Advertisement
retirement

Hire Help to Handle Hefty Medical Bills

When a sudden medical crisis occurs, health insurance claim specialists can assist with resolving bill payment issues.

When you or a family member experience a medical crisis, it can be hard enough to focus on getting the best care. The last thing you want to deal with is an overwhelming pile of medical bills.

Health insurance claims specialists can help. They serve as experts, advocates and detectives—knowing how to deal with the mysterious and complex insurance system, translate the jargon and codes, understand when you need to pay a bill and when to wait, and how to fix errors and build a case for an appeal.

Advertisement - Article continues below

“It’s not a process you get good at because hopefully you don’t go through it very much,” says Kathleen Hogue, president of Mediform Inc., in Twinsburg, Ohio, who has been a medical claims specialist for 37 years. Her job has changed a lot during that time, especially now that more people have high-deductible health insurance policies, complex out-of-pocket cost rules and narrow provider networks.

Claims specialists tend to charge $75 to $95 per hour, and they’ll generally give you a free consultation with a cost estimate and some basic advice. You can find claims specialists through the Alliance of Claims Assistance Professionals. Some prefer to work locally; others have clients throughout the U.S.

Advertisement
Advertisement - Article continues below

If you suspect there is an error in a medical bill, it helps to contact a claims specialist before making arrangements to pay. “You don’t want to negotiate 50% off something you didn’t owe to start with,” says Pat Palmer, a medical claims specialist in Roanoke, Va. “You want to contact someone with experience to do a thorough investigation into those charges.”

Advertisement - Article continues below

Contacting a claims specialist soon after discovering a problem can help avoid hours of frustration and missed deadlines (specifics vary by plan, but you generally have 180 days to file an appeal). “Many times people try to resolve it on their own, and they make a million phone calls and fight with the insurance company,” says Denise Sikora, president of DL Health Claim Solutions, which has offices in Monroe Township, N.J., and The Villages, Fla. “By the time they get to me, these claims are often more than a year old, and sometimes two and three years old,” says Sikora.

The claims specialist may be able to spot an error to get a claim paid quickly without filing an appeal. Pat Shea, a specialist in Green Bay, Wis., says about 80% of the denials he deals with are reversed once he resubmits the claim with extra information or coding mistakes fixed. Only about 20% go to a formal appeal.

Strategies to Trim Bills

Shea first studies the denial letter. “You look at the reason for the denial, and that’s what gives you the way forward,” he says. If payment was denied because the procedure was cosmetic, such as removal of a skin lesion, he asks the doctor to provide evidence that the procedure was medically necessary, for example. If the diagnosis or treatment was miscoded, Shea fixes it and resubmits the claim. He tries to deal with insurers through e-mail, so he has a paper trail. (His website at www.medicalclaimshelp.org offers more strategies.)

Advertisement - Article continues below

Shea can also help people avoid claims trouble ahead of time. Anne Richardson of Alexandria, Va., contacted Shea when she was helping her adult daughter get coverage for cochlear implant surgery. Her daughter works in Atlanta, but the surgeons recommended for her complex case were in Chicago. Before scheduling surgery, Richardson contacted Shea to find out if there was anything he could do to get coverage at the distant hospital. Shea found that her daughter’s plan has a reciprocal arrangement with certain out-of-state hospitals in the Midwest. He made sure that her surgeons, radiologists, anesthesiologists and followup therapy providers would all bill at in-network rates.

Richardson says the full price for the surgery and therapy would have been about $90,000, but with in-network coverage they paid just $6,000 (plus $225 for Shea’s help). “If you are facing a complicated surgery, get someone to check on the coverage ahead of time,” says Richardson.

Advertisement
Advertisement

Most Popular

18 Things You Can't Return to Amazon
Smart Buying

18 Things You Can't Return to Amazon

Before tossing these items into your virtual shopping cart, be sure to read Amazon's return policy first.
September 17, 2020
Election 2020: Joe Biden's Tax Plans
taxes

Election 2020: Joe Biden's Tax Plans

With the economy in trouble, tax policy takes on added importance in the 2020 presidential election. So, let's take a look at what Joe Biden has said …
September 18, 2020
7 Foreign Countries Luring Americans to Work Abroad During the Pandemic
careers

7 Foreign Countries Luring Americans to Work Abroad During the Pandemic

Work remotely – really remotely – in these appealing destinations offering special visas for American workers.
September 18, 2020

Recommended

3 Tips to Help You Navigate Open Enrollment in Your ‘New Normal’
health insurance

3 Tips to Help You Navigate Open Enrollment in Your ‘New Normal’

With all the changes going on in workplaces across the country since COVID-19, your insurance and benefits needs might have changed, too.
September 15, 2020
This Year’s Benefits Open Enrollment Period Is an Opportunity You Don’t Want to Miss
health insurance

This Year’s Benefits Open Enrollment Period Is an Opportunity You Don’t Want to Miss

Plan ahead to do a deep dive into the benefits your employer offers. Given what we’ve been through so far in 2020, you may need them!
September 9, 2020
Retiree Health Care Costs Are Rising
Healthy Living on a Budget

Retiree Health Care Costs Are Rising

Factors driving the increase include longer life spans, health care inflation and health bills for those who retire before they’re eligible for Medica…
August 18, 2020
HSAs Get Even Better
Financial Planning

HSAs Get Even Better

A health savings account is a powerful, tax-advantaged tool to cover out-of-pocket medical expenses and a smart way to save for medical expenses in re…
July 3, 2020