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 

Thursday, January 22, 2015

Improving Your Health and Well-Being

For many of us, the first month of the new year allows us to re-focus our goals and set resolutions going forward. Improving our health and exercise regiment are usually at the top of this list. While a great deal of our nation's debate around health continues to center around the Affordable Care Act and the broken healthcare system, there is one area that each of us can directly improve upon: Personal health maintenance.

Each of us have the ability to control what we do to our bodies. How we eat. How we sleep. How we exercise. Change is in our power.  And while there's still some cost associated with preventive care, it's still much less than treatment on things we could have easily avoided or at least, lessened our risk factor.

In 2011 the U.S. Department of Health & Human Services released a "National Prevention Strategy" which "envisions a prevention-oriented society where all sectors recognize the value of health for individuals, families, and society and work together to achieve better health for Americans." 

The report identifies 7 priorities:
Some of the findings are eye opening. We know tobacco products are bad for your health, but did you know tobacco is the leading cause of premature and preventable death in the Unites States? Most people identify weight gain with eating too much, but the reality is food is a factor in far more than just weight. The food you eat effects your heart, your blood pressure, your bones and many forms of cancer. Reproduction and sexual health are immeasurably tied to preventive care. Knowing how to prevent potential diseases and pregnancy issues are critical to your well-being.

Former President Bill Clinton's Global Initiative is an organization that recognizes the vital importance of "systematic health improvement throughout the United States." CGI holds its annual Health Matters Summit beginning Monday. You can live stream many of the sessions, including Clinton's opening remarks by going to their website.

The point of all this discussion and prevention is two-fold. One, if you take care of your body and your health, you're going to live longer and your day-to-day life will simply be easier and more satisfying. That's a fact.  And two, the financial burden of getting sick, which strains not only your bank account, but the overall economy is decreased. Medical expenses are the number one reason for personal bankruptcy filings in this country. The fact is a lot of health related debt could have been prevented.

Bottom line. As medical costs continue to spiral out of control, it's imperative we take care of ourselves now more than ever. Know what you can do to minimize your health risks - and do it!
The health of a nation depends on it.

Stay Informed. Stay Positive. Stay Healthy.
The Patient's Advocate
brought to you by 
Claims Security of America
The medical claims filing experts

Wednesday, April 23, 2014

How much does Medicare pay your Physician?

A couple of weeks ago the federal government released some disturbing data figures regarding Medicare pay-outs to Doctors. The Wall Street Journal examined many of the issues now being hotly debated in Washington and around the country. You can review the article here:   

In an effort for more transparency, The Obama Administration shared this previously unreleased data based on 2012 reimbursements to over 880,00 health care providers. These payments totaled in excess of $77 billion. Note, the data reflects only Part B Medicare payments which includes doctor visits, lab tests and other treatments provided outside a hospital that encompassed surgical procedures, chemotherapy and radiation treatments performed by physicians.  If you add what Medicare paid directly to providers, and any additional money they received from patients for deductibles and coinsurance this brings the total payout to providers to $99 billion.

Reimbursements varied by physician specialty and geographically.  While no personal patient information was disclosed in the release, you can see the list of all physicians reimbursed and their respective amounts here: 

Reimbursement by specific states is also available:

The two highest paid doctors are already under government review for suspected improper billing. One is a Florida ophthalmologist who received in excess of $26 million, more than 61 times the average for that specialty, to treat fewer than 900 patients; and the other is a Florida cardiologist who received $23 million which was 80 times the average amount for that specialty. 

So, what can we deduce from this data?  

The obvious conclusion appears this is an excellent way to identify fraud and abuse in terms of excessive and unnecessary billing.  However, this may not be a correct assumption in all cases.  According to Jonathan Blum, Medicare's principal deputy administrator, "providing consumers this information will help them make more informed choices about the care they receive."  The physicians with some of the highest reimbursements, notably ophthalmologists and radiation oncologists, contend that the reimbursements relate to very high overhead due to the cost of drugs administered to patients, and the high cost of equipment used to treat patients. Larger reimbursements may also mean that these providers have sicker patients, that they specialize in complex care or that their practice is heavily skewed toward Medicare patients.

A more comprehensive take-away from these startling numbers is that health care costs continue to surge AND there's on-going fraud in the system. Both issues need to be seriously addressed by Congress, and soon.  Remember, ObamaCare primarily addresses ACCESS and not system reform. Unfortunately, Washington lawmakers continue to singularly focus on the costs of the government run system; rather than seeking a solution to curbing actual health care costs and re-forming medical billing practices. Until this issue resolves, it doesn't matter how many people sign up under the ACA and maintain health insurance. Without developing a more effective method to lower costs within the system, financial waste and misappropriation of funds will certainly continue.

The only certainty remaining is that patients must always be diligent. Every bill received from a provider, along with every explanation of benefits received from an insurance company should be thoroughly scrutinized.  Do not accept at first glance these amounts are correct.  Don't be afraid to question a bill. Double-check you received the actual charged service on the date posted and that the insurance company paid the appropriate amount.  Understanding your benefits is key to understanding whether you were reimbursed and/or charged properly.   If you are not able to do this on your own, there is help available from professionals, like myself, whose job is to review your claims and advocate on your behalf. Most people don't even realize they've been charged incorrectly or received improper reimbursements.  Bottom line, you should only pay what you truly owe. The problem is often identifying what that amount actually is, and that is not always so transparent. 

Stay Informed. Stay Positive. Stay Healthy.
The Patient's Advocate
brought to you by 
Claims Security of America
The medical claims filing experts

Thursday, December 19, 2013

Healthy Resolutions for the New Year

While much of our nation's focus is on healthcare and insurance, the real root of the crisis is not getting enough attention. By and large, Americans are unhealthy. Most of us are overweight, overworked, overstressed and over-medicated.  That's the bad news. The good news is it's all fixable. It's just up to us, as individuals, to make the changes that will allow us to be healthier and lead more productive, happier lives. Yes, some medical issues and conditions are unfortunately hereditary and random facts of mortality; but a healthy lifestyle is absolutely, 100%, a choice. compiled a comprehensive Top Ten list of simple, healthy resolutions for the New Year. Here are their recommendations in short. I urge you to read the full article (link is below) and to share it with loved ones. Your lives depend on it.
  1. Lose weight
  2. Stay in touch with friends, family
  3. Quit smoking (Natural and Electronic)
  4. Save money
  5. Cut your stress (there are ways!)
  6. Volunteer
  7. Go back to school (or continue to educate your mind)
  8. Cut back on alcohol
  9. Get more sleep (Everyone wants just have to make it a priority. Remember the hours you keep is a CHOICE.)
  10. Travel,,20452233,00.html

Stay Informed. Stay Positive. Stay Healthy.
The Patient's Advocate
brought to you by 
Claims Security of America
The medical claims filing experts

Wednesday, October 2, 2013

The Affordable Care Act Roll-Out

Demand for affordable health care was even greater than expected as millions of Americans overloaded the new health care exchanges the day they opened.  Federal officials said more than 2.8 million visitors between midnight and late afternoon yesterday contributed to long wait times for access to  the website they are running for 36 states.  Officials in New York state, which is running its own insurance site, said an unanticipated surge of visitors in the first hours left the marketplace only partially functional. California said its website fielded five million page views by 3 p.m. local time.  Despite the computer glitches and over capacity usage, there's no denying people all over the country are desperate for health insurance. That's the good news. The bad news is, can the government handle the operation?  

Operating the ACA is a massive undertaking. A lot of folks will look at all the initial problems and blame the government. They'll argue it proves once again how inefficient the government is and they should not be running what needs to remain exclusively a private business. The reality is that even if the private health insurance industry had reformed its system on its own, there would be similar problems with the initial roll-out. And what business runs 100% smoothly on its first day of operation?

The most important thing to take away from the last couple of days is that people do want better coverage AND to maintain some patience with the early implementation. Let's remember that we are only in an enrollment period for coverage that does not take effect until January 1, 2014.  There's no early sign up discount or added benefits either. So, you can take your time with looking into your options. You have until December 15 to enroll for a January 1,2014 effective date.   However, you can enroll as late as March 31, 2014 at which time the open enrollment period ends for this year..

And for those who still have questions on how exactly the new system works, here's a simple to follow animated guide to the Affordable Care Act from the Henry J. Kaiser Family Foundation.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate 
A service provided by 
Claims Security of America

Tuesday, September 24, 2013

President Obama discusses Health Care with President Clinton at Clinton Global Inititiative 2013

Several years ago, Former President Clinton created a world philanthropy organization called The Clinton Global Initiative (CGI), which addresses and looks to assist with the world's most pressing issues. Every year, Clinton joins business leaders, political figures and philanthropists from around the world for a week in New York City. These meetings and speeches are streamed live on the internet. Today, a week out from the official Affordable Care Act roll-out, President Obama sat down with Clinton to discuss all the provisions of the new law, how it really works and how it's really being paid for. It's an intelligent, truthful, easy-to-follow conversation between two of the most highly educated American Presidents in history. Think what you want about each man's politics, but this exchange between the two is not a political one. Rather, it's an educated one. Here's the nearly hour long discussion, along with a brief introduction from a woman who knows both men, personally and professionally very well, Hillary Clinton.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate 

A service provided by 
Claims Security of America

Thursday, September 19, 2013

Medicare Open Enrollment vs Affordable Care Act Open Enrollment

October 1, 2013 is the beginning date for the "Open Enrollment" in the newly created Health Care Exchanges and Marketplaces that have been enacted under the Affordable Care Act (ObamaCare).  

Our blog from August 21, "What Are These Exchanges All About?" details the 2013 Health Care Marketplace for all insured and non-insured looking for new coverage. However, even if you are happy with your existing coverage, you may find the new system to be even better and offer additional coverage at a reduced rate. Everyone should be exploring all their available options now.

Unrelated to the Affordable Care Act, the Medicare population also has the opportunity to change their Medicare coverage during the Annual fall Open Enrollment (AEP) beginning October 15 until December 7,  for a January 1, 2014 effective date.  This is an area we previously addressed in our October 26, 2012 blog. 

So, how do you know whether to choose traditional Medicare with a Medicare Supplement that offers a Prescription Drug Plan or choose a Medicare Advantage plan with Prescription drugs included?  Asking the following questions could be helpful in making the most appropriate decision.
  1. Were you satisfied with your Medicare coverage this past year?  If you were satisfied with your Medicare coverage, perhaps you need not make any changes.  If, on the other hand, you had problems with accessing providers in your Medicare Advantage Plan or wished you could go out of network to see any physician you wanted, then you may want to consider a change.
  2.  Do you anticipate high utilization of services next year? (tests, procedures, surgery, etc.)   If yes, then a change from your present Medicare Advantage Plan to traditional Medicare may be warranted.  The cumulative cost of co-pays and co-insurance under Medicare Advantage Plans can be greater than the costs of a Medicare supplement and stand alone Part D drug plan. 
  3. Did you enter the prescription drug doughnut hole?  If you are presently enrolled in a stand alone Part D plan you should do an analysis of your present drugs to see which Plan is best for you. Plan D programs are very drug specific and what worked for you this year may not be beneficial for you next year. Formularies, co-pays and premiums are different from Plan to Plan.
  4. Are you planning to move from your present residence next year?  A move to another location could be a problem if you are enrolled in an Advantage Plan. Out of network services are generally not available. Check with you Plan to see if they have a program in your new area if you still wish to be enrolled in an Advantage Plan, rather than the traditional Medicare program.
The official Medicare website,, gives excellent instructions on how to further best select the most appropriate Plan D option, evaluate Medicare plans and understand what Medicare covers. If you're enrolled in a Medicare Advantage and/or Part D Plan, you should  receive an Annual Notice of Change by September 30th.  This notice informs you if your current provider network and drug formula will change. These changes may help you decide whether or not to shop for alternate plans for the coming year.

Stay Informed. Stay Positive. Stay Healthy.
- The Patient's Advocate 

A service provided by 
Claims Security of America