In Special Needs News

Do you become frustrated and overwhelmed when managing medical bills and filing health insurance claims? Managing and filing insurance claims can be a complex, frustrating, stressful, confusing and time-consuming process, particularly for families who have children with special needs.  But, given the high cost of health care today, it is critical that claims be filed and managed correctly to ensure you receive all the payments due to you and that you pay only the bills you’re supposed to pay. 

Here are some helpful hints on managing medical bills and health insurance claims paperwork from Harvey J. Matoren, MPH, CCAP, who is President/CEO and co-owner/founder of Claims Security of America, a nationwide medical bill management and claims assistance/filing service that helps patients and families manage their medical bills and insurance paperwork.  Matoren’s tips should help get you through the red tape, give you peace of mind and, hopefully, put more money back in your pocket.

1. Whenever possible, try to have the doctor's office file your claims and even accept assignment.  If your doctor accepts assignment, it means that she agrees to file the claim and to accept, as payment in full, the amount the insurance company approves. Your doctor cannot “balance bill” you for the difference between her charge and the approved amount. In most cases, the insurance company will pay the provider directly when she participates with the insurance program. If the provider accepts assignment or participates with your insurance program, your only obligation usually is the co-payment, as stated in the policy. Many providers will ask for this co-pay at the time of your visit. Try to have them bill you for the co-pay after they have filed the claim and been paid by the insurance company. Many people pay the wrong co-pay. For example, they pay 20 percent of the charged amount instead of 20 percent of the approved amount, and consequently overpay and never get back a refund.

2. If you have more than one insurance policy, do not assume that the provider will file the claim. If you have to file the claim, be certain to give the insurance company all the information it needs. Incorrect or missing information will only cause a delay in processing the claim. If you need to submit an itemized statement, be certain the following information is included:

  • Diagnosis
  • Description of service
  • Charge for each service
  • Date of each service
  • Location of each service
  • Name of the provider (doctor, hospital) who actually treated you
  • All appropriate insurance numbers

3. File your claims as soon as possible. Don't let the bills or receipts pile up — and, certainly, don't save all your claims until the end of the year. Timely submission of claims is critical in receiving reimbursement.  Even if your provider agrees to file the claim, you should be sure that it is filed within the filing time limits imposed by the insurance company.  Claims filed too late could result in a bill to you from your provider for services that should have been paid by insurance.

4. Don't pay any bill unless it is clearly understood that it is a final accounting and you are responsible for it.  Never pay a bill until you have received the explanation of benefits form from your insurance company, which indicates who and how much was paid.  Bills are sent prematurely and many patients pay bills before knowing if the doctor or hospital has received a payment from the insurance company.  Duplicate payments to the provider very often result in refunds that are due to the patient but not returned.  When you do pay a bill, keep records according to the date of payment and check number.  This is necessary if you receive a duplicate bill indicating that payment has not been received, and verification of payment is required.

5. Know what’s covered and what isn’t. A lack of knowledge regarding benefits often leads to patients being billed and paying for services that should be reimbursed or written off.  Check your policy to be certain of the covered benefits.

6. Appeal rejected claims regardless of the reason given.  The provider could be helpful, especially if he has not received payment for the service. In addition, appeal all claims that you believe were not paid at the appropriate level.  An insurance company may say that the provider's charge exceeds the allowed amount (referred to as exceeding the “usual and customary charge”), but this may not be the case.  A Government Accountability Office (GAO) study several years ago indicated that, of the millions of dollars of rejected Medicare claims annually, only about 2 percent are ever appealed.  However, of those 2 percent that are appealed, approximately three-quarters are overturned in favor of the patient.

7. If you have to file your own claims, make copies of everything you submit.  This will make it easier for tracking and follow-up. It will also facilitate resubmitting claims if and when the insurance company tells you it never received the information.

Above all, don't be intimidated by the system, Matoren says. If you are persistent, aggressive and assertive, you will be able to maximize your reimbursement, minimize your stress and get peace of mind.



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