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Liver transplant/auto-immune disease support. Conducted primary and secondary health plan (Aetna/Medicare) claims review, confirming that carriers paid bills accurately. Result: peace of mind during urgent phase of treatment.
Newly diagnosed stomach cancer. Support to patient’s family member to find in-network specialists, information about health plan options and resources. Savings: reductions of annual premiums.
Skilled nursing claims appeal. Investigated dual coverage (Medicare HMO/auto insurance) to validate benefits coordination. Assisted client and family appeal self-pay “custodial” phases of SNF care and re-submit for insurance payment. Billing by facility done incorrectly: client ultimately reimbursed and released from pending charges. Savings: $14,400.
Glioblastoma/brain cancer support. Obtained timely SSDI and long term benefits, negotiated with employer for extended payment of COBRA coverage. Transitioned client to new insurance (3 times over 2 years) due to changes in WA State individual health plan restrictions. Savings: lower premiums, reduced stress for family, improved documentation and time management.
Air ambulance bill negotiation. Obtained a self-pay discount, worked with hospital/provider/client to prevent account from being transferred to an external collection agency. Savings: $4,000.
Review of insurance plan options during open enrollment season. Detailed comparisons of individual health plans and State Exchange options with customized recommendations. Savings: premium adjustments, improved coverage and benefits.
Investigated Regence payment for breast cancer treatment received out-of-network due to provider and health plan miscommunication. Fast-tracked review resulted in co-insurance waiver and claims reprocessed as exceptions paid at in-network level. Savings: $7,100.
Assisted adult children of memory-impaired parent to research and confirm Medicare benefits and premium payment history. Result: reduced stress for family.
Expedited appeal to Group Health to pay for out-of-network care for bile duct cancer, due to specialized expertise of external oncologist. Result: consults approved for non-preferred provider.
Coordinated appeal for LifeWise member to cover orthopedic and pulmonary care received out-of-state as in-network benefits due to emergency nature of treatment preventing travel. Savings: $109,000.
Appeal prepared for Anthem member to cover hospital subcontractor claims as in-network benefits related to emergency cardiac bypass surgery. Savings: $27,000.
Reviewed out-of-network financial responsibilities for Moda Health member who chose treatment for brain tumor at New York hospital. Verified accuracy of claims and provider billings, developed payment strategy, explored resources. Result: client empowerment to develop action plan.
Long term care policy payout for family on behalf of elderly mother receiving assisted care. Coordinated 2 policy submissions and worked with facility to obtain detailed documentation to maximize payment. Savings: $27,000.
Out-of-network orthopedic surgery appeal submitted to Moda Health to review payment based on emergency nature of care. Savings: $8,200.
Cancer policy payout. Appeal submitted to American Fidelity to pay supplemental cancer care policy benefits. Savings: $1,300 reimbursement.
Short term insurance policy review for exclusion of gallbladder surgery. Negotiated with Texas hospital to adjust payment to market rate. Savings: $33,000 written off that was originally balance billed.
Short term insurance policy review for exclusion of hernia repair. Market review of benchmark charges, communication with Washington hospital to qualify client for customized financial aid. Savings: $20,000 removed from bill.
Ensured preauthorization for out-of-state spinal surgery. Untangled multiple insurance policies to confirm coordinated benefits and coverage for Anthem member. Proactive documentation prevented balance billing and need for appeals. Result: patient able to focus on treatment rather than paperwork.
Inadequate insurance for outpatient surgery bill. Prepared letter for senior management review at Montana hospital, requesting market rate reduction of charges. Savings: $7,900.
Behavioral health benefits and appeal review. Researched mental health coverage decisions of Optum Health/Providence Health, consulted with client’s therapist to advise on appeal strategy and next steps. Result: patient relieved to understand entire situation.
Appealed denial of out-of-network hospital bill. Contested Kaiser payment decision, claims reprocessed at in-network emergency care benefit level. Savings: $6,350.
Customized transition from Medicare Advantage HMO to original Medicare/supplement/drug plan in order to maximize insurance coverage for out-of-network cancer surgery and treatment. Result: client/family peace of mind to have optimal flexibility to obtain excellent care without restrictions.
Bill waived for psychiatric inpatient care due to disconnect between First Choice and hospital regarding out-of-network status. Result: client owed zero balance after a year attempting to resolve on her own with collection agency involvement. Savings: $8000.
Reversed insurer denial of psychiatric residential out-of-state treatment, a custom appeal process with BCBS Illinois to follow ERISA guidelines for self-insured employer group benefits. Savings: $3840.
Running Total of Dollars Saved for Clients: $288,170