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How To Fight Health Insurance Bills

A recent article in the Wall Street Journal highlighted 10 “easy” steps to fight insurance bills. With insurers and third party adjusters (TPAs) understaffed or unequipped to battle with providers over questionable charges, they just pay the bill. Learn more about 10 steps to challenge the providers.

In the article titled, “Health Care and the $20,000 Bruise” published in the Wall Street Journal on September 2, 2014, doctor and lawyer Eric Michael David describes the dysfunction of our current health care delivery and billing systems. The focus of the article is related to an accident involving one of his children, where he ultimately discovers and fights the ultimate costs from the emergency room visit. According to Dr. David, the key areas of review in any hospital or provider bill review should include:

1. “Get yourself a job as a doctor or nurse”, or as we advise our clients to have a doctor or nurse available to advocate on your behalf. For payers such as self-insurers, captive insurers, private health exchanges, or other forms of private insurance, it is advised to be certain there is qualified staff to challenge each and every charge according to the correct guidelines.

2. “Have or gather the legal knowledge to know when you are being lied to.” Using predictive analytics and modeling to foresee potential incorrect charges can enable more precise interventions and care coordination.

3. “Have the resources to pay huge bills up front while you wait the months it takes to correct billing errors.” This is not normally practical for most consumers, but for large corporations and private insurers it is recommended to have a dispute resolution process in the contract and withhold payment for questionable charges until the process is complete.

4. “Understand that only the billing department, not the physicians, decides what is billed.” While it is always easy to blame someone including your doctor for billing errors, they normally are not at fault or know anything about what is being billed for any of their procedures. Patience and written documentation are recommended according to the agreed upon dispute resolution process.

5. “Know where the hospital billing managers go to decide what kind of upcoding they can get away with.” Most hospital billing systems are based upon the Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual. They can’t justify charging any more than what is reasonable and customary for the procedure, and most times they will accept less rather than risk a bad relationship or lawsuit.

6. “Google like mad.” Research is the best medicine to resolve disputes. Have benchmarking resources in the specific region of the country where the source of the charges are being billed for appropriate documentation is recommended.

7. “Have the combined medical and legal knowledge to understand the implications of the coders' rules.” Again, this area of bill coding is always changing, and billing negotiations are a regular part of the process as the cost of care for procedures are becoming more widely known.

8. “Unleash the hounds.” With the confidence of research and support from your advocacy team, strong discussions and documentation will succeed to eliminate unnecessary and inappropriate charges.  If you have to sue the provider to achieve your objectives, the judicial system likes documentation and normally awards fairness.

9. “Be graceful in victory and realize you got lucky.” If the billing department finally understands your position, then a gracious attitude will always gain respect with the billing person. It is particularly helpful the next time there are errors. What goes around comes around.

10. “Skip medical school and law school and get your child a helmet.” Sound advice for all concerned parties.

By understanding how the health care delivery and billing systems work, you will be able to save money and gain respect with the providers knowing that you are watching every dollar according to the established guidelines and best practices. Remember, they are human beings and are learning too.

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