Assignment of Benefits Denial Sample Letter


Provider Appeals Department
City, State, ZIP Code

Re: Assignment of Benefits Denial


Health Plan ID Number: Group Number:
Insured/Plan Member: Patient Name:
Claim Number: Claim Date:

Dear Sir/Madam:

[Insert org name here] is deeply concerned about your apparent policy of ignoring a patient's request to assign benefits for services to treating non-participating emergency physicians. We believe that this policy serves to undermine the unique relationship that exists between patients and emergency medicine providers, places a superfluous burden on the patient, and has the potential to fuel access to unnecessary services.

In fact, several states have enacted legislation mandating that insurers honor a patient's assignment of benefits to non-participating providers of emergency care. Legislators and regulators are increasingly recognizing that a process whereby patients directly receive payments for performed emergency services, coupled with the fact that medical care providers cannot refuse to see anyone who comes to a hospital emergency department, might establish some pernicious incentives. When payment for services goes to the patient, the responsibility for its retrieval falls to the emergency medicine provider. We have observed that on occasion, some beneficiaries will retain this payment and, sometimes inadvertently or sometimes intentionally, not make their own payment for the services received. It is not difficult to see how such a system might provide an incentive to over utilize emergency medicine services in anticipation of inappropriately obtaining insurance payments.

As you are most likely aware, federal EMTALA law mandates that emergency department patients receive a medical evaluation, and any required stabilization and treatment. This stringently limits providers from restricting access to emergency medicine services, even were they so inclined to do so.

We ask you to reconsider your apparent policy with regard to this claim. And, we look forward to working with you to develop procedures so that in the future you can comply with patient requests to assign benefits to treating providers. Please let us know your respective decisions.

[Physician Name]


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