Who hasn’t heard of someone unjustifiably being turned down on a health-insurance claim? Or being billed unaffordable amounts of money, only to find out that someone with the same procedure was billed half as much? A recent article about this frequent problem appeared in the New York Times.
Indeed, Susan Dressler of the Alliance for Claims Assistance Professionals says that while Medicare and Medicare supplement claims are cut and dried, when it comes to reimbursements related to a retirement fund, four out of every five claims get denied. But not all turndowns are the result of restrictive insurance company policies, Dressler points out. “If a claim has to go to a mailroom to be taken apart, which frequently happens, mailroom personnel too often separate pertinent portions of the claim, which then don’t reach the claims examiner.” While mail is giving way to the electronic filing of claims, errors of all kinds occur.
It’s foul-ups like these that help create a demand for medical claims assistance professionals. Whereas medical billing services work with health care practitioners, medical claims assistance professionals, often called CAPs or Medical Billing Advocates, are hired by patients. CAPs file and follow-up on claims for people whose doctors don’t file private insurance claims. While doctors must file Medicare claims for patients, they’re not required to file private insurance company claims. Having a professional who will handle such claims is a great relief for many people who simply don’t want to file their own claims as well as those who are too ill or too befuddled by the process to do it themselves.
The effective CAP knows how to spot incorrect amounts or mistakes that cost the patient money. As Dressler points out, “A lot of follow-up needs to be done after a claim is filed. Often claims don’t get paid because there’s little human intervention.” The medical claims assistance professional goes the extra yard to reduce the chance of any foul-ups in reimbursement, and if there is one, to get it corrected.
Once a claim has been filed and processed, CAPs check the “explanation of benefits notice” to verify that the insurer or Medicare has paid the correct amount. Frequent mistakes occur with patient deductibles and stop-loss limits. Also the CAP monitors the co-payment that the patient makes to be sure that the doctor hasn’t charged a larger amount than the insurer has established as the allowable fee.
Finally, if an insurance claim is denied, CAPs investigate the reason and try to get the denial overturned. Many claims are denied because of simple mistakes such as improper coding by the doctor’s office, duplicated charges, or late filing. Some claims are denied based on a policy restriction, but an effective CAP can negotiate either with the insurance company to pay the claim or with the doctor to reduce the charges. Claims assistance professionals are quickly coming into prominence. The great need for this service is the main reason for its growth. Literally millions of consumers are recognizing that they desperately need help in understanding the complexities of our Medicare and private health-insurance systems.
As one CAP put it, there are many powerful groups to protect the interests of insurance companies, hospitals, and doctors, but the average person with insurance has nobody to help him or her. Lori Donnelly, who operates a successful claims assistance business in Pennsylvania, points out that this is such a new business that many consumers don’t even know about it, so there’s a wide-open client base for many new businesses.
Because of the high health and dollar stakes involved, this field is growing. Another professional organization is the Medical Billing Advocates of America.
What does it take to do this work? You need an excellent knowledge of the health-insurance industry: how it works, the terminology, how claims are processed and why they may be denied, what steps a person can take to appeal a rejected claim, and how to appeal. You also need to have a proclivity for finding mistakes in documents, and, of course, good communication and negotiation skills. Most of your clients will be seniors or families in crisis who need someone to listen thoughtfully to their medical and financial problems. You may find yourself disputing a denied claim with an insurance company on one side and, on the other, trying to get a doctor to lower a fee. You must be able to represent your clients and get them the maximum benefit possible. Finally, good organizational skills are required because you may have as many as 300 clients, each with many insurance claims at different stages of processing.
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