is knowingly acting in bad faith to State and other Legislative Bodies that regulate insurance. We may also report to the Office Of Inspector General, the FBI and other law enforcement of our findings.
  • Refer a case to a District Attorney where it believes that a Medical Director has acted illegally in denying a claim that has resulted in a serious injury; or, where a death has occurred as a result, a Medical Director may be held to have committed voluntary manslaughter, and noTRACH can provide expert testimony in support.
  • Report to and seek to have a Medical Director Physician struck off (no longer permitted to practice) if it believes he or she have engaged in unethical conduct by requesting a review by a State Board or Examiner of our evidence.
  • Add a Medical Director to our Concern Register For Unethical Practice, which is openly published and furnished to investigators, media, law firms, malpractice insurance providers, and law enforcement agencies.

To access our Concern Register, click here