After his father died last year and his mother was diagnosed with
Alzheimer's disease, Jay Brown and his three siblings began handling
their mother's medical paperwork.
They soon became overwhelmed.
"We're smart people, but were just unable to sort through the bills,"
says Mr. Brown, a 58-year-old home builder in Keller, Texas. The last
straw came this spring, when the insurer refused to pay a $1,600
ambulance bill.
He turned for help to Becky Stephenson, one of a growing group of
claims-assistance professionals who, for about $75 to $120 an hour, sift
through paperwork, track claims, decipher what needs to be paid,
uncover mistakes and appeal claims denials.
Most claims advisers have health-care backgrounds as well as
experience in medical billing at hospitals and doctors' offices. Ms.
Stephenson, a registered nurse with an M.B.A., ran physicians' offices
for a large hospital organization and performed audits for insurance
companies before starting her Austin, Texas-based business, VersaClaim, a
decade ago.
The services aren't for everyone. Most people have relatively few
health-care expenses and can probably handle their claims themselves.
But if you have a complex situation, the services can save you a lot of
time and money, says Gary Sastow, a health-care attorney in Harrison,
N.Y.
Typical clients include busy individuals or families dealing with
catastrophic health issues—car accidents, cancer, strokes and chronic
conditions—who are overwhelmed by medical-related paperwork.
Adult children who are helping elderly parents can also find the
services useful. By the time they get involved, the stack of unresolved
bills might be years old, and bill collectors are dunning the parent or
their estate.
The first thing claims advisers do is round up the paperwork, examine
the insurer's rules, determine deductibles and co-pays, and contact
doctors or insurers if anything is missing. They then audit the
documents and often turn up errors.
Doctors, for example, might have billed the patient for treatment the
insurer should have paid, simply because the hospital didn't provide
the patient's insurance information, says Katalin Goencz of
MedBillsAssist, a claims-assistance firm in Stamford, Conn. Similarly,
if a hospital doesn't receive payment from an insurer, it bills the
patient.
Cracking the Code
Claims advisers also scrutinize billing
codes, which are health-care hieroglyphics that determine how much you
will be charged and whether the insurer will pick up the tab.
Some health plans treat colonoscopies, for example, as preventive
procedures that are fully covered. But if a polyp is discovered, the
doctor might code it as "surgery," for which the patient is partially
responsible, says Mary Kesel, a former benefits manager at a large bank
who founded Benefit Advocates, which provides claims assistance to
individuals and employers and is based in Winston-Salem, N.C.
Claims advisers can challenge the codes and negotiate with doctors
and hospitals to try to lower your bills, which can mushroom during a
crisis. If you end up in an intensive-care unit, you might have no
control over which trauma surgeons, infectious-disease specialists or
anesthesiologists treat you. If they aren't in your insurance network,
you can end up with thousands of dollars in bills the insurer won't pay
for.
In these situations, claims advocates might ask the doctors for a
discount if the patient pays in full, or arrange a payment schedule for
their client. "They're sick themselves, or a loved one is sick, and
dealing with bills is the last thing they need to do," Ms. Kesel says.
If insurers balk at paying for a treatment or deny a claim
altogether, whether for medical care or long-term care, the claims
advisers handle the appeals. Ms. Stephenson's appeal to the insurance
company that denied the Brown family's claim for ambulance coverage is
pending.
Medicare Decisions
An increasing part of their practices
involve helping clients with Medicare decisions, including applying for
benefits, selecting their prescription-drug plans and warning them of
pitfalls, such as choosing a Medicare Advantage plan that might not
cover them out of state.
Claims-assistance professionals shouldn't be confused with so-called
Medicare advisers, who provide information about retiree health plans,
typically when an employer is outsourcing the plans and cutting
benefits. Medicare advisers earn commissions and don't provide other
services.
One resource for claims-assistance referrals is the nonprofit Alliance of Claims Assistance Professionals. It screens potential members and requires three references.
Mr. Brown, the home builder, pays an hourly rate of $85 for Ms.
Stephenson's help. "We put the bills in an envelope and send them, or
scan them, and she takes it from there," he says. Without the paperwork
headaches, "we can focus on loving our mother and giving her the best
care."
