An eye for the fine print Claims: About 7,000 people in the United States make a living by handling medical forms for patients. Claims assistance professionals can earn as much as $90 an hour.

February 10, 1997|By M. William Salganik | M. William Salganik,SUN STAFF

For some, medical bills and insurance paperwork are a nightmare. For Connie Wax, it's a career.

She's a "claims assistance professional" -- sorting through medical bills, poring over the fine print in health insurance policies, calling back doctors to complete claims forms, writing to insurers, holding on the phone.

She is hired by patients themselves, by people caring for relatives or by lawyers who are administering the affairs of elderly clients.

There are others like her, but not many.

Norma L. Border, director of the National Association of Claims Assistance Professionals, says her association has about 2,000 members, less than 10 in Maryland.

Because the association, founded in 1991, is fairly new, Border said she believes more people are out there doing the work but not in her organization. She estimated that 6,000 to 7,000 people in the country are handling medical claims for patients.

(Doctors and hospitals have staff who handle claims, sometimes pursuing appeals on behalf of patients.)

Wax, who calls her company Medical Claims Solutions, learned about handling medical claims from a slightly different angle, working for a durable medical equipment company.

"I learned a lot," she said. "I saw what goes on in the insurance business. I also saw people were very confused about what their policies covered."

She also learned by pressing a claim on her own behalf -- when she had seen a doctor on Dec. 6 who had been dropped by her medical plan on Dec. 1.

Her claim was denied twice -- but she got the insurer to pay for the visit on the third try.

About two years ago, she decided to go into business for herself. She consulted a cousin, who has run such an operation in Seattle for about 10 years.

In part, she said, she was looking for work she could do from her Northwest Baltimore home to fit in with family plans.

She had a baby in June; Sarah goes to a sitter part of the day, and Wax said she is able to do some other work while the baby naps.

In some cases, she is willing to work for a percentage of the claim she recovers but generally gets $30 an hour.

According to Border, that's at the low range of fees charged by claims assistance professionals nationally. Many charge in the $60 to $75 range, she said, and rates in New York might be as high as $85 or $90.

But, Border said, a claims professional can often save clients money.

Louis J. Weinkam Jr., a Catonsville lawyer who uses Medical Claims Solutions for some of his clients, said, "I used to do it myself, and my hourly rate is $125. And I was running around in a maze, not always able to maximize the client's benefits.

"She's gotten a number of refunds on bills our clients had already paid. It's a nice windfall for the client."

Some of the claims are hard to untangle.

Wax recalled a complex case in which a client with Maryland insurance was injured in a car accident in New Jersey and treated in New York, by a doctor who was not a member of the insurer's medical panel. In another case, a woman believed she was uninsured, but Wax, by talking to her late husband's employer, was able to get back premiums paid out of a widow's benefit that the woman was owed, thus covering a number of medical claims.

If the case is simple, a claims assistance professional is unlikely to get called in.

More likely, said Border, it is "somebody walking in with Grandma's shopping bag full of unresolved medical bills."

Wax said she once entered a client's home where there was so much insurance and billing paperwork that "it took me four hours just to make piles."

Often, Wax said, the resolution of a claim is not difficult, once she has figured out what's missing and tracked down the right policy number from the client or the procedure code from the doctor.

Other times, she determines, after scanning the fine print, that a client's policy doesn't cover a particular procedure.

Rather than being angry at having to pay, she said, the majority of clients are relieved just to have a clear idea of what they owe to whom.

On the other hand, she said, "If someone has benefits coming, I'll challenge it to the end of the Earth."

Although she is persistent, Wax said, insurance company people are generally happy to deal with a claims assistance professional -- someone who understands the policy and isn't sick or upset.

As in the case of Connie Wax, preparation for a claims career is "usually experiential," Border said. She added that a few community colleges have started offering courses in processing medical claims, although these are aimed more at people who would work for insurance companies, doctors or hospitals.

Her association offers a certification program based on a 160-question multiple-choice exam, but fewer than 100 have gone through the voluntary program.

There is always talk in the medical and insurance industries about simplifying paperwork, through such means as standardized forms and electronic processing. And paperwork is eliminated for some in health maintenance organizations, said Richard Koorsh, a spokesman for the Health Insurance Association of America.

But Connie Wax is not afraid her work will disappear: "As long as there's -- unfortunately -- ill people in the world, there's going to be work for me."

Pub Date: 2/10/97

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