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March 01, 2015

Experienced, Effective Health Benefits Advocacy

Sometimes getting a medical claim paid correctly can be a real battle. It starts when a charge that should be covered is denied. You call customer service, and they tell you that it will be reprocessed. Then, in a few days, another denial arrives with a brand new denial code. You call again. It's denied again, and chances are that it will stay that way because it's now caught up in an insurance company-induced inertia - a claims netherworld where nothing is paid easily if at all. This is underscored every year by the AMA's scorecard of claims payment accuracy in their Heal the Claim initiative. It generally shows somewhere around a 20% error rate for the big seven insurers which would never be tolerated in any other industry that I know of.
Recently a clinic manager told me; "Resolving wrongly denied medical claims used to be a simple process. A biller working in our office would stamp “APPEAL” in big red letters on a photocopy of the claim, and mail it back to the insurance company. These days, you’d be wise to put the cost of that postage in the bank, and throw away both the APPEAL stamp and its red ink stamp pad because it won’t even make it past the insurance company’s initial computer screening. They’ll toss it into the trash and you’ll never hear anything back from them. Today, you need to get your 'A-game' on. Otherwise, you won’t see a penny."
Getting your A-game on is why was created. Available here is what you need to get medical claims paid correctly. The tools, case studies, helpline and all other resources are specifically designed to enable you to overcome all the obstacles that a health insurer commonly puts up. If you understand what's really happening through the various stages of the life of a claim, you can usually avoid the pitfalls that often result in wrongly denied or rejected medical claims. Once you know that, you can then determine where the system went sideways and proceed accordingly to get it done right. Be your own advocate!
If you have claims that you still can't get paid right - and you don't have the time, inclination or stomach for dealing with the process, it would be a privilege to act as your advocate. Our goal is to provide expert medical claims help to you without blowing your already-stretched (by the insurance company) budget. If you think that we helped you, feel free to donate whatever you can afford. Around here, getting the insurance company to pay what they owe without their usual hoops and pushback is the goal.

It's a fact that 64% of all appeals win! But the saddest news is that less than 10% of all providers or patients actually appeal bad decisions made by the insurer. They don’t demand their right to be compensated for services rendered in good faith and in times of intense anxiety for all concerned. However, if a health insurance company is not living up to the contract that they have with you – fight back; If they find that you can’t perform or receive X, Y and Z procedures all on the same date even though you added modifiers correctly – fight back! Or if they deny your care as experimental or not medically necessary, don’t accept their word as gospel - fight back! If they do anything with which you fundamentally disagree, use the resources provided here to research it and fight back!

We'll do our best to help you in every way possible because I and everyone that I work with is a veteran employee of a major health insurer with a proven personal track record of looking after the interests of members and providers. In short, we know how claims should be paid correctly. Let's start getting yours paid that way today.
Pat Shea, F.H.I.A.S.
Claims Assistance Professional   

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