Archive for the ‘Follow up’ Category

PostHeaderIcon 5 Tips for Handling Medical Claims — guest post by Erin Palmer


It can be upsetting to undergo medical treatment, but when medical bills start to arrive it’s easy to move from upset to completely overwhelmed. For families and patients, understanding how to handle medical claims can make all the difference in dealing with the financial stress and time-consuming nature of medical bills.  Consider these tips when handling medical claims:

1. Don’t wait!  Many families wait until there is an unbearable amount of medical paperwork to wade through before beginning the process.  A better way to handle medical billing is to deal with them when they arrive.  Take time to carefully read the information that is enclosed and determine if action needs to be taken.  If the letter is unclear, then immediately call the physician’s office, medical billing organization or hospital to get clarity.  Keeping up with the process is the best way to decrease the stress of medical billing.

2. It’s OK to ask.  Many patients feel intimidated and confused by paperwork that arrives in the mail.  Medical paperwork may be complex and leave patients with more questions than answers.  It is critical for patients to know that not completely understanding their billing is not a problem. It only becomes a problem when patients and their families don’t take time to ask pertinent questions. Virtually every billing statement has a customer service phone number.  Taking the time to call customer service and have questions answered is another effective practice in handling medical claims.

3. Analyze the EOB.  The EOB – or Explanation of Benefits – is one of the first pieces of information provided to a patient and their family.  Before calling the insurance company or provider, there are certain items to identify on the paperwork that will assist in determining next steps.  First, look for the name of the doctor or hospital and the date of the services provided.  The next item to identify is the total charges, noting the amount paid by insurance and the amount owed by the patient.  There should also be a section that shows contractual adjustments. This section should indicate the amount the doctors write off.

4. Know about insurance benefits.  Understanding insurance coverage will help to determine what needs to be paid and what is covered by insurance. Taking time to read the insurance booklet before medical services can help to answer questions before bills arrive.  Also, it is critical to understand the amount due for deductibles as well as co-payments or co-insurance.  To decrease the amount of bills that have to be sorted through, consider paying co-payments at the time of service and pay all bills by check or credit card so that there is a clear payment trail in case of questions later.

5. Don’t ignore bills.  No matter the situation, simply ignoring bills will not make them go away.  Whether there are unexpected bills or too much financial strain, there are ways to effectively work through the process.  The best place to start is to speak with the medical office and ask questions.  Many times, issues can be cleared up quickly and physicians are often willing to take a lower payment for services rather than receiving no payment at all.  Simply ask if there is a way to work out the billing to resolve the issues. Calling the insurance company also often yields results, either by explanation or a promise of reprocessing a claim. Taking a proactive approach, rather than ignoring the bills, will help to avoid frustrating collections calls.

Clearly, it’s upsetting to get a stack of bills while trying to heal from a major medical episode.  With these practical tips, understanding the paperwork, dealing with billing and communicating with doctors and hospitals should be much easier.

This guest post was provided by Erin Palmer. Erin writes about medical billing training programs and medical assistant degrees for US News University Directory. For more information about healthcare careers please visit


PostHeaderIcon Appeals – what to look for – how to file

Medical claims can be denied for many reasons. In most cases the reason for the denial is listed by codes right next to the service line. At the bottom of each Explanation of Benefits (EOB) there should be a code explanation. If the explanation is not listed or you don’t understand the first thing to do is find out or clarify what is being denied and why.
By calling your insurance customer service you can ask questions about a denial and full explanation should be given. During this phone call you may find out that the insurance made a mistake and your phone call of inquiry can prompt the customer service person to send back the claim for reprocessing. In this case, don’t feel completely relieved just yet. There are many things can go wrong and your denial could stand the same after thins phone call. So, the best thing to do in this situation is to mark your calendar in 30 days, note the date of your phone call, the name of the person you spoke with and if any reference number given. This way in 30 days you can follow up with a second call if the claim has not been paid.
Once the reason for denial is fully understand you can file an appeal. Always be sure to have the correct appeals address for your insurance. Letters and faxes often go to a specific department, so sending a letter to the wrong address can further delay the answer. Some of these companies are big that your letter can be easily misplaced and land in the “black hole”. I have heard insurance company representatives using this term.
The next important part is listing your information before your letter begins. This should include your name, your insurance ID number, the date services were provided, your address and the claim number listed on the denial.
The first sentence should state that this is an appeal and you are disputing the denial.
The body of your letter needs to explain what taken place and why this claim should be paid. Try to be clear and free of emotion. Accusing a person reading this letter will not help your appeal.
The closing sentence is the repeat of your demand for payment.
If you have supporting documentation of any kind you need include that with the letter.
Time: most claims have 180 days appeal limit, from the time a claim was processed. State laws and policies may vary slightly.

Types of denials:
• Coverage based
• Technical
• Medical

Coverage based: these are denial when the insurance company states that your policy does not cover this service.
Example: a client had an oral device made by a dentist to treat his sleep apnea. The claim was denied based on the dental component. I successfully argued that his oral appliance was to treat a medical condition.

Technical: these are claims denials mostly for timely filing or coding problems.
Most claims have to be filed within a 180 days from the time services were provided. Missing this deadline will produce a timely filing denial.
Example: the patient was hospitalized for an extended time period, therefore could not file a timely appeal.
Coding problems: each medical claim have to contain a several numbered codes, such as provider tax ID, place of service, CPT or HCPCS, diagnosis, NPI or license numbers. Missing or using a wrong one will produce a denial. In this case there is no need for an appeal. Simply you need to decipher which code needs a correction and simply can resubmit a claim with correct codes.
I am fully expecting these denials to multiply starting on October 2013. That is when the ICD-10 coding change will be implemented and codes will multiply by nearly 55,000.

Medical: these are services denying by the insurance saying that the service was not medically necessary for your specific condition. The appeal should explain why it was necessary and be paid.
In case the first level of appeal is denied I always file a second level of appeal. The review of this appeal takes place with a different department and there is a chance to overturn the first level of denial.

If a second level of appeal is denied there is always an option to file the next level to the Commissioner of Insurance or the Benefit Administrator. The deciding factor is based on the type of policy the person have. Fully funded insurance policies are appealed at the Commissioner of Insurance level, and self-funded insurance policies are appealed at the Benefit Administrator.

PostHeaderIcon Personal Money Manager

In June, I invited Karen Caccavo, Personal Money Manager, to provide a guest blog for MedBillsAssist Blog. Karen is a daily money manager (DMM)—which was NOT the topic of her blog, but this month it is because I find that a DMM is another professional that my clients might need in their quest to come up from under overwhelming paperwork. While I handle the medical bill tasks, Karen is a “paper generalist.” She has an MBA in finance from the Wharton School, so really knows the financial paperwork and how to make sense of it and how to communicate with your broker, financial planner, attorney and CPA.

But I will let Karen explain what she does:
Late payment notices, overdraft fees, missed paperwork deadlines, confusing invoices–not keeping up with paperwork can be costly and stressful for people of all ages and especially overwhelming for people facing medical challenges and seniors. A trusted family member or friend can help, but people often do not want to be a burden or might not have a support system in place. Letting things “slip through the cracks” can be disastrous and costly.
Here is where a daily money manager comes to the rescue. Ours is a relatively new profession but a needed one. We’re not accountants, attorneys, or financial planners but we often provide the “boots on the ground” for these professionals working with individuals who want or need in-home help with paperwork and accumulated clutter.
My current clients range in age from 18 to 94 and access my services on a weekly, monthly or “as needed” basis. Some of my clients are simply outsourcing that aspect of their lives—relying on me to open mail, pay bills, track their spending, organize paperwork for taxes and bring to their attention important correspondence. Others simply can’t keep up with these essential tasks any more because of age or medical condition. My assistance helps them keep their independence. Each client is different and I tailor my services to their needs.

Karen Rosenberg Caccavo, MBA is owner of Personal Money Manager, a daily money management firm. She can be reached through her website, or or LinkedIn.

PostHeaderIcon If you don’t like the answer…

A significant part of a claim assistance professionals work consists of follow up with insurance companies.  We send claims, appeals, and other items, and wait, usually 30 days, to have it processed.

Today I called an insurance company to follow up on a claim submissions as well as two appeals.  I was told by the customer service representative that they cannot do anything until the Human Resources department update specific files.  I was advised to request this information to be sent to the insurance company directly from the member’s HR Department.  Having been doing this for several years, I’ve learned not to argue and didn’t get carried away.  After all, this is business as usual….

So, naturally I waited about 10 minutes to simmer over and called again the same insurance company, the same phone number, and naturally about the same claims and appeal letters.  The second call yielded a completely different result.  The customer service representative checked the claims, verified that all information is correct, and on the file, and promised to reprocess these same claims by the end of this week.

The lesson of my story: if you decide to call your insurance, and push all the necessary buttons on your phone, while lucky enough to get a life human being, the answers aren’t always the same.  Therefore, if you don’t like to response, call again and repeat as necessary.