Health claims assistance: Intriguing, demanding business
Running a business that takes the mystery - and, often, the errors - out of reams of doctor, hospital and insurance bills should be something of a slam dunk.
For one thing, there are only four easily-findable such businesses in Illinois, all in metro Chicago. In fact, the membership roster of the Alliance of Claims Assistance Professionals lists members in only 16 states, just 33 total.
Hmmm. A service many households need at one time or another. Not much competition. That's a business to explore - except you might want to do the "hmmm" again: The business of helping households figure out their medical bills requires a skill set that isn't learned in a short course.
"The skill set is very complex," says Katalin Goencz, co-president of the Alliance and head of MedBillsAssist.com, Stamford, Ct. Among the typical services listed on the ACAP website are reviews of medical bills and determination of proper payment; audits of hospital and provider charges; and challenges, when appropriate, of insurance company claims denials.
"We have to understand medical transactions, all kinds of insurance issues, claims processing, insurance processing, Medicare coding, medical terminology," Goencz says. "Most of our members have hospital or physician billing experience - or have worked for insurance companies."
Goencz' list probably could be longer, but that's likely enough to at least partly explain the small number of professionals in ACAP.
"There's no clear path to be trained," says Susan Loeb, whose Chicago-based Your Benefits Advocate is 10 years old. Loeb, an attorney, was a benefits counselor and manager at the University of Chicago.
For Susan Dressler, owner, Health Claim Assistance Inc., West Chicago, and a savior I found 20-plus years ago when I couldn't figure out my mother's medical bills, the claims review process "is relatively easy, but for clients the situation often is emotional.
"I listen to (the client's) story and ask questions. I try to arrange a time when I can go to them because that's where the paperwork is handy and I can get the HIPAA release signed, which allows me to work with Medicare and the insurance companies.
It helps that Dressler began her career paying claims for a Wisconsin-based insurance company, a hands-on way to learn the ins and outs.
It's something of a paradox that health claim assistance businesses whose services when they're needed are really needed can be difficult to find.
"How do people find us?" Goencz repeats. "When the pain reaches a certain threshold, people go on the internet and start searching." Loeb's suggestion: "Troll the internet and look for benefits denial."
Dressler and Loeb both offer pre-need advice that perhaps could eliminate potential issues:
• Understand your policy. Know your deductible. Know exclusions. Know which providers are in the network and which aren't - and what happens if you go outside.
• Understand how Medicare works and what it covers before you migrate to that coverage. Understand Medigap and prescription drug policies.
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