As caregivers, we may become responsible for our loved one’s health coverage, claims and correct reimbursement.
Advantage plans have become the Medicare coverage of choice for many beneficiaries. Many Advantage plans offer great benefits beyond Medicare coverage like Vision and Dental. We may have coverage confusion for the Vision and Dental coverage. Remember Vision and Dental benefits are “outside” Medicare coverage, and therefore defined by our particular insurance plan. We see more problem billing for these types of claims.
We may have coverage, but payment depends on correct submission of the claim, correct coding, correct identification information, and correct billing addresses. Advantage plans are straightforward for the beneficiary, not so much for the providers.
There are many ways for billing, coding, and claims submissions to go wrong. It generally starts with receiving a bill we hadn’t anticipated. We need to investigate our claim processing before paying that bill. We use providers that are in-network if in an HMO (Health Maintenance Organization). We have options in a PPO (Preferred Provider Organization). All of these providers have signed a contract with the insurer (in part) to bill claims correctly. It’s the provider’s responsibility to ensure there are no errors. If we find ourselves with an improperly paid claim or a denied claim, we need to follow-up before paying the accompanying bill.
The first step is to check with our provider to make sure the claim was filed correctly. As an example, my Advantage plan included a vision plan with EyeMed. The provider failed to send the claim to EyeMed, instead the claim was sent to the health insurance included in the Advantage plan. It was reimbursed as a specialist visit and the refraction was denied. I checked with my provider. They did not send the claim to EyeMed. Once resubmitted, the claim was processed and paid correctly.
In some cases, the provider contracts with a vendor to submit their claims. In one case, a beneficiary reported non-payment of an anesthesia claim for outpatient surgery. The outpatient surgery facility failed to provide a copy of the back of the insurance card with the correct billing address. The claim was denied.
There are things we can do to manage these types of claims errors.
- I recommend calling the 1-800 number on the bill to call if we have questions. It might be fixed as easily as providing the correct information from our card that does the trick.
- I recommend calling the provider to discuss why the claim was denied or paid incorrectly.
- I recommend calling the Advantage plan to discuss the claim.
- If still looking for answers, contact the insurance agent who sold the insurance. Sometimes these folks have contacts not available to the rest of us.
If the other person on the call or in the discussion is condescending, it may indicate they don’t know the answer. Ask to talk to someone else. Be persistent, polite, and ask questions until your claim is resolved. We are the client and deserve respect and help.
Wanda Cantrell, RHIA, CCS, CCS-P, LPN
The column is based on Medicare guidance and reflects the views of the writer.
see also
Medicare Authorizations and Privileged Health Information
Disability MEDICARE AND COBRA
Post Hospital Care