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Caregiver Duties: Add Medical Bill Negotiating

The August issue of Health Affairs includes a study that finds that U.S. doctors spend over $82,000 a year per physician on interacting with health plans/insurance companies about claims, coverage, and billing issues. Their staff members spend 20.6 hours per week interacting with insurers. In comparison, Canadian doctors spend $22,205 per physician per year and their staff members spend only 2.5 hours a week, due to the fact that Canadian doctors only have to interact with one insurance company- the Canadian government.

A doctor commented on the report in a New York Times article about the study:

“The amount of time we spend on this is just crazy,” said Dr. Sara L. Star, a partner in a three-physician pediatrics practice in suburban Chicago. “But each insurance company has its own language, its own set of rules and specific contracts with certain laboratories, hospitals, physicians and pharmaceutical companies.”

The authors of the study explain that the extra expense of working with insurance companies totals $31 billion a year, a sizable amount.

While the results of this study are shocking- it would also be interesting to know how much time and energy is spent by family caregivers doing the same activity– for example, when an insurance company denies a claim incorrectly.

In many cases, family caregivers are thrust into the additional role of medical bill reviewer, negotiator, and payer, especially when insurance companies decline to cover services. The GAO found in a report earlier this year that when people appeal insurance company decisions, the insurer reverses the denial in between 39 to 59% of appeals. The Washington Post reports that a similar study by an insurance trade commission found a 40% denial reversal rate when consumers appeal insurer decisions.

The Affordable Care Act includes changes to empower consumers when they appeal denials, though Kaiser Health News noted earlier this summer that the final rules that were released give consumers less time to prepare an appeal, less information about why an appeal was denied, and also limit what types of denials can be appealed. One advocate also noted that allowing the insurers to choose their own external reviewers for appeals may create conflicts of interest.

On the bright side, decisions by external review panels are binding and patients can appeal if their coverage is cancelled by their insurance company.

The two studies referenced earlier in this post suggest that the odds are pretty good for appealing an insurance company denial, though it hardly seems fair to add this duty to family caregivers who are already over-burdened.

If you are a family caregiver appealing insurance billing decisions, here are a few tips and resources to get you started:

•Start a notebook where you can track the date, time, and name of the person you talk to (and their ID number and department) every time you call your insurance company. Also, always keep copies of records, bills, and statements. If an insurance representative makes a promise, try to get it in writing.

•Avoid companies that promise to extinguish your medical debt. These companies often cost you more money, can’t guarantee their results, and may also harm your credit score.

•Inquire at the hospital or your doctor’s office if there are programs to assist if you can’t pay your bills.

•Healthcare experts suggest carefully checking every bill you receive to ensure that you’re being billed for the correct service, date, medications, etc.

Here are some additional resources:

1) Chicago Parent Website: What to do when your insurance claim is denied: Chicago experts weigh in

2) Consumer Reports: “How to Haggle With Your Doctor or Hospital

3) NPR’s “Forum” show addressed Medical Debt on September 12, 2011. During the show, experts suggested two resources for people in need of help in navigating medical bills:

Hospital bill Help: http://www.hospitalbillhelp.org/

Just health in CA http://www.justhealthnow.org/