US News & World Report - November 12, 2001 issue:

Health & Medicine 11/12/01 

"Taking action to Save bucks by finding and fighting costly errors in medical bills 

The two pieces of paper lay flat on Michael Weiss's desk earlier this month, and Weiss just shook his head. One was a big, complex form sent by his doctor, with all sorts of medical conditions and check boxes; the box marked off was "low back– lumbar." The other paper was a letter from his insurer, Aetna, saying that this service was not covered. Weiss would be lighter in the pocket by $140. 

Many patients would throw up their hands in frustration and just write the check. But Weiss has been down this road many times before. A health law attorney and patients' advocate in West Orange, N.J., Weiss, 38, saw a solution. "Low-back pain is kind of a vague area for insurance companies, and this just threw up a red flag," he says. So he requested from his doctor a letter detailing the treatments–involving anesthetic injections into his lower back–and sent that to the insurer. They paid. "This kind of stuff happens all the time," he says. "As patients, we just have to learn to deal with it." 

Indeed we do. According to a Kaiser Family Foundation/Harvard School of Public Health survey this summer of 1,200 Americans, nearly half of those with private insurance reported some problem in the past year. For 13 percent, it was delays or denials of coverage or care, and for another 13 percent it was billing or payment problems. Nearly a quarter reported that the problem caused them to pay more for medical care. And dealing with these denials can be a long and frustrating process. Many people just give up, writing off their losses. 

Spotting errors. But in a faltering economy, as the number of healthcare options offered by employers is reduced, writing off insurance mistakes is something people can no longer afford. So making sure you get what you pay for becomes an essential part of your finances. Many of the problems come from paperwork errors in the doctor's office or by the insurance company. You can learn to spot some of the common errors and take steps to prevent them, and also to present your case more effectively to your insurance company. Or you can hire an advocate like Weiss who–for a fee–will plow through the paperwork for you, saving you time, major headaches, and often, some money. 

Linda Larson, 48, of Elkhart, Ind., knows very well that the costs of an insurance snafu can be extreme. "We've lost everything–our jobs, our savings, our home of 13 years," she says in a small, tight voice. "We declared bankruptcy. We're living in a mobile home, and my 18-year-old son is paying our rent. All because our insurance company didn't pay us $200 a week like they were supposed to." 

The trouble started in 1999 when Linda's husband, Leonard, a welder, pulled up a boat anchor and threw out his back. The injury kept him out of work. He'd been paying premiums on a supplemental disability policy to provide $200 a week just in case something like this happened. But the insurance company denied the claim, saying it was a pre-existing condition; Leonard had previously had back trouble. "They said this even though he'd herniated a disk that had never had problems before," says Linda. Meanwhile, the insurer, which the Larsons did not want to identify, was refusing to pay his doctors for treatments, saying the Larsons had gone out of their network to seek treatment. "But that was on a referral from the network doctor," says Linda. "Bills just kept piling up. It was like a mountain we couldn't get out from under. Look, we're just an average family. We were barely getting by anyway. And I fought this from September of 1999 to the summer of 2000 and just couldn't get anywhere." 

Then the Larsons hired Mary Jane Stull, a professional bill sleuth whose Web site is called insurancenightmare.com. It seemed an apt description of the Larsons' situation. Over the next few months, Stull–a former insurance claims processor–sifted through every bit of correspondence from the insurance company. She sought supporting letters from doctors, determined what documentation the company wanted and supplied it, and eventually secured nearly $10,000 in disability payments for the Larsons. Stull took 25 percent as her fee, and the Larsons are using the rest to pay creditors. "It's worth it, every penny," says Linda. "She's been a godsend." 

Godsends, however, can get expensive. Both Stull and Weiss–who will charge $100 an hour for patient advocacy work–say patients should typically have a substantial amount of money at stake or should be in a crisis medical situation before hiring an advocate. In other situations, "there are lots of things people can do on their own to help resolve billing issues," says Stull, whose office is in South Bend, Ind. 

One is to be aware of several hot spots in the billing process that are the source of many errors. One of the major sources is the "superbill" filled out by your doctor. It's a long form with rows and columns listing types of tests, length of visit, types of treatment, and various diagnoses that read like Greek to the layperson. If your doctor checks the wrong box, it can lead to a claims denial. For instance, a woman may be covered for a mammogram on a typical "wellness visit." But if the doctor checks something else as the reason for the visit, the insurer might not cover the mammogram. So take a good look at that superbill before it goes to the insurance company. If it denies the claim, you need to get a copy of the doctor's office visit notes: the scratchings made on your chart that say the visit was for a wellness checkup. Submit these notes to the insurance company, along with the explanation of the denied benefit. "Ninety-nine percent of people don't know how to do this," says Stull, "and it can save you a lot of money and a lot of hassles." 

Credentials, please. "Not medically necessary" is another message that frequently appears in a denial letter from an insurance company. It's insurance parlance for a claims processor questioning your doctor's judgment. Call the insurer and ask for the name and medical credentials of the second-guesser. Be polite but insistent, and take careful notes. Then ask for a medical review by a doctor with an appropriate background. If you have a bone problem, ask for a review by an orthopedist, not just the plan's medical director, who may have another specialty entirely. 

Multiple services on the same day can also lead to a denial, particularly if the doctor sends the insurance company two separate bills. "Claims processors are human; they make mistakes," says Weiss, author of Confessions of a Professional Hospital Patient. So a bill for interpreting an X-ray on November 12 can get confused with a bill for the actual X-ray procedure on that day; the insurer treats them as duplicate bills and denies one. Get clear copies of the bills indicating separate services and send them in. 

Become very familiar with your plan's booklet, which specifies procedures and time frames for these appeals. Try to stay calm when you call to dispute a bill, and insist on getting the full name of the person on the other end of the line. If he or she refuses, ask for a supervisor. Keep notes on everything, with dates. "It can be incredibly frustrating. People call me at their wits' end, crying," says Stull. "Hey, I feel that way when I deal with my own medical claims." When all else fails, you may want to seek an advocate's help. Many are registered with a local chamber of commerce. Others are on the Internet. Ask for references, and be sure to call them, because this is an unregulated industry. But used carefully, it can restore some health to your aching wallet.

U.S. News and World Report, Nov. 12, 2001.