Organizing Your Medical Claims

Keeping track of your medical bills and what insurance paid and didn’t pay and what you owe the doctor can be a harrowing task. To make sure you collect all that you are entitled to and to make it much easier on yourself, you need to be organized.

If you do not have a good system in place for keeping your claims up to date as you proceed though the year, start a system now. Get a manila file folder for each member of your household. Or for some true excitement – go to Staples and buy a variety pack of colored folders, a different color for each member of the family. While you are in Staples, buy a columnar pad with at least 11 columns on the page.

Next, use a page from that columnar pad for each family member and make headings at the top as follows: Date of Service, Provider, Type of Service, Charge, Date to Ins co 1, deductible, Ins. Co. # 1 paid, date to Ins co 2, deductible, Ins. Co. #2 paid, Balance due. When a family member has a medical experience, start recording the data on the sheet. Put a number next to each line item to indicate the claim number. Then when the bills and explanations of benefits start appearing, number them accordingly, and record the remainder of the information. This will help you to ensure that your claims are being processed correctly, and if you are balance billed any amounts from the doctor’s office, you will know how much you should pay. This will also help you to see, at a glance, if all of your insurance carriers paid their share of the claim. If not, make copies and submit it yourself. Most companies will let you submit claims for the current calendar year and the preceding calendar year. Some will only go back one year from date of service.

If you are on Medicare, the column headings will be a bit different. Start with date of service, type of service, charge, Medicare allowed, deductible, Medicare paid, Balance due, date to secondary carrier, secondary paid, Balance due.

When the end of the year rolls around, you will know what your medical expenses were, and what your out of pocket expenses were. (This information comes in handy when you do your taxes and wonder if you can claim a medical expense deduction.)

DEDUCTIBLES AND THE STOP LOSS

Next, review the explanations of benefits and make sure that your deductible was satisfied only once. If you have a $500 deductible, check that only $500 has appeared in the column “deductible” for 2004. Keep in mind that deductibles run according to the calendar year, and start all over again on January 1. An easy error is for insurance companies to keep applying money to your deductible once it has been satisfied. Our office does not see this error as frequently now, as we did a few years ago. Perhaps the advancement of technology and better computer programs are preventing it from occurring, but it is always a good idea to keep an eye on it, nonetheless. If you do find that more money has been applied to your deductible than what should have been, simply call the company and advise them of the error. When you call, be sure to have the explanations of benefits in front of you that show money being applied to the deductible. If no errors were made, you will have the satisfaction of knowing that your claims have been processed correctly, and you are maximizing your insurance benefits and minimizing your unnecessary out of pocket expenses.

The Stop Loss is also referred to as Maximum Out of Pocket Expense. The dollar amount can vary from plan to plan, but the most common one we see right now is $10,000. That’s not when you spend $10,000 but rather when the total eligible charges for one person in the family reach $10,000 in any calendar year; the plan will pay 100% for the remainder of the calendar year. If you had a medically challenged year, did you reach the stop loss? Was the remainder of your claims paid at 100%? If not, call the insurance company and inquire. Again, be sure to know what the stop loss is on YOUR policy.

MEDICARE & SECONDARY

If you are on Medicare and have a Medigap policy, which is also known as a Medicare Supplement, have you matched the medical bills to the Medicare Summary Notices and made sure that your supplement has paid all your claims? Most companies will receive the information electronically from Medicare and you do not have to submit claims yourself. This scenario is often referred to as the claims “going automatically”, or “cross-over”, or “spin-over”. We find that this system of automatic processing is not airtight. Occasionally claims fail to make it to the secondary carrier for some reason. If they have not gone automatically as planned, don’t sweat it. Submit it yourself. Many Medicare supplement carriers simply require the explanation of benefits from Medicare; others may wish to also have a copy of the medical bill. Find out what your Medicare supplement requires and submit those claims! Be sure to write your Medigap policy number on the Medicare Summary Notice. Always make a copy for your records.

For those of you who are thinking, “now she tells me what to do, just when I am approaching the busiest time of the year for me”. If this means you, just cut out this column and save it for January. When the snow flies and you don’t want to go out in the bad weather, it will be the perfect time to “get organized”. Just buy the file folders and columnar pad now so you will have it when the weather is inclement.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.

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