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Claims-assistance professionals help with medical bills

When Dawn Hampton was diagnosed with cancer 10 years ago, it was a life-altering experience. But it wasn't overcoming the cancer that put her onto a new track; it was battling her medical bills.

"I discovered, gee, if I'm having this much trouble managing my bills and I really manage my stuff well, what do people do that don't?" she says.

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Dawn went back to school, earned a Registered Health Information Technology degree, and opened Ph.D. Organizational Services, a medical billing and claims-assistance service in Santa Barbara, Calif. She has been thriving on the chaos of modern health care billing ever since.

No, she's not a Ph.D. The initials stand for Piled High and Deep, which is usually the state she finds her clients' bills in when they call for help.

Hampton is one of a small group of entrepreneurs known as claims-assistance professionals, or CAPs -- health care hired guns who will wade through your medical morass, light a fire under your insurance company to pay up and keep your doctor and the collection agencies in the loop and off your back.

Although no formal training or degree is required to become a CAP, many have the extensive background in either insurance claims or medical billing that enables them to be effective advocates for the majority of us who don't speak medicalese.

Hampton previously worked in mortgage and construction. Susan Dressler, the owner of Health Claim Assistance Inc. in suburban Chicago, worked in insurance claims for 17 years with Northwestern Mutual Life and John Hancock. Carol Hess, who in 1985 founded Medical Claims Service of Southwest Florida in Cape Coral, sold insurance. Elizabeth Oldenburg, owner of Medical Claims Assistance Service in Woodruff, Wis., did billing for a mental health clinic.

CAP licensing varies state to state. In Florida, CAPs must obtain a Public Health Adjuster's license and post a $50,000 bond; in Illinois, they must pass an insurance specialist exam. In more than half the states there is no licensing requirement at all.

The cost of hiring a claims-assistance professional varies widely, too:

  • In Chicago, Health Claim Assistance charges $80 per hour.
  • In Florida, Medical Claims Service of Southwest Florida charges $60 per hour.
  • In California, Ph.D. Organizational Services makes anywhere from $75 to $150 per hour on a project basis.
  • And in upstate Wisconsin, Medical Claims Assistance Service charges between $25 and $30 an hour.

Most CAPs have a core clientele who pay monthly to outsource their medical bills.

In 1995, Dressler started the Alliance of Claims Assistance Professionals, or ACAP, an industry group that serves as a referral service and start-up resource. If you're looking for a CAP, the site is a good place to start. Dressler sums up the industry's mission this way:

"I just hate to think of the people who are just paying these bills even though they don't owe them, and there are a lot of providers who won't refund; even though they know it's not right, they just don't."

Part Columbo, part pit bull

Don't confuse CAPs with medical billing associates or electronic billing specialists who work on behalf of hospitals and physicians. These hired guns -- part Columbo, part Perry Mason and part pit bull -- save you the time and indigestion of fighting the screw-ups, double billing, misbilling and random errors that have become epidemic in health care billing today. Healthcare Business Advisors estimate that insurers reject 4.5 billion claims a year, roughly three out of every 10.

CAPs offer a free initial consultation; they need to see your medical mess to determine if they can help you. Be sure to bring along the summary of benefits from your insurer. In almost all claims cases, the answer to disputes lies within the terms of your policy or the medical provider's agreement with your insurance company.

The next step seems drastic: Stop paying your medical bills. But Stan Grigiski, owner of Medical Claims Service of Southwest Florida, says it's usually a necessity.

"Usually, we tell our clients not to pay any bills, to just send everything over to us," he says. "That way, we can tell if it is correct with the insurance company. These bills may very well still be pending with insurance, but the individual doesn't know that and they think that amount is due and they go ahead and pay it. You could add another layer of confusion because you then have to try and get refunds."

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-- Posted: Dec. 13, 2004

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