Today I had the opportunity to really battle with Horizon Blue Cross Blue Shield of NJ. I felt sorry for the representative in member services for getting my call.  Here's what happened:

 

In August 2011, someone called me because his 4 year old daughter was having some dental work and the dentist didn't think she could sit through it all, so he recommended that she be given some IV anesthesia. Since the medical insurance was an HMO plan, the father needed to get authorization, so he called us. BCBS told us that the primary care doctor would have to call them to get the authorization, and they even gave us the doctor's name & phone #. We had them call, and they were told that they could not get authorization or precertification & that the father would have to pay out of pocket. We then just went ahead and submitted the claim for the anesthesia, and of course it was denied for no authorization. Fortunately, I had 4 call reference numbers from every time we had called BCBS. I submitted an appeal with all of this information. The appeal was denied. Today I had a battle with July C. in provider services, and she again advised me that the primary should have gotten a "tracking number" from their precert dept. But precert wouldn't issue a tracking number because they said they couldn't;t do a precert. So frustrating!

 

So the next step now is to send in a 2nd level appeal and at the same time, an appeal to the Dept. of Banking & Insurance. This scenario happens every day to providers and who bears the brunt of all of it? The patient, because they are the ones that have to pay the bill. In this case they already paid the provider $775.00. That's a HUGE amount of money for a family to have to pay, on top of the dental work costs.

 

We are determined to get this issue resolved, and so should you if you disagree with your insurance company's determination. Remember, ask for a call reference number and the full name of the person you talk to. gather that ammunition so you can do battle for your rights!

Did you know that when you have  dental work done in your dentist's office, you can bill your medical insurance for the anesthesia costs? Yes, that is right! You may be able to be reimbursed for this cost by your MEDICAL insurance. The CPT (procedure code) for oral procedures is 00170. Ask the dentist to give you a statement for the services and then submit the claim to your medical insurance. The claim will be processed under your out of network benefits, so you will need to meet your deductible and coinsurance.

 

I had dental anesthesia a few years ago to have a wisdom tooth removed. I was terrified of the whole process, so I asked to be anesthetized. The bill was $375 and I paid the dentist in full. I then submitted the claim to my medical insurance and received back $225 from the insurance. The thing to remember is that you need to know the correct way to bill for anesthesia services in order to get the claim paid. Billing incorrectly will cause a huge mess for you that will take time to unravel. So the easist course of action is to have someone who is knowledgeable about anesthsia billing, to submit the claim for you.

 

At DL Health Claim Solutions, we submit anesthesia claims for dental services to the insurance for a small fee of $30 per service date to file the claim & follow it until it is paid.

Did you know, that a colonoscopy is considered preventative care and covered at 100%. It is not subject to any deductibles or coinsurances. This is good news, right? Our doctors recommend this test every 10 years and more often if there is family history of colon cancer or if you have ever had polyps removed. And if the test is so important,  then not having to meet high deductibles is good encouragement for getting the procedure done.

 

But, did you know that if you have the screening colonoscopy done and they find and remove any polyps, the test is no longer "free" to you. It is now a surgical procedure. This means that it is no longer considered preventative care and the claim is processed against any deductibles and coinsurances that you may have.

 

If your insurance has an in network deductible of $2500, and the test costs $4000, and you have not had any other medical care before the test, then the first $2500 is going to be deductible and then you will pay a coinsurance on the remaining $1500. This can really add up, especially if you weren;t planning for it.

 

It is really important that you should know your benefits in detail because there is nothing worse than receiving a large medical bill for a test that you thought was going to be completely covered by your insurance. Preventative or not, I for one do not like surprises in the form of high medical bills that I didn't expect.

This post is for people with Medicare and a secondary insurance that is NOT a Medigap policy. 

 

 Did you know that if you have medical services that are not covered by Medicare, but ARE covered by your secondary insurance, there is a certain way you must submit your bills to the insurance? Suppose your doctor is opted out of Medicare, so you have to pay him up front and he gives you a statement to submit yourself. You MUST complete a 1490S form, found on the Medicare website. Attach copies of the bills from your provider to this form. Write in big bold letters: FOR DENIAL ONLY across the top of the form. Mail it to Medicare so that they will create a Summary of Benefits for this service denying payment. Then you must take a copy of that summary from Medicare, a copy of the bill, and your secondary insurance claim form, and send it in to the secondary insurance.

 

If you do not first send it in to Medicare, your secondary insurance will either deny payment outright stating you must first bill Medicare, or they will pay against some arbitrary number they have dreamed up as the amount Medicare would have paid.

 

This whole process sounds complicated, but it is really about being organized and keeping copies of everything.

Someone recently asked me how you would know if your doctor was coding something incorrectly. When you receive a bill or statement from your doctor for a visit, look it over to see the charges that you are being billed for. If you saw your primary care doctor for a sore throat and he did a throat culture, gave you a some medication and sent you on your way, then you should see charges for those services. However, if you see charges for venipuncture (blood collection), urinalysis, and an EKG, then he billed incorrectly and you need to call his office and request the office note for that visit. Everything that is done in the visit must be documented in the chart, otherwise he cannot bill the insurance for that service. So if your office note doesn't include any mention of those extra services, then bring it to his attention so that it can be corrected. I would recommend sending a letter to the office manager and enclose a copy of the bill and the note stating that the bill shows these extra charges but he didn't perform them, nor did he document them in your chart. It is always important to include written documentation to show the error. Then ask for an updated statement to make sure the corrections were made to your account.

 

We had a client in our office who had a large error on a bill, and the doctor was suing him for non-payment of a $7500 bill for a surgery performed in the ER. My client said he didn't remember ever seeing the doctor nor having this surgery done. We requested the operative report and an itemized bill from the doctor. This is where our medical coding expertise came in, because we discovered that the doctor had coded the claim incorrectly and charged for a much more extensive procedure than what was actually performed. We sent him a letter explaining his error, along with supporting documents and his office corrected the bill. Catching this error resulted in a savings of $6000 to my client!

 

 

 

 

Do you ever see medical providers: doctors, therapists, etc. who ask you to pay in full at the appointmentt and then give you a statement so you can bill your insurance yourself? If you don't save those statements and submit them within six months after the date of the visit, then you will lose out on getting reimbursed from your insurance. The other night I was at a Chamber of Commerce event at a local law firm near my office. I was speaking to  someone in the health insurance business. He was responsible for selling medical insurance to companies. He told me that last year, he never submitted several thousand dollars worth of claims to his insurance simply because he was too lazy. His laziness in getting to this paperwork resulted in a significant loss of money to him.

 

Most insurance policies have a deductible, coinsurance and maximum out of pocket amount that must be met before they cover your claims at 100% of their allowed amount. When you don't submit all claims to your insurance, then these claims don't get applied to the maximum out of pocket dollar amount that you must pay each calendar year. Suppose he would have reached that amount by September if he had submitted everything? Then not submitting all of his claims resulted in his claims being processed at the lower level of benefits simply because he had not yet reached the maximum out of pocket dollar amount for that year. This scenario really bothers me, because we pay so much for all of our various insurances, why not get back every penny we are entitled to each year?

 

If you have claims that need to be submitted, call us at 732-640-1006. We will submit them for you so you can meet your deductible and maximum out of pocket sooner.

 

 

Mental Health Medical Claims

 

In today's crazy, complicated world, many people are seeking help with coping through therapy and counseling. I have found that most licensed clinical social workers do not participate with health insurances. They require that you pay them in full for their time. They then give you a statement to submit to yoour medical insurance to get reimbursed. One major problem I have been seeing is that many health plans require precertification of these services, and no one is getting it. Here is the rule on precertifications: If your insurance requires it and you don't get it, you will NEVER get payment for these services from them. If you do get the precertification, you may get reimbursed.

 

So, who is responsible for getting the precertification? Since you hold the insurance, it is your responsibility to call your insurance to start the process. If the insurance company needs information on your treatment, your provider can either give it to you to submit, or fax it over to the insurance company themselves. You, as the patient must be proactive about making sure that you follow all of the rules of your insurance company so you can get reimbursed by them for your treatment. Mental health therapy is very expensive, sometimes up to $250 per hour and you may see this provider 4 times per month. That is an outlay of $1000 per month that you may never get reimbursed for if no precertification is done!

 

Don't allow your insurance company to have an excuse not to pay you for your therapy. If there is no information on your card on where to call for mental health services, then just call member services and ask them who you need to talk to. Then call and get that precertification.

I am working with a family whose child received early intervention services for developmental delays from age 0 to 3 through the state. This system is very different from privately paying for medical services.The state is very unhelpful about giving the parents the proper informaiton so they can submit their cost share to be reimbursed from their medical insurance.

 

Every parent whose child is getting services through this program should be requesting a monthly receipt which includes all of the information insurance companies need to pay on their medical claims. This information includes diagnosis and procedure codes, cost of the service, NPI and tax ID numbers, the names of the providers and and the location of the services, and they should also request progress notes to submit to their insurance. I had to request the medical records from the state archives for this child so I could determine the diagnosis codes.

 

In addition, the parents might also want to contact their insurance before services are started to determine if anything needs precertification. Without precertification, you will never get reimbursed.Having precertification for the occupational, physical and speech therapies can make a world of diffference down the road in getting paid.