Mastering Legal Concepts for Complex and Problem Claims: A Comprehensive Guide

Read Time:

What You’ll Learn:

This comprehensive blog, based on a recent webinar hosted by Becker’s Health Care, aims to shed light on critical aspects of this subject.

Read Time:

What You’ll Learn:

This comprehensive blog, based on a recent webinar hosted by Becker’s Health Care, aims to shed light on critical aspects of this subject.

Source: Wakefield
June 12, 2024

Navigating the complex landscape of legal concepts for complex and problem claims can be daunting. This comprehensive blog, based on a recent webinar hosted by Becker’s Health Care, aims to shed light on critical aspects of this subject. The webinar featured Joseph Parton, Esquire, Vice President of Complex Claims and Denial Management, and Taylor Foster, Vice President of Revenue Cycle Services, who shared their extensive knowledge and insights on the topic.

Key Takeaways For Effective Revenue Cycle Management In Healthcare

1. Rise in Claim Denials: The increasing rate of claim denials, particularly a 17% rise reported in 2021, highlights the importance of understanding complex claims and denial management to improve acceptance rates.

2. Importance of State-Specific Knowledge: Navigating complex claims, such as workers’ compensation and auto accident claims, requires familiarity with state-specific statutes and regulations to ensure compliance and streamline processes.

3. Effective Denial Management Strategies: Key practices include maintaining detailed records, understanding managed care agreements, and developing robust appeal processes to support medical necessity and appropriate care claims.

Meet the Experts

To fully appreciate the depth of the information shared, let’s first introduce our esteemed speakers:

Taylor Foster

With over 13 years of experience in revenue cycle management, Taylor Foster has made significant contributions to the field. Having spent a large part of his career at Cerner, Taylor now holds a pivotal role at Wakefield, where he has been instrumental in advancing revenue cycle services. His deep understanding of the industry trends and best practices has helped numerous healthcare organizations optimize and control their revenue cycles.

Joseph Parton

Joseph Parton brings a wealth of experience with 30 years in both legal and healthcare revenue cycle management. As the former Vice President of Complex Claims and Denial Management at Wakefield, his expertise is unmatched, particularly in handling intricate legal scenarios in the healthcare domain. His insights into complex claims and legal frameworks provide a solid foundation for navigating the most challenging aspects of healthcare revenue management.

complex claims

Webinar Agenda Overview

The webinar covered several key areas, structured as follows:

  1. Introduction to Wakefield

  2. Industry Trends

  3. Complex Claims: Definitions and Examples

  4. Problem Claims and Denial Management

  5. Best Practices

  6. Q&A Session

Introduction to Wakefield

Wakefield distinguishes itself from typical revenue cycle management companies by fostering partnerships rather than transactional relationships. Their focus is on recovering lost revenue through advanced technology and a team of expert personnel, delivering high-yield results with transparent communication.

High-Yield Results

Wakefield prides itself on delivering high-yield results by leveraging cutting-edge technology and skilled professionals. They employ a data-driven approach to both identify opportunities and recover lost revenue, ensuring that their clients see tangible improvements in their financial performance.

Transparent Communication

Transparency is a cornerstone of Wakefield’s approach. They believe in open, honest communication with their clients, ensuring that all stakeholders are informed and engaged throughout the revenue recovery process. This transparency builds trust and fosters long-term partnerships.

Industry Trends

Rising Claim Denials

One of the most pressing trends identified is the increasing rate of claim denials. According to a survey by the Medical Group Management Association (MGMA), nearly 70% of organizations reported a 17% increase in denials in 2021. This surge highlights the necessity for healthcare providers to deepen their understanding of complex claims and denials management.

Importance of Understanding Trends

Understanding these trends is crucial for healthcare providers to adapt their strategies and improve their claim acceptance rates. By staying informed about the latest industry developments, organizations can proactively address the factors contributing to increased denials and implement effective solutions.

Deep Dive into Complex Claims

Workers' Compensation Claims

Workers’ compensation claims are inherently complex, driven by state-specific statutes and fee schedules. These claims involve multiple parties, and legal experts, including the injured employee, employer, attorneys, and insurance adjusters, each adding to the complexity. Understanding the intricacies of state regulations and any relevant contracts is crucial.

State-Driven Regulations

complex claims

Each state has its own unique workers’ compensation statutes and fee schedules. These regulations dictate how claims should be handled, including timelines for filing and payment, as well as specific requirements for documentation and reporting every claim made. Healthcare providers must familiarize themselves with these state-specific rules to ensure compliance and streamline the claims process.

Multiple Parties Involved

Workers’ compensation claims involve several stakeholders, including the injured employee, their employer, attorneys representing both parties, and insurance adjusters. Coordinating with all these parties can be challenging, requiring effective communication and negotiation skills. Healthcare providers must manage these relationships carefully to ensure that claims are processed smoothly and efficiently.


In addition to state regulations, contracts between healthcare providers and insurers often govern workers’ compensation claims. These contracts may specify payment rates, timelines for payment, and penalties for non-compliance. Understanding and adhering to these contractual obligations is essential for maximizing revenue and minimizing disputes.

Auto Accident and Third-Party Liability Claims

Auto accident and third-party liability claims involve various payment sources, such as health insurance, medical payments coverage, and personal injury protection (PIP). Healthcare providers must navigate state-specific healthcare lien laws, which can differ significantly.

Multiple Payment Sources

Auto accident and third-party liability claims often involve multiple sources of payment. These can include health insurance, MedPay, PIP, and third-party liability coverage. Identifying and coordinating these payment sources is critical for ensuring that claims are paid promptly and in full. Healthcare providers must be adept at managing these complex financial arrangements to avoid payment delays and denials.

Healthcare Liens

State-specific healthcare lien laws govern the filing and enforcement of liens on settlement proceeds in third-party liability cases. These laws vary widely from state to state, with some states having very specific requirements for filing and perfecting liens. Understanding these regulations is essential for protecting the healthcare provider’s right to payment in third-party liability cases.

Letters of Protection

Letters of protection are agreements between patients, their attorneys, and healthcare providers, allowing the healthcare provider to defer collection efforts while the patient’s case is pending. While these letters can help manage cash flow and patient relationships, they are not always enforceable and may lack the legal strength of a properly filed lien. Healthcare providers should use letters of protection cautiously and ensure they understand their limitations.

Handling Problem Claims and Denials

complex claims

Common Denial Reasons

Understanding the reasons behind common claim denials is essential for developing effective resolution strategies. The most frequent and complex claim denial reasons include issues related to medical necessity and authorization.

Medical Necessity

Medical necessity denials occur when an insurer determines that the treatment provided was not necessary based on their criteria. These denials often involve disputes over the appropriate level of care, such as whether inpatient care was justified versus outpatient treatment. To combat these denials, healthcare providers must ensure that their documentation clearly supports the medical necessity of the services provided. This includes thorough clinical notes, evidence of the patient’s condition, and rationale for the chosen treatment plan.

Authorization Issues

Authorization issues arise when there are problems with obtaining prior authorizations or retroactive authorizations for services. Insurers often require pre-approval for certain treatments, tests, or medications, and failure to obtain this approval can result in claim denials.

Healthcare providers must have robust processes in place to manage authorizations, including tracking which services require prior authorization, ensuring timely submission of authorization requests, and following up diligently.

State and Federal Statutes

Healthcare providers must be familiar with applicable state prompt pay statutes and federal ERISA guidelines. State prompt pay statutes set timelines for insurers to process and pay claims, and may impose penalties for non-compliance.

ERISA (Employee Retirement Income Security Act) governs many employer-sponsored health plans and has its own set of requirements. Understanding these legal frameworks can help service providers enforce timely payments and appeal denials effectively.

Medical Necessity

Medical necessity denials occur when an insurer determines that the treatment provided was not necessary based on their criteria. These denials often involve disputes over the appropriate level of care, such as whether inpatient care was justified versus outpatient treatment. To combat these denials, healthcare providers must ensure that their documentation clearly supports the medical necessity of the services provided. This includes thorough clinical notes, evidence of the patient’s condition, and rationale for the chosen treatment plan.

Best Practices for Denial Management

  1. Detailed Record-Keeping

    Maintaining thorough documentation of all interactions with insurance representatives and ensuring claims are submitted accurately and timely is crucial. Detailed record-keeping helps support appeals and provides evidence in disputes. Providers should document every step of the claims process, including communications with payers, submission dates, and responses received.

  2. Understand Contracts and Statutes

    Knowing the managed care agreements and state statutes that govern claim payments and recoupments is essential. Providers should review their contracts with insurers regularly to understand their rights and obligations.

    Additionally, staying updated on state and federal laws can help providers navigate the legal landscape and enforce compliance.

  3. Develop Robust Appeal Processes

    Developing robust appeal processes involving clinical and utilization review staff to support the medical necessity and appropriateness of care is critical. An effective appeals process includes gathering all relevant documentation, presenting a strong case for why the denied claim should be paid, and following up persistently. Engaging clinical staff in the appeals process ensures that medical arguments are well-supported and credible.

In-Depth Case Study: Medical Necessity and Prior Authorization

A compelling case discussed during the webinar involved an attorney diagnosed with stage 4 throat cancer who required proton therapy, a precise but costly treatment. Despite his oncologist’s recommendation and an expedited authorization request, his insurance denied the treatment based on medical necessity.

The attorney ultimately paid out-of-pocket and later won a lawsuit against the insurer, underscoring the importance of persistence and legal expertise in such cases.

Details of the Case

The attorney, who had a small group policy with Blue Cross Blue Shield of Louisiana, experienced a life-threatening delay due to the denial. His oncologist recommended proton therapy, a targeted form of radiation with minimal side effects, which the insurance deemed unnecessary. This denial not only posed a significant health risk but also highlighted the arbitrary nature of some insurance decisions.

Legal Battle and Outcome

complex claims

Determined to fight the denial, the attorney engaged in multiple appeals and eventually filed a lawsuit. He argued that the denial was arbitrary and capricious, and under ERISA, he sought reimbursement for his out-of-pocket expenses.

The court ruled in his favor, awarding attorney’s fees and the cost of treatment. This case emphasizes the need for healthcare providers and patients to be vigilant and persistent in challenging unjust denials.


Mastering legal and business concepts for complex and problem claims demands a comprehensive understanding of industry trends, state and federal regulations, and effective denial management strategies. This multifaceted approach requires healthcare providers to stay current with evolving industry practices and legal requirements, ensuring they are well-prepared to address the challenges that arise in managing complex claims.

Understanding Industry Trends

Healthcare is a dynamic field where trends continuously evolve. Recognizing these trends, such as the increasing rate of claim denials, helps providers anticipate and address potential issues before they escalate. Industry reports and surveys, like those from the Medical Group Management Association (MGMA), offer valuable insights into common claim denial reasons and emerging patterns, enabling healthcare providers to adapt their processes accordingly.

Navigating State and Federal Regulations For complex claims

State and federal regulations play a crucial role in claim management. State-specific statutes, such as prompt pay laws, set clear guidelines on timelines and penalties for claim processing, while federal regulations under ERISA govern employer-sponsored health plans. Healthcare providers must familiarize themselves with these regulations to ensure compliance and leverage legal frameworks effectively. This knowledge is essential for preventing and appealing denials, ensuring timely payments, and protecting the financial health of their organizations.

Effective Denial Management Strategies

Effective denial and claims management is critical for maintaining a healthy revenue cycle. Developing robust strategies involves detailed record-keeping, understanding managed care agreements, and establishing strong appeal processes. Healthcare providers should document all interactions with insurance representatives meticulously and ensure claims are submitted accurately and promptly. This documentation supports appeals and disputes, providing a clear trail of evidence.

Adopting Best Practices

By adopting best practices, healthcare providers can streamline their claim management processes and reduce the likelihood of denials. Best practices include maintaining thorough documentation, understanding contractual obligations, and engaging clinical staff in the appeals process. These practices not only enhance claim approval and denial rates but also improve overall operational efficiency.

Staying Informed About Regulatory Changes

The healthcare regulatory environment is continuously evolving, with new laws and regulations frequently being enacted. Staying informed about these changes is vital for healthcare providers. Regularly reviewing updates from regulatory bodies, participating in industry conferences, and engaging with professional networks can help providers stay current and ensure their practices remain compliant.

For those interested in exploring these topics in greater detail, we invite you to access the full webinar, Wakefield Webinar with Becker’s: Mastering Complex Claims with Legal Concepts. This resource provides an invaluable opportunity to deepen your understanding and equip yourself with the knowledge needed to manage complex and problem claims successfully. The webinar offers expert insights, detailed case studies, and practical tips that can help you navigate the intricacies of healthcare billing and claim management with confidence and efficiency. Don’t miss this chance to enhance your skills and improve your organization’s claim handling capabilities.


Table of Contents

What is Revenue Cycle Management in healthcare? (RCM)

Revenue cycle management (RCM) is the financial process that many healthcare systems and facilities use to track patient care episodes, from registration and appointment scheduling to the final payment of a balance. It includes various administrative and clinical functions crucial for healthcare organizations’ financial health.

How can updating patient registration and eligibility verification improve RCM?

Updating patient registration and automating eligibility verification processes streamline data accuracy and reduce the time spent on manual checks with insurance payers.

This efficiency speeds up the revenue cycle and enhances financial stability by ensuring that services rendered are covered.

With ever changing healthcare regulations why is accurate coding crucial in healthcare RCM?

Accurate coding ensures that healthcare providers are properly reimbursed for the services provided. It is essential for patient payments, reducing billing errors and avoiding claim denials, which are often linked to medical or insurance eligibility errors. Thus, accurate coding supports the organization’s financial health.

What strategies can be used to support claims processing?

Supporting claims processing involves providing training and resources to staff, understanding their challenges, and implementing solutions to optimize the billing processes. This proactive support helps minimize claim denials and ensures timely billing and cash flow.

What are the benefits of embracing innovation in RCM?

Embracing innovation, such as EHRs and artificial intelligence, helps streamline claims submission, enhances insurance verification, and improves overall financial performance.

Innovative tools save time, reduce human error, and allow healthcare providers to focus more on patient care.

How does prioritizing patient satisfaction affect revenue cycle management?

Prioritizing patient satisfaction improves the likelihood of patients fulfilling their financial obligations and enhances the healthcare provider’s reputation. Clear communication about costs and payment options also supports efficient payment collections and contributes to a healthier revenue cycle.

What role does data analytics play in RCM?

Data analytics are crucial for tracking the performance of the revenue cycle. They help healthcare organizations monitor revenue goals, identify trends, and make informed decisions about where improvements are needed, ultimately leading to better revenue generation and financial stability.

Why consider outsourcing in healthcare revenue cycle management?

Outsourcing RCM tasks to experts can provide significant advantages, especially in complex medical billing and coding areas.

Experts like Wakefield can help optimize revenue cycle management processes, leading to more efficient claim handling and reduced denials.


Surprise Billing Important Takeaways

Surprise Billing: Important Takeaways

Wakefield delivers key insights on the complex issue of surprise billing in healthcare, offering valuable takeaways for patients and providers alike. With a confident grasp of the nuances in healthcare finance, they dissect the implications of unexpected medical bills that arise from gaps in insurance coverage or out-of-network services. Wakefield’ analysis is both comprehensive and accessible, shedding light on regulatory changes, patient rights, and provider responsibilities.

Read More »