The Gibson Firm specializes in Individual and Group Health Plan issues involving the following types of coverage (“Payers”):

• ERISA (Self-funded Employers) Plans
• Group (fully-insured) Health Policies
• ACA Marketplace (Exchange) Policies
• Medicare Advantage and Medicaid Replacement Policies
• Traditional and/or Indemnity Policies, including short-term and travel
• Workers’ Compensation
• Third Party Liability (i.e. auto and property)

Payers will use any means or reasons available to deny or reduce payments. Payers, adjudication of medical claims, denials and other resultant and related actions are governed by a complex array of laws, regulations, policies, and contracts. TGF expertly determines which sets of rules govern each situation and develops a comprehensive strategy to reverse denials and prevent problems from reoccurring. While TGF is adept at handling any healthcare denial, the following types of denials are especially prevalent, and TGF has extensive experience dealing with these issues:

• Pre-authorization / Notification Denials
• Medical Necessity Denials
• Usual, Customary & Reasonable (UCR) Reductions
• PPO Network & Other Contract Issues
• Emergency Medical Services
• COBRA Issues
• Coordination of Benefits (COB)
• Retro-termination of Coverage
• Refund Demands & Offsets