Help! My client has a medical claim question and I’m not sure where to start.

Help! My client has a medical claim question and I’m not sure where to start.
One of the most common reasons for a client to call you is when they receive a bill. Familiarizing yourself with the basics of claims will help you walk them through their problems and build your client relationships. They look to you for guidance and advice (consider it a compliment that they think of you in their time of need), trusting you to help them, just like you did when they were selecting their health plan.

How to guide your clients to a solution: 

  1. Make sure they are familiar with their current benefits and feel comfortable calling Member Services.
    This is very important because the calls are documented and recorded. If there is an issue later, that phone call can be referenced. Representatives are available to assist with any eligibility, claims, or benefit question that the client may have. Offer to do a three-way call with them if they are not sure what to ask. This extra step really will go a long way with your client.

  2. Does their bill show that the insurance paid anything towards the service?
    If not, perhaps the insurance never received the claim. Have them call their insurance carrier to verify. This happens frequently, especially with ambulance claims!

  3. Your client accidentally paid a bill that they should not have. How do they get their money back?
    If the provider received a double payment, it is their responsibility to reimburse the appropriate party. If they aren't willing to do so, have Member Services call the billing department of that provider. They can provide proof of what the member should or should not have paid.

  4. Was this bill in result of an emergency hospital stay where they received services by providers such as a pathologist, radiologist, anesthesiologist, etc.?
    Your client may not have even interacted with these providers, however they will still bill for their services rendered behind the scenes, such as the reading of your X-ray or processing your lab work. Hospitals don't typically check to make sure your anesthesiologist is participating with your health plan before they assist with an emergency surgery.

  5. Does your client's doctor participate with their plan? Are they part of a larger practice?
    Sometimes the practice might be participating, but the individual doctor is not.

  6. Was the bill for a procedure that the client thinks should have been covered?
    Clients may have a covered procedure performed, but the reason for having it may not be a covered diagnosis. Or the client may have a routine procedure done, but then was charged for an outpatient surgery co-pay. Most likely, the providers performed a biopsy or additional service that changed that routine screening into an outpatient procedure.

  7. Don't forget about the appeals process!
    If your client isn't happy with a decision that the plan made, they have the right to appeal that decision.

There are so many reasons why a client may call you about a claim. Hopefully this list will help you feel confident in answering them. The Medicare Offerings Department is here to help, so if you have additional questions or specific client issues to talk about leave us a comment below or contact us directly.

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Sunday, 22 May 2022