Friday, December 8, 2017


Anyone who’s ever filed a health insurance claim or received a medical bill knows how difficult and frustrating the payment process can be. Now, try doing it for autistic patients.

Roughly, 1 in 68 American children, every year, are diagnosed on the spectrum of autism (ASD) and, with that, comes an array of special challenges regarding proper insurance reimbursement.  The Centers for Disease Control and Prevention (CDC) estimates “it costs $17,000 more per year to care for a child with ASD, compared to a child without autism. Extra costs include health care, education, ASD-related therapy, family-coordinated services, and caregiver time. For a child with more severe ASD, costs increase to over $21,000 more per year.” And those are the baseline numbers. 

A Texas mother shared her story with Autism Speaks. Both of her children needed rigorous treatment at a cost of nearly $60,000 each. Luckily, Texas is one of the more autistic friendly states, allowing for “child-only” insurance through the Affordable Care Act (ACA) exchange system. Upon signing up in 2014, the family’s out-of-pocket expenses and monthly premiums dramatically decreased. In the mother’s words, “it has been a godsend.” All autistic caring parents understand how critical regular treatment is to the proper development of their child.

If this family lived in Florida, they’d only be eligible to receive up to $36,000 per child per year, with a $200,000 lifetime cap on coverage. Do the math- it’s not pretty. In Tennessee, autism is considered a “neurological disorder” and as such, benefits do not fully address many of the  needs specific to autism treatment.

TIP #1: Know your rights. Research the benefits allowable in the states you live. 

Literally, every state has its own rules regarding autism coverage including the age range for coverage. Georgia only provides coverage up to age 6; where other states allow up to age 18. The National Council of State Legislatures provides a comprehensive state-by-state breakdown of all health insurance mandates and regulations for autism.  Heres a link.

Why such disparity between states? For starters, despite the implementation of the ACA, which guarantees certain elements in all healthcare plans, Congress offered states the option to set their own benchmarks within the federal minimums. This was the necessary “compromise” to get the ACA passed. Most people think that President Obama and Democrats “jammed the bill through.” That is not accurate. The majority of Congressional Democrats favor far stricter federal standards. So, if you think the ACA is the real problem, think again- prior to the ACA,“autism” could be identified as a “pre-existing condition” and thereby allowing all insurance companies to deny any coverage, at any price, in any state.

TIP #2: If you want the current ACA to work better for you, start by calling your Governor and your State Legislatures and demand they offer better coverage for autism- in addition, remind your Congressman and Senators that coverage under the ACA needs to be strengthened on the national level, not replaced or further allowed to be weakened by individual states. Any changes that lessen current mandates could be devastating to autism coverage.

Given the high cost of healthcare today and complexity of coverage, it is critical that claims be filled out and filed correctly to ensure all eligible payments. Due to the nature of autistic treatment, the proper filing is even more essential than with normal medical treatments.

TIP #3: If a claim is denied, always check with the service provider that they marked the proper codes and diagnosis. Never pay a bill until you identify why theres even a bill in the first place and you confirm with your provider AND insurance company the reasons for the denial. Sometimes, the denial is justified- more often, someone made an error with the paperwork.

To further protect yourself and to help maximize reimbursement, you might want to consider a professional medical bill management and claims filing service. They not only know what to look for in the event of errors and processing, they know what questions to ask and how to make the required adjustments. Even if your provider files your claims, you need to be in control in managing the process regarding reimbursement and paying bills.

TIP #4: If you receive a bill, DO NOT expect the doctor or service provider to follow-up with your insurance company on denied or rejected claims. This is YOUR responsibility. 

TIP #5: ALWAYS ask the doctor's office to file your claims if they accept assignment. 

If your doctor accepts assignment,it means that he/she agrees to file the claim and accepts,as payment in full, the amount the insurance company approves. Providers cannot balance bill you for the difference between their charges and the insurance approvedamounts. 

In most cases, the insurance company will pay Providers directly when they participate with the insurance program. If the Provider accepts assignment or participates with your insurance program, your only obligation usually is the co-payment, as stated in the policy. Many Providers will ask for this co-pay at the time of your visit. Don’t be afraid to ask them if they can bill you for the co-pay AFTER they file the claim and have been paid by the insurance company. 

TIP #6: Understand your co-pay. 

Many people pay the wrong co-pay. For example, they pay 20% of the charged amountinstead of 20% of the approved amount,and consequently, overpay and never receive a refund. Providers often will hold onto this extra money and use it as a credittoward your future balance. In many cases, they wont even tell you about it.

If you carry more than one insurance policy, do not assume the Provider will file the additional insurance company. 

TIP #7: If you file the claim, be certain to give the insurance company all the information it needs AND be sure to make copies. Incorrect or missing information will only cause a delay in processing the claim. If you need to submit an itemized statement, be certain the following information is included:
  • Diagnosis 
  • Description of service 
  • Charge for each service 
  • Date of each service 
  • Location of each service 
  • Name of the provider (doctor, hospital) who actually treated you 
  • All appropriate insurance numbers 

TIP #8:  File your insurance claims as soon as possible. 

No one wants bills to pile up. Many people think it's easier to file their claims all at once, say at the end of the year. This is wrong. Haste makes waste and may also cost you money and coverage. Timely submission of claims is critical in receiving reimbursement. Even if your Provider agrees to file the initial claim, you should be sure that it is filed within the filing time 
limits imposed by the insurance company. Claims filed too late could result in a bill to you from your Provider for services that should have previously been paid by your insurance.

TIP #9: Never pay a bill until you receive the Explanation of Benefits form from your insurance company, which indicates who and exactly how much they paid. 

Providers routinely send bills out prematurely. Many patients pay them before the insurance company pays.  As a result, duplicate payments often occur. Refunds that are rightfully due to the patient may never get returned. 

When you do pay a bill, keep records by date of payment and check number. This accounting is necessary when verification of payment is required. Often, a lack of knowledge regarding benefits leads to billing and paying for services that should be reimbursed or simply, written off.  Frequently, check your policy to be certain of the covered benefits. 

TIP #10: Always appeal rejected claims regardless of the reason given to you. In addition, appeal all claims that you believe were not paid at the appropriate level. 

An insurance company may say that the Provider's charge exceeds the allowed amount( the usual and customary charge), but this may not be the case.  A Government Accounting Office (GAO) study several years ago indicated that, of the millions of dollars of rejected Medicare claims annually, only about 2% are ever appealed. However, of those 2% that are appealed, approximately 75% are overturned in favor of the patient! APPEAL- APPEAL-APPEAL.

Above all, don't be intimidated by the system. If you are persistent, aggressive and assertive, you will be able to maximize your reimbursement, minimize your stress and get peace of mind. Remember, the insurance company works for YOU! After all, you’re paying for it!

Harvey J. Matoren, MPH, CCAP

(The author is President, CEO and co-owner/founder of Claims Security of America (CSA), a nation-wide medical bill management and claims assistance/filing service helping patients, families, caregivers, retirement communities, trust officers and attorneys.  For more information- Call: 1-800-400-4066