MATERNITY CLAIM ASSISTANCE

One of our client's employees placed a call directly to our Service Team to discuss a denial she had received from her medical insurance carrier for coverage of an in-home fetal heart monitor. She was 23 weeks pregnant with twins who were expected to be premature. Because the pregnancy was considered "high risk", the OBGYN had requested an in-home fetal heart monitor, traditionally a non-covered expense. We phoned the OBGYN and obtained some detailed information regarding the necessity of the monitor. We shared this information with the insurance carrier's case manager and medical team. They agreed that it appeared the monitor was "medically necessary" and subsequently approved the equipment.

We continued to stay in contact with the employee throughout her pregnancy. After the birth and mom and babies were home and settled, our Service Representative personally met with the employee to review and audit all of her medical bills, totaling more than $300,000. During the meeting, we identified approximately $90,000 in charges on which the insurance carrier had denied payment..

The Service Representative prepared an extensive claim audit and summarized the activity in an easy to follow Excel spreadsheet format. The audit identified claims that had been processed incorrectly. The carrier, upon receipt of our audit agreed to conduct an internal audit and assign a special claims supervisor to the employee's account. Our Service Representative met with the claims supervisor and the account manager to analyze the audits and determine the necessary procedures to resolve the claims issues. The unpaid claims were reprocessed resulting in the employee's financial responsibility being reduced to the expected out-of-pocket expense according to the policy.