Professional Health Claims Assistance

A Medical Claims Professional [also called a Claims Assistance Professional (CAP)] can take the entire claims process off your hands. In addition to doing the work for you, the professional seeks to assure that you don't over pay, and that your insurer doesn't under reimburse you.

Medical Claims Professionals generally work for people who can't or don't want to deal with the paperwork or who need help straightening out a mess of bills.

A Medical Claims Professional does not have to be in the same locale as the patient(s) being assisted. The work can be done anywhere in the country using telephone, e-mail, fax and snail mail.

Medical Claims Professionals are not generally regulated on either a federal or state level. Some states require Medical Claims Professionals to be licensed. For example, Florida, Illinois, Michigan, New York, Oregon and Virginia. 

If your claims involve Medicare, be aware that every state offers free assistance to Medicare recipients in sorting through bills, benefit statements, Medigap claims and Medicare coverage. The assistance goes by different names in different states. The generic name for these programs is State Health Insurance Assistance Programs. Contact information can be found at www.shiptalk.org .

What a medical claims professional does: Claims professionals can:

• File claims.
• Coordinate payments when more than one insurer is involved.
• Track the progress of claims and reimbursements.
• Handle appeals when claims are denied or billed incorrectly.
• Provide counsel about which health insurance policy to purchase.
• Provide you a year end summary for tax purposes.

What to look for when hiring a claims professional

• Experience. Many professionals worked either in insurance, doctors' office administrators, or the administrative side of the health-provider business.
• Education (in general and specifically about health insurance and claims assistance).
• Written list of services to be provided.
• Fees. Fees may be hourly, monthly or yearly. There may also be a fee in the form of a percentage of claims the person helps you obtain.
• References (and call them!)
• A license, if required in your state.
• Contact your local Better Business Bureau to find out if any complaints have been filed against the person or his or her company. For local information, see: www.bbb.org 

How to locate a medical claims professional  

Potential sources of referrals include:

• Your employer may offer these services as an employee benefit either on its own or through an outside company.
• The Alliance of Claims Assistance Professionals at www.claims.org  , Tel.: 888.394.5163.
• Medical Billing Advocates Of America, www.billadvocates.com  , Tel.: 540.387.5870.
• Ask a social worker, lawyer or accountant.

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