Help with health insurance claims


November 01, 1992|By JANE BRYANT QUINN | JANE BRYANT QUINN,Washington Post Writers Group

New York -- You know it's time for a change when once-simple job gets too complicated to handle yourself. That's the sorry situation with health insurance claims.

When you file your own claim, you cannot be sure that you'll receive all the money you're owed. You might be turned down because of a minor error on the form. You might have put two people's medical bills on a single form, which leads to mistakes in computing your portion of the payment. Your doctor might not have described your surgery properly, causing the insurer to underpay. You might be so buffaloed by the paperwork that you don't file smaller claims at all.

Enter a new service industry: the "claims assistance professional." Over the past decade, an estimated 3,000 to 5,000 firms -- most of them small ones -- have opened their doors to patients who hate to struggle with health-insurance forms. "Just XTC as you need a professional to do your taxes, it's gotten to the point where you need a professional for your health insurance claims," says Irene Card, head of Medical Insurance Claims in Kinnelon, N.J.

These services make sure that your claim form is fully filled in, pursue delayed payments, get further information from your doctor if your claim has been denied, catch insurance-company errors and collect all the money that you're due if you're covered by more than one health insurance policy. They may also evaluate your health insurance (be sure not to go to someone who's also in the business of selling insurance).

For all this, they typically charge individuals in one or more of the following ways, says Norma Border, director of the 18-month-old National Association of Claims Assistance Professionals (NACAP): (1) a flat fee, such as $300 a year; (2) by time spent, billed at anywhere from $25 to $70 per quarter hour (you should get a free initial consultation and fee estimate); and (3) a percentage of the insurance claims.

Often, claims processors combine these fees. For example, Card charges a one-time sign-up fee of $75 per person, $125 per couple and $25 per dependent. After that, she takes 15 percent of any reimbursement under $300 and 10 percent of higher amounts.

For the names of claims processors, check the Yellow Pages under Insurance Claim Processing Services or write to NACAP at 4724 Florence Ave., Downers Grove, Ill. 60515.

One thing claims processors cannot do is rescue any payments denied because you failed to follow your policy's rules. To get full coverage for elective surgery, for example, you may have to inform your insurance company in advance, get a second opinion and check out of the hospital within a specified number of days.

Understanding your health insurance is the first step toward getting all the coverage you're due, says Sharon Stark, author of "Health Insurance Made Easy . . . Finally" ($16.95 from Stark Publishing, P.O. Box 8693, Shawnee Mission, Kan. 66208). Stark, who spent eight years inside an insurance company, says there are payment guidelines that patients normally don't know about.

For example, insurers won't pay any portion of a bill that exceeds the "reasonable and customary" charge for doctors located within the same zip code. These ceilings aren't published, for fear that the doctors will then charge the maximum. But you can call your insurance company and ask if the fee your doctor plans to charge for a particular procedure will exceed the limit. If it does, ask your doctor to lower the fee.

Also, the handbook that comes with your health insurance policy doesn't always disclose exactly what's covered. For example, wheelchairs may be listed, without specifying that the insurer will pay only for basic features. A phone call to the insurance company can usually clarify your coverage, Stark says, but not always.

Bottom line: If your insurer denies payment on a bill, never assume the denial is right. Find out what the problem was. With more information about your claim, maybe the insurer will pay.

(Jane Bryant Quinn is a syndicated columnist. Write her at: Newsweek, 444 Madison Ave., 18th Floor, New York, N.Y., 10022.)

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