Anomalous Claim Clearance Case Study

Rather than having the other claims adjusted, the provider insisted that we not look into the matter further because they did not want us to take back any money. Sadly this is just one example of fraud; it is not uncommon to see providers change the coding of claims to get something that they know should not be paid to process for payment. Cracking down on this type of fraud will reduce the amount of money paid out on claims by insurance carriers. Since claims payments directly affect the cost of insurance, this will also help in lowering premiums.

(Exhibit 3). Having received no response since March 8, 2017, on March 20, 2017, Counsel for State Farm sent Arnold a letter: 1) reminding her of her outstanding discovery requests; 2) indicating that we had not yet received her outstanding discovery requests; and 3) requesting that Arnold provide her discovery responses within five days of the date of the letter. (Exhibit 4, March 20, 2017, letter from Green). To date, despite repeated requests, State Farm has not received Arnold’s Answers to Interrogatories, and the docket entries for this matter do not show that the same have been served. (Exhibit 2).

The undersigned attended the Lien Conference held at the Fresno Workers’ Compensation Appeals Board on May 11, 2017. The undersigned appeared on behalf of Mr. Rod McClelland. Mr. McClelland had an unavoidable calendar conflict on the day of the hearing. If you have any questions regarding this Lien Conference, please do not hesitate to contact either myself or Mr. McClelland.

With any claim for monetary compensation, you are held to a specific set of deadlines. The deadlines that apply to your claim depend on the type of claim you are seeking. These deadlines include more than just the length of time following your military discharge that you are eligible for benefits – they can also include the length of time you have to appeal your claim if it is rejected.

10. Once it's complete you will file the claim and ensure you have a copy. Be sure to review the claim prior to sending it out for any possible mistakes that could have been

It appears that Ms. Smyth sent a request to Jim (Assigned Case Manager) to amend her claim on August 25, 2015. On August 27, 2015, Ms. Smyth provided the amendment information to Jim.

Almanza further claimed she nor her administrative staff of office employees were informed by the claimant or from the claimant’s two Supervisors, Mr. Jose Maldonado, and his brother who is deceased, Mr. Estevan Maldonado that the claimant had any internal complaints or issues. She said the claimant’s work performance was never an issue and that there was no anticipation of any pending layoffs or workplace harassment issues for any related industrial stressors. She said both brothers supervised the claimant and from her knowledge, she never received any incident reports or complaints from either Supervisors that suggested the claimant may have suffered from a slip or fall at his job where he may have injured his head or back.

On September 16, 2015, the attorney, Rachel Macon, became involved in the case and requested an administrative review. On October 7, 2015, the hearing officer advised the Lien Unit that the acknowledgment of hearing request has been accepted. The original hearing was scheduled for January 5, 2016. On January 6, 2016, the Lien Unit received a letter from the hearing officer rescheduling hearing for March 10, 2016. On March 10, 2016, the hearing was continued until May 19, 2016. On May 19, 2016, the Lien Unit received partial information to verify that the account that was levied is a joint account. The Lien Unit has spoken with the attorney and the NCP about providing additional information regarding the joint account so that the Lien Unit can complete the calculations on the account. That is all at this

After holding furthermore, she explains that the disbursement TL, however, she is able to offer a follow up the cover person to address the issue. She shows understanding

I attended a hearing on your behalf in the above matter before Judge Burke in Hudson, New York, on 05/17/2017. The claimant was present and represented by attorney Ed DeLauter. Your insured, Robert George, was present to give testimony.

The Applicant/Claimant, Mr. Cleveland Edwards, is the father of the Defendant/ Respondent, Mr. Clive Edwards. The subject matter of the dispute is a property that both parties are registered owners as joint tenants. The Claimant maintains that he is the legal and equitable owner of the property because the Defendant’s name was only on the Title for convenience and this was clearly conveyed to the Defendant prior to his name being placed on the title. The Claimant wishes to sell the property and the Defendant does not oppose. However the Defendant wants the proceeds of the sales to be apportioned having regards to his interest in the property.

I have reviewed the M&T request that you referred to in the Board’s electronic case folder along with a copy of the claimant’s counsel’s letter dated 07/20/17. They are requesting out of pocket expenses, although they do not specifically clarify what expenses the claimant had occurred.

Upon completion of reviewing your letter in regard to the dates of service January 19, 2017 – January 24, 2017 claim processing. You ask for confirmation that the patient account is accurate and the claims were processed accurately. Moreover, any discrepancy identified requires that you send the related documents and payment if applicable to CareFirst.

Just an FYI, escalation#1580 is not a true escalation. Claim#124210654800 had an appeal sent back on 05/05/2015 appeal# APP-1186293. I understand that the appeal was dismissed because of the rep. didn’t note the document ID#. But we must understand that this is the first level of appeal. Once the appeal has been closed out, the provider must send in a 2nd level appeal. I’m not sure, if you advise the provider that the submission of your escalation doesn’t halt the timely filling of the 2nd Level. Which has now passed. Going forward, please be sure to review the appeal to determine if it is a true escalation or not. This can be based on discrepancies in the discussion based off the reason why the appeal was sent back. For this escalation, I

Step 2, Claim’s Particulars: Within 42days after the contractor became aware or should have become aware of the event, a complete set of supporting particulars should be submitted, consisting all the records anticipated to this claim, in addition to any necessary analysis required to evaluate this claim such as schedules, critical path, and materials’ invoices, etc. The