Going The Distance:
Claims Mitigation Stories
By Kelley Wallick - Benefits Claims Specialist
SHOULD I JUST GO AHEAD AND PAY THIS MEDICAL BILL, OR SHOULD I PUSH BACK?
After going through a major health event and receiving a steep statement in the mail, the answer can be quite complicated. Maybe there was a mistake, maybe there was a misunderstanding over which services were “in network,” or maybe the full amount should be paid promptly. Or maybe, as the insured, you owe less than you think.
This is where insurance claims experts like myself and my colleague, Julie Penso, come in to potentially save people from paying more than they should. We figure out what needs to be corrected, working with insured employees and their family members, the insurance carrier, and sometimes the health provider’s offices to determine what the issue is and how to resolve it. Ideally, our services are requested before a medical visit (which is not always possible) so that we can help our clients determine their expected share of cost for an anticipated service, such as hip replacement surgery, and whether the medical services fall within their provider network.
Most of the time—I estimate 75% of the time—the issues are fairly routine, and we can confirm whether a billing statement is correct or needs to be corrected and either work with the carrier on the client’s behalf or let them know what they need to do to get it resolved. The other 25% of our time, however, involves more complicated or unusual situations.
The fact is, most people do not understand how their health insurance plans work. Most know that they have a deductible to meet and that it’s in their best interest to keep their care within the plan’s network. But sometimes, the full scope of health coverage does not match expectations. They may not know the right questions to ask. They may be handling the expenses of a loved one they have recently lost, or they may be dealing with their own serious illness and need a helping hand. Here are a few relevant situations illustrating how Hummel supports clients while administering benefits plans:
Untangling A Mess
A dying man told me he was worried about leaving his wife with hefty medical bills. I assured him I would be there for her if she needed me. About a week after his passing, I heard from her. “All he told me was that when it comes to all this stuff, I’m supposed to call Kelley at Hummel,” she said. “Will you help me?”
Of course, I did. Her statements showed she owed tens of thousands of dollars, yet what she was getting billed did not match the plan’s out-of-pocket limits. She clearly did not owe the portion she was being billed.
Dealing with grief and unfair expenses is a high burden, and I was happy to do my part to sort out this mess with the hospital and explain to her what she should and should not pay. I also helped her by sharing resources like a widow support group in her area, as I could tell she, understandably, needed additional support at this time in her life.
Acting As A Supportive Force
The spouse of an insured employee was diagnosed with breast cancer for the second time. With her permission, I used her login to access her insurance portal to view her explanations of benefits (EOB). I noticed a mismatch: The carrier had been incorrectly processing her care as out of network. This mistake kept happening, so I continued to help her make sense of her medical bills for about a year. Fortunately, her health improved, and she is now able to process her bills completely on her own.
Researching A Resolution
A skin cancer patient came to us after a doctor recommended a less traditional method of removing cancer from his arm. Rather than Mohs surgery, where cancer lesions are removed layer by layer, the provider wanted to use laser-guided treatment, which is much less invasive.
The carrier denied this request. The doctor appealed, but the request was denied again. The last recourse was for the patient to appeal. Since the insured did not know how to do this, we helped him put together a letter stating his case. First, I went to the National Institutes of Health website to research clinical case studies about the effectiveness of this type of treatment. I found a couple that supported the doctor’s plan and included them in the letter.
The appeal was approved! The doctor’s recommendation was the right treatment for this client, and I’m pleased we were able to reach a resolution with the carrier Hummel supports employees and their families when they have questions or concerns about their benefits plans.
We know it’s not always easy. In most cases, we can act on the insured’s behalf to get answers and resolve claims issues or walk through what the next steps should be.
Some people look to us to guide them on what to ask, while others request that we handle it for them. We do both. We can also help before a major event by aiding employees in determining whether the services they are signing up for are in network or whether they need preapproval to be fully or partially covered.
Whether we aid clients before or after a procedure, we can help clarify the details of any health insurance plan. We’ve found that for most people, a sense of understanding can help them feel like they have at least some control over a scary or overwhelming situation. These are the times when my job is most gratifying, when we make a real difference in people’s lives.
.png)
