HEALTH INSURANCE LAW
Health insurance law governs the complex and evolving relationship between patients, healthcare providers, and insurance companies. Navigating health insurance issues can be daunting for all parties involved—patients, providers, and employers—due to ever-changing regulations, intricate policy language, and the high stakes of securing proper medical coverage and payment. Understanding your rights and obligations under health insurance policies is essential for protecting your interests, ensuring access to care, and maintaining financial stability.
Disputes often arise over denied claims, coverage limitations, policy exclusions, or misunderstandings about what a health insurance policy actually covers. Both patients and providers may find themselves facing challenges such as incorrect billing, coding errors, or unexpected out-of-network charges—even when care was sought at an in-network facility. These issues can result in unfair financial burdens for patients and delayed or lost revenue for providers.
Recent laws like the No Surprises Act have introduced important protections against certain surprise medical bills, but implementation and enforcement can be confusing for both patients and providers. Effective legal guidance is crucial—whether you are seeking to interpret policy terms, resolve disputes, correct billing errors, or ensure compliance with new regulations.
Tooke Law is dedicated to supporting both individuals and healthcare organizations in resolving health insurance challenges, protecting financial well-being, and ensuring fair access to coverage and payment. Our approach is comprehensive, addressing the needs of all parties in the healthcare system and working toward practical, equitable solutions.
What We Do
Health Insurance Claims Assistance: We help patients and providers navigate the claims process, ensuring proper documentation, timely filing, and effective pursuit or appeal of denied or underpaid claims.
Dispute Resolution: We represent clients in resolving disputes with insurers over coverage denials, payment delays, and benefit determinations, through negotiation, settlement, or litigation as needed.
Policy Interpretation and Coverage Analysis: We review and interpret health insurance policies, contracts, and Explanation of Benefits to clarify coverage, exclusions, and limitations for both patients and providers.
Medical Billing and Coding Error Resolution: We identify and challenge billing and coding errors, duplicate charges, and upcoding, working to correct mistakes and reduce or eliminate improper charges.
No Surprises Act Compliance and Advocacy: We advise on rights and obligations under the No Surprises Act, challenge unlawful balance bills and surprise charges, and assist with arbitrations, appeals, and compliance.
Appeals and Administrative Hearings: We prepare and submit appeals for denied claims and represent clients in administrative hearings and regulatory proceedings.
Contract Review and Negotiation: We draft, review, and negotiate contracts between providers and insurers, including network participation agreements and reimbursement terms, ensuring fair and compliant agreements.
Regulatory Compliance: We ensure compliance with federal and state health insurance laws, including ACA, FCA, HIPAA, ERISA, NSA, AKS, Stark, and state-specific mandates, and advise on billing, coding, and documentation practices.
Patient Advocacy and Support: We educate patients on their rights, coverage options, and the appeals process, and assist with negotiating payment plans, discounts, or waivers for excessive or erroneous bills.
Provider Revenue Cycle Support: We advise healthcare providers on best practices for claims submission, denial management, and appeals, helping optimize revenue cycle processes to reduce denials and improve collections.
Medicare and Medicaid Issues: We address billing errors, denials, and appeals for Medicare and Medicaid beneficiaries and providers, ensuring compliance and maximizing entitled benefits.
Employer-Sponsored Health Plan Guidance: We advise employers and plan administrators on plan design, ERISA compliance, and employee communications, and assist with disputes involving group health plans and COBRA coverage.