It’s a typical health insurance scenario. You or a family member has some medical procedure done. It usually involves a hospital stay. Within a few days or weeks, all of the bills come to you from the doctors, the hospital, the anesthesiologist, the labs, the radiology department, the surgeon...everyone who had a part of your health care event.
If you have health insurance through your employer, you’re usually only concerned about the amount of the bills not covered by the insurance. That would be your deductible amount and any co-pays you might have.
But what if some medical procedures are denied? What if some are underpaid? How do you challenge the determinations of the insurance company examiners?
Those bills can be in the thousands of dollars. For more serious illness and treatment, the bills can be in the hundreds of thousands of dollars.
Unfortunately, many of the bills are incorrect...sometimes wildly incorrect. Billing miscommunication happens daily on all levels. Doctor to patient, doctor to coding staff or billing service, billing service to insurance company, and insurance company to patient. Many miscommunications are due to poor interpretation of the facts. The right hand doesn't know what the left hand is doing.
The patient is caught in the middle, doesn't know who to believe, and being the ultimate bearer of the financial obligation, many times just pays the bill out of frustration. There is no average case, all situations are different, and no two problems are the same.
But, what can be done? How can a regular person...an average American faced with giant medical bills...determine the correct medical charges and get correct medical bills?
Strategy #1: Remain calm.
When calling the insurance company to dispute a payment amount or challenge a denial, insist on obtaining the full name of the person you’re speaking to. If they refuse, ask for a supervisor. I also strongly recommend recording every call. When you call into the insurance company, you’ll regularly hear that “this call may be monitored or recorded for quality purposes.” Don’t you believe it. They are covering their butt in case the claim goes into litigation. Get a recording of your own. Make sure you know the law on recording conversations in your state. You can find that information at: www.insurance-claim-secrets.com/support-files/phonerecordinglaw.pdf
Strategy #2: Become aware of “hot spots” in the health insurance billing process that are the source of many errors.
A major source of errors is the “superbill” filled out by your doctor. It is a long form with row after row of medical procedures, types of tests, diagnoses, types of treatment and codes. If the doctor checks the wrong box it can lead to a claim denial. For instance, a woman may be covered for a mammogram for a typical “wellness checkup doctor visit.” But if the doctor checks a different reason for the visit, the insurer might not cover the mammogram.
If the insurance company denies the claim in that instance, you need to get the doctor’s office visit file notes to see just what the doctor wrote in your file. Send the notes to the insurance company along with the explanation of the doctor visit. This one strategy could turn a claim denial into a claim paid.
Strategy #3: Ask for Credentials
Insurance companies use the term “not medically necessary” frequently in denial letters. This is another way of saying a claims processor is questioning your doctor’s judgment. If you get this denial message, call the insurance company and ask for the name and medical credentials of the person doing the second-guessing. Be cordial and polite, and take good notes. Record the conversation. If you find that the credentials of the claim processor are less than your doctor’s credentials, then send a letter to the insurance company, Certified Mail, requesting a medical review by a doctor with appropriate qualifications. For example, if you have a thyroid problem, ask for review by an endocrinologist, not just the insurance company’s medical director, who may have a completely different medical specialty.
Strategy #4: Separate Multiple Services
Multiple medical services that occur on the same day can also lead to a claim denial, especially if the doctor sends the insurance company two separate bills. So a bill from the doctor for reading an X-ray can get confused with the X-ray procedure that happened on the same day. The insurer may see them as duplicate bills and denies one of them...probably the larger of the two. So, get copies of the bills, highlight the separate charges, include a letter of explanation and send it all into the insurer. You might turn a denial into a payment.
Strategy #5: Retain a Patient Advocate
A Patient Advocate is a person or company that
• Organizes the endless bills, statements and claims forms
• Appeals denials of claims and incorrect payments
• Negotiates settlements with medical providers
The Patient Advocate gathers all the medical bills for a patient, analyzes them for accuracy, works with the insurer and medical provider to get the bills corrected, and negotiates settlement of the bills. They can cut thousands out of incorrect bills.
Finally, remember that everything about a medical bill is negotiable. Medical providers constantly accept negotiated amounts as payment in full. Don’t be the guy that “pays retail”...NEGOTIATE!
You can find out more about Patient Advocates at: www.insurancenightmare.com