Introduction to Health Law and Practice

Welcome to From the Clinic to the Courtroom, Health Law Unpacked, hosted by Kevin Rosenquist. In this episode, we explore the intersection of medicine, our guest, Maria Santi, founder and managing partner of a health and medicine law firm, is an expert in health law, particularly in areas such as health insurance coverage denials, patient rights, and medical billing negotiations. Maria and her team are committed to providing exceptional legal services with a high level of accuracy, attention to detail, and efficiency.

Focus of Maria's Health Law Practice

Maria primarily handles cases related to health insurance coverage denials. A significant portion of her work involves advocating for patients who have been denied treatment or medications, addressing issues that can directly impact their health and well-being. She also works on patient rights issues, including those faced by individuals in substance abuse and mental health facilities. Additionally, Maria helps clients navigate medical bill negotiations. However, health insurance coverage denials are the core focus of her practice.

Reasons for Health Insurance Denials

Health insurance denials often arise from a few key reasons. The most common justification for denial is "medical necessity," a broad term that allows insurance companies to reject coverage even when a specialized doctor has deemed the treatment necessary. Other reasons include exclusions under the insurance policy or categorizing treatments as experimental or investigational. Many people are unaware that there are legal avenues beyond the appeals process, and Maria frequently helps her clients pursue legal action when necessary.

Why Maria Chose Health Law

Maria's journey into health law is deeply personal. From a young age, she aspired to be a pediatrician and even worked with doctors during high school. However, her life took a different turn after becoming a single mother at a young age. Initially pursuing a career as a paralegal, Maria later decided to become a lawyer. Her personal experiences, including frequently helping family members with medical bills and insurance issues, fueled her passion for health law. Maria's desire to help others in situations where healthcare is denied led her to establish her own law firm focused on supporting patients in need of medical care.

Patients' Rights Under the Law

Patients have several important rights under the law, which are often overlooked. For example, while the Health Insurance Portability and Accountability Act (HIPAA) ensures the privacy of medical information, patients are not always aware that they can file complaints with government agencies if their HIPAA rights are violated. Additionally, patients have the right to continue the appeals process when their healthcare claims are denied. In some cases, legal action can be taken. Other patient rights include the right to access and amend medical records and the right to informed consent. The latter ensures that patients are fully aware of their treatment options and can make informed decisions about their care.

The Complexity of Health Law

Health law is a complex field, with numerous layers of regulations at the federal, state, and administrative levels. Each health insurance plan, such as Medicaid, Medicare, or employer-sponsored plans, has its own set of laws that apply. Legal practitioners must thoroughly assess each case, taking into account various factors and nuances. This complexity makes health law a highly specialized area of practice. Maria emphasizes that, in addition to legal expertise, working in health law requires a great deal of compassion and patience, as clients are often facing challenging personal circumstances.

Staying Updated in an Evolving Field

Given the constantly changing landscape of healthcare laws and regulations, staying updated is crucial. Maria stays informed by subscribing to numerous health law newsletters and legal updates, using resources like Westlaw for research. Healthcare news is constantly evolving, and Maria thrives on the challenge of staying current and continually learning. This commitment to professional development helps ensure that her firm provides the best possible legal guidance to both patients and healthcare providers.

The Challenges of Health Law Practice

One of the key challenges in health law is the time and effort required to gather all necessary information to support a case. Legal actions often involve dealing with various health insurance providers, each with their own set of policies and regulations. While this may discourage some attorneys from specializing in health law, Maria views it as an opportunity to help those in need, providing invaluable assistance to patients who might not otherwise have a voice in the system.

Memorable and Impactful Cases

Maria has worked on numerous memorable cases, but one that stands out involves a young girl with a genetic condition who needed a life-saving medication. The medication, which cost $2 million, was critical to the child's ability to thrive and potentially walk. Maria was able to secure coverage for the medication, making a significant difference in the girl's life. The gratitude expressed by the family left a lasting impact on Maria, reminding her of the profound difference legal intervention can make in the lives of patients.

Collaboration with Healthcare Providers

While Maria primarily represents patients, she also works closely with healthcare providers. For example, when advocating for a patient who needs a specific treatment, Maria collaborates with the treating physician to ensure that the medical necessity of the treatment is clearly communicated to the insurance company. This collaboration is essential to ensuring that patients receive the care they need.

The Growing Issue of Insurance Denials

Insurance companies have increasingly denied coverage, and the problem seems to be worsening. One contributing factor is the rise of artificial intelligence in the healthcare industry, which has led to automatic claim denials without proper review. This trend has frustrated both patients and healthcare providers. Doctors are overwhelmed by appeals and preauthorization requests, which only adds to the burden on the healthcare system.

Conclusion: Challenges in the Healthcare System

Maria acknowledges the growing frustration with the healthcare system, especially when it comes to the financial burden placed on individuals. Many people pay high premiums for coverage that offers inadequate benefits, and the constant denials of necessary treatment exacerbate the problem. Maria is committed to helping patients navigate this complex system, even in the face of significant obstacles.