Medical Claims Advocates

Do Not Pay in Advance!

Prior to a scheduled surgery, a doctor’s representative called to report what they believed to be the anticipated out of pocket expense for the upcoming services. The next day, the hospital representative called and said virtually the same thing.  Both wanted payment in advance.

In this case, MCA told the health care provider that the patient would rather wait to see the insurance company’s Explanation of Benefits (EOB) before paying any coinsurance. The answer was graciously accepted and services were paid after the surgery. This gave MCA the opportunity to match up all claim invoices with EOB’s. 

Unless the refund is noticed by the patient and requested, it may not be returned.

This scenario happens quite often: multiple providers, who are in the network, sometimes request payment in advance.  If everyone is paid upfront, chances are the deductibles would be met more than once.

Rarely, if ever, do providers work together. If two deductibles are paid, then one of the providers must reimburse the patient.  Typical reimbursement practices from most providers are slow, if at all. Oftentimes, unless the patient notices the error and requests a refund, it may not be returned.

Customer Representatives Can Be Misinformed

Now with HealthCare Reform partially in place, insurance must pay 100% for annual preventative visits. Why was an invoice received for a mammogram?

The insurance company had the wrong plan listed in their computer!

Prior to September 2010, not all insurance plans covered preventive cancer screenings at 100%. As it turned out, the mammogram in question was performed prior to the new law taking effect. MCA made a call to the insurance company to determine if the mammogram was a covered benefit. The customer service representative at the insurance company said that it was not. The MCA advocate read the individual’s contract and determined that the insurance company had the wrong plan listed in their computer! Knowledge, patience and persistence on the part of the MCA advocate resulted in the ability to identify the error get the system corrected.  The mammogram screening was ultimately paid at 100%. 

Charged for Two Deductibles

While managing an account, MCA noted that two deductibles were being imposed in the same calendar year.  Although not uncommon for insurance companies to charge an in-network deductible and an out-of-network deducible, this situation was curious.

An additional $175 deductible charge sent up a red flag for the MCA Advocate.

In this case, a common outpatient surgery was performed. However, an additional $175 deductible charge sent up a red flag for the MCA Advocate.  The in-network deductible had already been met for the year.  During an audit, various provider services were identified.  An out-of-network deductible was being applied to a doctor that was actually in the network!  Verification and confirmation led to the claim being re-processed and the additional $175 charge removed.

$8,500 Refund!

Accidents happen that can turn life upside down in a heartbeat. This working mom was holding down a full-time job and raising a toddler and an infant when she learned her husband had an accident that instantly left him a paraplegic.  As the bills came in, they were paid immediately to avoid collection issues.  The insurance company and doctor’s offices were entrusted to be true to their contracts.

After paying over $10,000, she thought there must be a stopgap somewhere.

After paying over $10,000, she thought there must be a stopgap somewhere.   She called the insurance company and learned there was!  It was after she paid $3,500 out-of-pocket.  (This is referred to as an “annual out-of-pocket maximum”, or OOP.)  Assuming there would be a refund she was informed that all invoices and charges had been paid according to the contract, and she still had not met the OOP. This is when she called for help.

Her Personal Advocate performed a claims audit, and persisted with the right people until the appropriate refund check was received from the insurance company for approximately $8,500.

Prescription Headaches

Prescription coverage can become a real pain, especially when you think your responsibility will be $40 per month and it ends up costing you $220 per month because the medication was denied by insurance. 

Denial was overturned and prior payments were reimbursed.

This person tried on her own, with the doctor, to appeal to the insurance company for her husband’s pain medication.  It was denied at the first appeal level.   She then called Medical Claims Advocates for assistance.  Learning about the drug, and the personal issue, the MCA Personal Advocate was able to make an educated appeal at a higher level within the insurance company. This was also denied. MCA then took the appeal to the appropriate governmental agency where denial was overturned and prior payments were reimbursed. From that point forward, the monthly medication was covered at the $40 co-pay level.