As a healthcare subrogation firm, we pride ourselves on execution. Serving over 30 TPA's nationwide, we are in the trenches every day keeping abreast of developing state and federal case law, negotiating with plaintiff attorneys, third party adjusters, and communicating to Plans. Over the last 17 years, our industry has become more complicated. Providing a competitive service demands our attention to a growing number of ancillary challenges. We separate ourselves by providing same-day no-cost resolution to the following types of issues:
- Coordination with other available coverage: Most plans will not pay claims until other coverage is exhausted. In an auto injury cases, for example, we determine if the member has such coverage. Is it mandatory in a particular state? What if it's available, but not mandatory – does the plan language dictate order of payment? In pre-settlement Workmen's Compensation cases, we determine what liability is based on the carrier's decision and their language. After the member settles his work injury case, we recovery any health plan payments from the carrier, medical providers or even directly from the member.
- Pre-Payment Document Requirements: Most health plans and stop loss carriers require a police report and the execution of a subrogation questionnaire before releasing payment. How do you get a police report and what if you can't? Often these documents are not provided from a participant following attorney advice. Could your plan face a bad faith claim if the plan language does not allow them to deny claims in this situation? We obtain the required documents in a timely manner to avoid reinsurance deadlines and unnecessary claims against the plan.
- Stop Loss: Is stop loss coverage involved in the subrogation claim? And if so, are they entitled to recovery before the plan? Can or should the recovery be pro-rated between the plan and stop loss? Balancing the interests of the plan along with their obligations to Stop Loss is a critical piece to many subrogation cases.
- Plan Language Exclusions: The interpretation of exclusions can be challenging, especially when a crime or work related injury is present. Can claims be denied? Is the crime a misdemeanor or felony and does it even matter? Does the member actually need to be convicted? On a daily basis, we are involved in conference calls with plans, brokers and TPA's consulting on plan language issues. Many of those calls result in our drafting of plan amendments to address these situations - at no extra cost.