Navigating the Maze of Medical Claims

It’s a cool, crisp Wednesday afternoon and Amy Ford Keohane of Greenwich is making a house call. She pulls onto the circular driveway of a stately, whitewashed brick colonial in New Canaan. Shannon Broder, who lives there with her husband and two sons, leads Amy inside. They pass the gourmet kitchen and the grand family room, chatting about mutual acquaintances, former roommates and families they both know from Chicago. It’s cheerful and friendly chitchat, a way for the women who’ve never met before to get comfortable before the serious stuff starts. When they take seats across from each other in the formal dining room, Amy knows to stop talking. Shannon has a lot to say and her story flows as readily as her savings once did.

Usually Amy is a talker, possessing a seemingly unending source of energy when it comes to conversations about health care. Because of her enthusiasm and expertise, she’s been interviewed on countless TV talk shows and blogs and radio programs. But today she’s just listening, nodding in acknowledgement to a story she’s heard recounted again and again from dining rooms throughout the nation.

“My friends wondered why I never went out, what I was doing every night,” Shannon says. Each evening, after she tucked in her kids, she would hunker down in her office across from the dining room, open the binders again, spread out the files again, turn on the computer again and get to work. “I would stay up til one in the morning working on this. Every single night.”

“It’s such a frustrating consumer experience,” Amy soothes. She is wearing a black leather waist jacket over a trim-cut classic black dress, black slingback pumps and a matching purse. Her intertwined chunky necklaces make a little sound as she nods and takes notes. Note-taking, point-making Amy could just as easily be presiding over a marketing meeting at InStyle Magazine, where she worked for years, helping to craft the magazine’s brand to best reach its customers. But she’s in the medical business now—health-care claims to be precise—and that’s the reason for the house call, so she can learn firsthand how to serve consumers.

The consumer isn’t very happy these days when it comes to health care, reports Amy, who in December was named the president of MedClaims Liaison, a national firm that manages health-claims reimbursements for patients and their families. As health- care coverage gets more complicated, businesses such as MCL are thriving. Why? Policies change, coverage shifts and new medical issues emerge each day in a family, triggering a quagmire of questions. How many physical therapy treatments are you allowed before you have to pay in full? Junior needs braces and the orthodontist wants money up front—is this covered? It’s bad enough that Mom’s memory is going … Who’s minding her medical bills? In the meantime, in dining rooms like the Broders’, stacks of paperwork chronicle claims, appeals, receipts and denials. By Amy’s account, those paper trails are growing nationwide like some invasive plant species.

Linda Lovelace hears the stories too. Linda, a Greenwich resident, directs National Medical Claims Service, which is headquartered in Darien. Linda founded her company in 1983, long before there was such a thing as a “medical insurance specialist” who didn’t actually work for an insurance company. But that’s what she became after her mother died, when the bankers and attorneys she’d hired to sort out huge nursing bills stemming from her mother’s care seemed baffled by the whole endeavor. Linda decided to figure it out herself. She became so adept at it that she quit her job as a product manager for General Foods and started her own medical claims consulting firm. Her company joined just a handful nationwide that helped customers manage medical claims, review bills and serve as an advocate and consultant. One of the first customers she signed up was the law firm she’d hired to help resolve issues with her mother’s trust. They still use her services.

Don't Give Up

In theory, submitting medical claims isn’t supposed to be that difficult. Not so long ago, your employer would pay for most of your health insurance, you’d contribute the balance, and then you’d add a co-pay at the doctor’s office. The folks at the doctor’s office would send the rest of the amount owed to your insurer, who would take care of the difference. But these days, there are more diagnoses, more tests for diagnoses and more treatments dispensed. At the same time, health providers, health insurers and companies insuring their employees are all squeezed to make profits, making the actual cost a hot potato tossed from one to the next, often landing squarely in the patient’s hands. Many people are tired enough from figuring out treatment options and dealing with different doctors and specialists—in the network, out of the network—that they lack the time, energy and expertise to deal with the deluge of complicated health forms, tricky deductibles and time-consuming appeals that follow treatment. And when there’s a major medical problem in the family, those issues get multiplied. Many patients and their families give up trying to get reimbursed and just start forking over the money.

Shannon Broder was determined not to suffer that fate. She was an educated consumer, having worked as a medical/scientist liaison for ten years before becoming a full-time mom. She understood medical terminology, diagnoses and proper protocol. Several years ago, when her son was diagnosed with a complicated medical issue, she dedicated herself to getting him the best care. Like many parents, she paid for services, then submitted the claims. In time, she would receive the dreaded “Explanation of Benefits.”

“I would open up the letter and it would say the patient’s gender is missing, or the provider failed to include their tax I.D. There is no date of service. We don’t cover this service,” she tells Amy. She thumbs through a four-inch binder stuffed with logs and claims and correspondence with insurers, reeling off a string of reasons for why her claims were denied. The wrong diagnosis, the patient’s misspelled name, a missing date of birth. “I would say ‘What do you mean I didn’t include the person’s name? Of course I did! I have a copy right here!’ It seemed borderline illegal what they were doing, but they told me it was missing so I fixed it and sent it in again.”

Apparently, Shannon’s plight is not uncommon. One in five medical claims that were submitted correctly were denied by insurance companies when they should have been approved, according to the American Medical Association’s 2010 National Health Insurer Report Card. This doesn’t surprise Linda. She says that in her twenty-eight years in business she has seen claims systematically lost, rejected, resubmitted, misinterpreted and misfiled by health insurance companies. Countless customers of hers had gotten the same message—denied—when they should have been getting a reimbursement check. Many times the doctor’s bills themselves are wrong; a University of Minnesota study found that about a third of medical bills contain mistakes. Unpaid medical bills are among the most pervasive threats to credit scores, and almost half of all bills at collections agencies are medical bills, according to a study by the Federal Reserve.

Get What You're Entitled To

Even if the bills are accurate and the forms are submitted correctly, sometimes a person’s medical situation is so complicated that it seems nearly impossible for them to navigate the tricky waters of health claims. If there’s someone who can help navigate, though, it’s Linda Lovelace, a longtime sailor whose office walls in Darien are decorated with prints and photos of yachts she once owned or admired. Like a sailor in a storm, when problems arise with customers’ claims Linda hunkers down, gets to work and refuses to give up until the issue is resolved. She and her colleagues have had only one appeal denied out of thousands brought in all their years of service (and she’s bitter about it still). “We’re like pit bulls here,” she says from her office, a peaceful oasis nestled in a sea of medical offices. Soft-spoken and with kind eyes, Linda doesn’t come off as a pit bull. But her actions are a different story.

Linda recalls one customer from many years ago, a man on Medicare who had been hospitalized in several states for different procedures. He had usurped his “lifetime reserve days” in three different states and was counting on a supplementary policy for coverage. But no one from the federal government seemed able to calculate the days accurately enough to write the letter necessary for the other insurance to kick in. “You have all these elderly people who need help and they just don’t have anyone looking out for them. We don’t appreciate that,” Linda says. “We called this office and that office and no one would give us a straight answer. So I said, ‘Well then, let’s call the president.’” Their call to the White House triggered action by federal and state representatives who worked out the bureaucratic redundancies, and the issue was resolved, with Linda’s customer recouping in excess of $20,000.

Not all folks who turn to help from a medical claims consultant have so much money at stake; many just don’t know where to turn. Linda counts among her steady customers a large number of actors whose jobs might fluctuate between stage and screen, or big screen and little screen. What does this matter? A great deal when it comes to health insurance. The major unions, Screen Actors Guild, American Federation of Television and Radio Artists, and Actors’ Equity Association, for example, have very different health care plans, and they go back and forth from being primary claims to secondary claims. The actors send their bills and claims to Linda, and she and her staff of three take care of the rest.

Linda and Amy encourage customers to bring or send in their claims, regardless of the state they’re in. One customer of Linda’s dropped off an entire dresser drawer at National Medical Claims Service; one of Amy’s swept up the soda-stained contents of the back seat of her car and turned them over. Once customers sign up they must send releases authorizing the medical claims consultants to speak on the customers’ behalf to doctors and insurers. From then on, customers simply drop their claims into a pre-paid mailer and poof, there they go, off to where they’ll be dealt with by an advocate who is one part accountant, one part personal assistant, two parts claims expert. Some consumers might consider this service a luxury but Amy feels otherwise.

“My goal is to change this misperception,” she says. “Our research shows it’s the majority of women handling the insurance paperwork and they think they need to bear this burden themselves. But the husband is taking responsibility for the taxes or the lawn and he’s outsourcing these tasks.”

Fees vary for the service. Charges at National Medical Claims Service typically run about $75 per hour. Reimbursements are sent directly to customers. MCL offers several different options, ranging from a premier membership, which charges an annual fee plus 10 to 15 percent of reimbursements and savings recovered, to a trial plan which charges no out-of-pocket costs but takes about a third of the amount recovered.

Getting money recovered is great, customers say, but better still might be the peace of mind. “I literally spent hours and hours on the phone with people who were supposed to help me,” Shannon tells Amy. “The benefits people at my husband’s office—the company’s so-called ‘patient advocates’—couldn’t help me; they told me I owed more money. The people at CIGNA wouldn’t help me. The nurses at the doctors’ offices would spend hours on the phone with me; they were wonderful but there wasn’t much they could do to fix it.” When her sister’s husband mentioned that he’d heard of somebody who could maybe help, Shannon said she went along with him but didn’t believe it was possible. “I was not hopeful at all. I had gone through every channel. I was like, ‘Yeah, whatever.’ But I figured I’d give it a try because I had nothing to lose.”

Imagine her surprise, then, when the folks from MCL visited her at home and thumbed through the binders, pointing out in one claim after the next where she was entitled to payment. Shannon loaded them up with copies and kept her fingers crossed. “They took control and one after the next they did get those reimbursements back. Literally, within less than a month of when I met with them, I was getting huge checks back totaling tens of thousands of dollars.”

“They’ve taken an incredible weight off my shoulders,” she says. “Before I would spend every single night on my computer. Now at night I can go to bed or read a book if I want to.”

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