As Open Enrollment Date Approaches, Medical Insurance Advocate Adria Gross Alerts Policyholders on How to Get Health Insurers to Pay More Claims

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CEO of Medical Insurance Advocacy Firm Advises Individuals to Explore How Initial Claim was Prepared and Filed, and to Understand What is Covered in Their Health Plans

The more that people understand about how the medical insurance system works, and the recourse they have, the more success they will have in getting the health coverage and medical reimbursements they deserve,

Open enrollment for medical insurance plans starts on November 15, 2014 for individuals and families, and many Americans will shop the market for the best health coverage. However, as many people discover with their health plans, there is a strong possibility the insurance company will look for a way to reject a claim. Adria Gross of Medical Insurance Advocacy , a division of Medwise Billing, Inc. advises patients that when they receive a claim rejection, to carefully review their explanations of benefits to make sure the health care providers have properly filed the claim.

“The more that people understand about how the medical insurance system works, and the recourse they have, the more success they will have in getting the health coverage and medical reimbursements they deserve,” said Gross, who assists patients and attorneys with securing just and proper healthcare benefits from insurance carriers. “With the new enrollment period about to start, it’s important that individuals really understand what all these plans cover and how to best work with the insurance company in order to avoid huge, unexpected out-of-pocket expenses.”

Gross has nearly 25 years of experience in the insurance field and has helped clients recoup hundreds of thousands of dollars in unreimbursed medical expenses or reduced clients’ medical bills since starting her company in 2012. She offers several important tips on how to reduce the odds that a health insurance claim will be rejected, and what to do in case that happens.

  • Understand your medical insurance policy. Know in advance what is considered non-emergency medical care, what you will pay for unusual or out-of-the-ordinary treatments, and which providers are in network and out of network. Read your benefits manual and ask questions.
  • Get preauthorization from your insurer. For medical procedures that are beyond a typical office visit, get the go-ahead from the insurance company first to avoid huge out-of-pocket expenses or bureaucratic runaround. Have this preauthorization sent to you in writing to prevent the insurer from later denying your claim.
  • Ask your doctor to submit a letter. If your insurer will not preauthorize a procedure, do not assume this rejection is final. Ask your doctor to submit a letter to the insurer explaining why the procedure is required in your case.
  • Be persistent. If preauthorization is again denied, ask your doctor to try again, this time describing your health situation and the necessity of the procedure in greater detail. Insurers often back down when patients and doctors persist.

If a medical claim has been rejected, Gross advises not to pay it right away but rather, investigate why the insurer did not cover it the first time. Several issues may be in play:

  • Incorrect billing codes. An incorrect procedure or diagnostic code by the healthcare provider will get the claim kicked out. If this is the case, ask the provider’s billing department to resubmit the bill to your insurer with the correct codes.
  • Billed under the wrong insurance policy. Confirm that the policy number and/or group number on the paperwork corresponds with your current policy and if not, have the billing office resubmit the claim correctly.
  • The insurer continues billing you after you’ve met your deductible and/or out-of-pocket maximum. Keep a file each year of your medical bills and your explanations of benefits (EOBs) to track your expenses. Compare your records against those of the insurer and find out why its tally doesn’t match yours. Keep in mind that the insurer may not count the full amounts charged by out-of-network providers.

When a medical claim is denied, Gross offers these steps that individuals can perform on their own or hire a medical insurance advocate to do for them.

  • Get on the phone. If it is not clear why the insurer rejected a claim, call the customer service department and ask for a clear explanation of why. Ask to speak to a supervisor if you don’t agree with or understand the answer, or call back repeatedly until you get a representative who will explain it clearly. Document your calls and take notes.

Individuals under group coverage should contact their plan administrator or human resources representative for negotiating assistance.

  • Contact your Department of Aging or similar agency if you are age 65 or older, to request assistance if you cannot get resolution on your own.
  • Ask your state’s Department of Insurance for guidance. Often the regulators are very aggressive and helpful in getting insurers that are licensed by the state to pay—sometimes with interest.

If someone is unable to manage this process, Gross suggests hiring a claims-assistance professional. Professionals are listed on the National Association of Healthcare Advocacy Consultants website ( or the Alliance of Claims Assistance Professionals (

“A professional medical insurance advocate understands state insurance laws and policy details and will make all contacts up the insurance and, if necessary, legislative chain,” explained Gross. “Advocates relieve the stress of this process by working with the insurance company to get your legitimate claims covered and get the reimbursements you deserve, or negotiate down your medical bills with the billing departments and insurance companies.”

For more information about how an insurance advocate works for the services offered by MedWise Insurance Advocacy, visit Medwise Insurance Advocacy or call Adria Gross at (845) 238-2532.

About Adria Gross

Adria Gross is CEO of MedWise Billing, Inc. a medical billing and credentialing firm that works with healthcare providers; and its subsidiary, Medwise Insurance Advocacy, a medical-billing advocacy company that assists health insurance customers in disputes with their insurers. She supports individuals and their families, and elder law and personal injury attorneys on medical claim matters. Gross previously worked as a claims examiner with Blue Cross/Blue Shield and American International Group. For more information visit

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