JUST THE FACTS : FIVE STEPS FOR TACKLING MEDICAL PAPERWORK LIKE A DETECTIVE cont.
5. CALL FOR BACKUP
Knowing when to call for backup is critical. If you can't figure out a health care billing problem on your own, there are agencies that can help. Case management services are available through private insurance, Medi-Cal and California Children's Service, in California. Think of case management services as a private detective that you're hiring to do some of the legwork in your investigation. The Department of Managed Health Care Services regulates private health insurance companies and provides resources to help you understand the appeals process.
The Health Consumer Alliance operates a hotline that can provide direct assistance with health insurance appeals and grievances.
Children and youth with special health care needs don’t always qualify for Medi-Cal insurance, but if they do, there are special protections. Children with intellectual disabilities or medically intensive care needs can qualify for Medi-Cal through waiver programs, even if their family income is over the established limit. If you go to a provider who accepts Medi-Cal, they are legally required to accept what Medi-Cal pays them as payment in full, even if they’re not in-network with your Medi-Cal Managed Care Organization. That means they’re not legally allowed to bill the patient for anything. (If a provider does not accept Medi-Cal payments at all, this rule doesn’t apply). If you have a problem with a Medi-Cal provider that you can’t resolve, the Medi-Cal Managed Care Ombudsman can help.
My hope is that these steps will help all the harried caregivers out there struggling with medical paperwork. Admittedly, I still get a knot of fear in my stomach when I open bill-sized envelopes from medical providers, even though I know we have good insurance coverage. But once I sit down at the table with my trusty yellow highlighter, I know I have the tools to figure out the problem. These same detective skills can work in advance of a bill too — you can troubleshoot prior authorizations and pharmacy approvals using the same set of steps, you just have to do it before the bill arrives instead of after.
Exciting, right? Who knows, maybe medical billing detectives could be the next crossover primetime show. Instead of handsome doctors performing surgery, it would show overworked moms sitting at the kitchen table, on hold with insurance companies, and billing department employees, faxing prior authorization forms. I doubt anyone else would watch it – but I would.•
This article was produced in collaboration with the California Health Report; Check in your state for corresponding organizations .
| Agency or Service | Availability |
|---|---|
| Medi-Cal (CA’s version of Medicaid) | Different names in other states |
| California Children's Services | Doesn’t exist in other states |
| Dept. of Managed Health Care | Every state has an equivalent |
| Regional DD Center | Each state has their own |
| Health Consumer Alliance | Each state has their own |
| Managed Care Ombudsman | Some states have this, most don’t |
ABOUT THE AUTHOR:
Jennifer McLelland has a bachelor's degree in public policy and management from the University of Southern California and a master's degree in criminology from California State University, Fresno. She worked for the Fresno Police Department in patrol for eight years. She is currently a stay-at-home mother and paid caregiver through the In-Home Supportive Services program. She is active in advocating for disability rights and home- and community-based services.
