Working in the medical field, in a capacity where you rely on getting money back from insurance companies like Medicare, can make a big difference in keeping you working. 

Having a range of reimbursements for care will keep you working or your medical center running, if one or several payments are refused or paused, this can cause a backlog of payments to staff and rent, causing a large amount of stress in an already stressful workplace. 

If this happens, you may need to go to a legal professional who can work with you on the costs you need to be reimbursed and figure out why this has been refused or the payment delayed, this will mean going over financial information with your legal representative. 

You may not have had any issues with Medicare or other insurance companies covering the bulk of a medical bill. However, this does not mean that, at some point, you will not be subjected to a review or have a payment refused or held. 

In this article, we will discuss some steps you can take to ensure that you have the best legal representation if this happens to you and what you will need to do to get your business back up and running. 

What Happens First?

The first sign you will know that there is a problem is when Medicare or another insurance company declines the reimbursement of the charge for the medical care you have given. When this happens, you can file for an ALJ hearing

There are several different circumstances in which you can file for an ALJ hearing. These include not receiving the costs for care, Medicare not calculating the correct amount for care, not paying the full bills, and not classifying the medical care given as under their regulations and allowances, among others. 

Medicare can make errors without any incorrect paperwork or filing, and their audits can show discrepancies that are not real. 

You must act fast if you realize that you have not received a payment or an audit has been returned by an insurance company as incorrect. This is because there is a strict time limit on how long you have to get to an ALJ hearing to have your case seen and an outcome decided.

What Happens At An ALJ Hearing?

Before the hearing, you will want to contact trusted legal professionals who will assist you with your ALJ hearing. You will need all of the paperwork to show that the person you gave medical treatments to had Medicare or another insurance company and that this company would provide the payment when filed. 

When working with a legal professional, you will be guided in how to phrase your case and aided with this. You will also be given advice and assistance around what you will need to provide to prove your case. This does not, unfortunately, mean you will get your full payment. However, you do have a better chance with a professional lawyer working alongside you. 

There are only three outcomes for an ALJ hearing, this being that you get the payment in full, part, or not at all. A Legal professional will conduct the ALJ hearing and will decide the outcome based on what information they are given, this is why you can be better off with your legal help. 

Do I Need A Lawyer?

When you have a legal professional who has worked in these cases before you will find that they know how to find the flaws in what the insurance companies have put forward as their reasons for not paying. Not only this but you will have help from someone who knows what to look for and what you need to show to prove your case. 

With legal guidance, you will also be informed as to how long of the window you have left for an appeal and to start with the hearing procedures. It is also possible with legal help to get a more accurate representation of how much your company will be owed by the insurance company, not just for lack of payment but also for the costs of having to go to a hearing for a failing on their part. 

It can also be beneficial to have someone speak on your behalf and on behalf of your company regarding the costs and reimbursement for the care you have given. Not only will a lawyer be able to help in this way, but they will also help you build a comprehensive case to get you the most favorable outcome for you and your business. 

You do not need a lawyer to file for an ALJ hearing. However, it can benefit you, not only with the costs of filing for the hearing but other paperwork you must do to get to this point. 

It is also worth factoring in that when you are filing for an improper or incomplete payment from a medical insurance company, you can get a free consultation to get some legal advice to determine if you are following the right lines to get a favorable outcome or if you need legal advice. 

In most cases having a trained legal professional helping you will give you a more favorable outcome as you will have someone knowledgeable in this area to guide and support you through the whole process. 

What Is Next?

If you agree with the outcome of your hearing, that would be the end of the legal route, and you would either receive a full or partial payment. If you disagree with the outcome, there are further routes you can follow. If you do continue, it would benefit you to have legal representation and to have had this from the start. 


Having a payment partially or fully refused by an insurance company can be the worst thing to happen to a small business in the medical field. It is always advantageous in this situation to know and have a legal team you can trust on hand to help you. 

If you are concerned about the results you have had from a recent insurance audit or you are not getting the payments, In that case, you should get in touch with a trained legal professional for a free consultation and see if they can help you get the cash flowing and the business moving again.