Case Studies > Zero Balance Case Study

Patient claim repeatedly denied coverage, then overturned through dedication and persistence

Key Takeaways
  • An insurance claim was denied as 'cosmetic', despite it affecting the patient's ability to eat. 

  • A Titan Nurse auditor spent over 7 months gathering documentation to pursue the claim.

  • The denial was overturned and $52k was recovered from the insurer.

  • The hospital was able to reimburse the patient's parents who had borrowed from their retirement to pay.

Background

A young man just over the age of 18 underwent a temporomandibular surgery due to a congenital defect. He had difficulty eating because of the defect. His insurance repeatedly denied the claim as “cosmetic” and therefore not a covered benefit. The hospital balance billed the patient due to the services not being covered, and the patient’s parents had to borrow from their retirement account to pay their son’s medical expenses.

The Challenge

The hospital had been unable to get the patient’s claim paid. Multiple appeals were unsuccessful, and the balance was finally transferred from insurance responsibility to patient responsibility. The hospital billing staff was unable to overcome the cosmetic denial. The unpaid claim was ultimately assigned to Titan for resolution. 

The Solution

A dedicated Titan nurse auditor spent over 7 months pursuing insurance reimbursement for the claim. The auditor coordinated with multiple physicians involved in the case, assembling volumes of medical documentation in order to make a persuasive medical necessity argument for the insurer to cover the claim. 

The Results

The Titan auditor finally succeeded in overturning the cosmetic denial and the hospital received a $52,000 insurance payment for the claim. Further, all ancillary charges (surgeons, anesthesia, labs, etc.) ended up being covered as well.

“The young man’s parents had taken a loan against their 401K to pay for the care of their son. When we notified his mother of the overturn, she called us in tears. She was so appreciative.”

Gidget Bowers VP, Revenue Integrity Solutions, Titan Health

 

By the Numbers

40 follow ups over 7 months. 

$52k recovered

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