Claims-assistance professionals help with medical bills -- Page
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,"
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.
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
"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