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Claims-assistance professionals help with medical bills -- Page 2

Most clients are more than happy to oblige. "We hear individuals say all the time that once they drop off their papers, they feel like the weight of the world has been lifted off their shoulders," Grigiski says.

As your advocate, a CAP dives into your medical bills looking for double billing, misbilling and assorted errors. They organize and prioritize in order to stop the clock on bills that may be headed to collections. Then they get on the phone and start what can be months or even years of dialogue with your doctor and your insurance company to get matters resolved. They excel at writing appeals packed with the data that makes it easy for a claims adjuster to say yes.

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Lots of trouble spots

Hampton says bills often begin to go astray the minute you set foot in a hospital.

"Historically, hospital admitting does not take in good information," she says. "So you go into the hospital for surgery and the little bit of information they get goes to the ambulance service, the anesthesiologist, the surgeon. And if they have one number wrong on your ID or your address, you might not get your bill. If you don't think to contact each of those providers when you don't receive a bill, you can get into collections very quickly."

The convoluted medical coding system used to price services you receive at your doctor's office holds all sorts of potential for problems.

"The coding is really what complicates it," says Hampton. "If the office doesn't put the right modifier or uses the wrong code, then it can get rejected. It's not like they're trying to be fraudulent; they may just be trying to work the system."

When bills sit around unpaid for too long, as can easily happen when the bill payer is sick or tending to a loved one who is, they can start to fall into collections. To a CAP, collections is a black hole where little information gets in or out. Once a bill goes into collections, the doctor's office has washed its hands of it and is disinclined to help the CAP or the collections agency with information that might help resolve a dispute.

It is not unusual for a CAP's work to continue beyond a client's death. Hampton once helped the son of a heart attack victim whittle down $500,000 in medical bills through four different health plans; the estate only owed the doctor $6.71 when she was done. Oldenburg was still working on one client's medical bills nine months after the woman's death.

Dressler agrees tenacity usually pays off. "I had one woman at Cigna say to me, 'You're not going to give up, are you?' and I said, 'No, ma'am, this is not a giving-up situation. My client paid the hospital $48,000 and she didn't have to do that and you owe this.' And they finally did pay and she got her money back."

Who is using the services of claims assistance professionals? It all depends on location.

In Florida, 90 percent of Grigiski's clients are over age 65 and on Medicare as well as secondary insurance. In Chicago, Dressler's clients include busy professionals such as attorneys and accountants, as well as double-income young parents who have more money than time. In California, most of Hampton's clients are busy business and professional people on the go. And in upstate Wisconsin, a vacation destination, Oldenburg's CAP business is slow; after all, who wants to hassle with medical bills on vacation?

Are there scam artists to be wary of when looking for a CAP? Sure, says Dressler. That's why ACAP won't admit members without three letters of recommendation, which are thoroughly vetted. She advises asking a CAP candidate all the same questions you would a doctor, lawyer or accountant. Get referrals and check them out; any CAP who balks at that should be eliminated immediately.

Grigiski notes that claims assistance is not a field where a con artist could easily scam insurers. "The insurance company keeps records of everything that has been submitted to them," he says. "We could not submit a claim on behalf of the individual and receive payment directly from the insurance company because you would have to be a registered provider and have an ID number."

But all agree that the CAP business is growing as medical billing becomes more and more labyrinthine. CAPs like Dressler and Hampton are increasingly in demand by small businesses and even doctors who seek help in unraveling the billing mess on their end.

"All of my skills and personality are really matched to this business," says Hampton. "I had always wanted to have my own business, but couldn't figure out doing what. I get diagnosed with cancer and suddenly, 'Oh, I'll do this!'

"How can something good come from something so awful? But it did and I'm doing better than I ever thought I would."

Jay MacDonald is a contributing editor based in Mississippi.

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-- Posted: Dec. 13, 2004

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