From Claims Denier to Health Care Advocate | MedWise Insurance Advocacyadria
From Claims Denier to Health Care Advocate
One woman’s journey from one side of the insurance industry to the other
Last Updated: October 15, 2015 5:29 pm
MONROE—Adria Goldman Gross, a resident of Monroe who grew up in Port Jervis, started her career as a health advocate after a fall down some restaurant stairs in 2001.
It wasn’t her that fell but her first client, a 68-year old man who had been in a wheelchair for most of his life due to polio and who broke both legs in the fall.
He sued the restaurant for failing to make their building handicapped accessible and years later, won the lawsuit. Medicare claimed part of the damages owed to him for the hospital bills he incurred from the accident, but when they sent him a 28-page bill, he knew they were asking for too much.
“The first five pages included the doctors names and just looking at that I knew immediately that there was stuff that didn’t belong there,” he said in a phone interview.
They had included procedures like colonoscopies, a fishhook in his hand, and bills from his eye surgeon, which were not related to his accident.
“It was like reverse Medicare fraud,” he said.
Goldman Gross, who had worked for two health insurance companies: AIG and Access America, as well as for a doctor, was just starting her medical billing business Medwise Billing, when Dunitz asked her to help translate the prescription codes on his bill.
What Goldman Gross discovered is, like Dunitz suspected, they were asking for reimbursement for things he never had. When all was said an done, Goldman Gross saved him $86,000.
“And when I realized I could do this,” she said, “That’s when I thought ‘I need to open up another type of business.’”
In 2012 she opened up MedWise Insurance Advocacy, a division of MedWise Billing, Inc. with the logo “We give a hoot about your claims.”
The idea of a health advocate, or someone who has the knowledge and skills to navigate a client through the maze of insurance jargon and roadblocks, is still fairly new.
There are only a handful of advocates in the New York state area.
There are only a handful of advocates in the New York state area, and Denise Sikora, who founded her company DL Health Claim Solutions, L.L.C. 10 years ago in New Jersey, said she has never met another face-to-face.
“And believe me, I do a ton of networking,” she said in a phone interview.
The industry has grown since she first started though. “When I was first starting my business, I had to not only market my business, but also the whole concept of what an advocate is,” she said.
Health advocates work with insurance and billing companies, health care providers, and even with lawmakers to help patients manage medical insurance claims.
Some health advocates come from legal backgrounds, others from insurance or medical backgrounds, and yet others have no relevant background at all.
“I was a technology executive and then I was retired at home for 10 years,” said Martha Bradt, who founded her company Health Claims Concierge four years ago, in a phone interview.
She did work with an insurance company on the technology side, but more importantly, she saw a need for health advocacy and found she was good at it.
Besides persistence and patience, health advocates need a willingness to learn. They say no two cases are alike, so advocates are constantly having to expand their knowledge to keep up with changes in the industry and the laws that regulate it.
To this end, some join organizations like the Alliance of Claims Professionals (ACAP) that connects advocates around the country. These associations are invaluable for advocates who use them to get advice, brainstorm, and draw on the experience of advocates with different backgrounds.
She is proud of the millions of dollars she has saved her clients.
Because it is such a niche industry, most health advocates deal with clients across state borders, and in some cases, several states borders.
“I’ve handled a case where the son lived in Georgia, his sister, the daughter lived in North Carolina and I dealt with hospitals in Georgia, two in South Carolina, and one in North Carolina,” Goldman Gross recalled.
In some states, like New York, a health advocate is required to have a license, but not all states require the same license, or have reciprocity with other states that require them.
“You can be either a life consultant, which is really life and health, or a broker, literally an insurance broker,” said Bradt, who has a license in Connecticut and New York where most of her clients are.
Advocates usually work on multiple cases at a time. Sikora said she averages between 35-40 active clients at any given time. “But in the insurance world, this is how it works: You work on something—you call, you write appeals, whatever—and then you wait 30 days,” she said.
Goldmann Gross admits it is a time-consuming job.
“I work a lot,” she said.
She doesn’t plan to retire anytime soon, though. Like many advocates, she is proud of the millions of dollars she has saved her clients, and she likes the feeling of helping others.
“Every time I’m able to save someone money, it’s like a gift to both of us,”she said.
When Goldman Gross worked for her first insurance company, Access America, they taught her to deny claims within the first two weeks of her working there. Later at AIG, she did the same thing.
“The first thing they [Access America] taught me is to look at the exclusions and see if there is a way from the exclusions that you can deny that policy,” she said.”It was so heartbreaking, especially [to deny] people who had cancer. And to know what they were living through.”
Goldman Gross lived with epilepsy for almost 25 years, so she knows what it’s like to be dealing with medical bills and medical problems at the same time.
And even when a person is covered for their treatment, like John Ziolkowski was, insurance companies can make it so hard to get the claims processed that some people will just give up, even if it means losing thousand of dollars.
Ziolkowski had comprehensive health insurance through UnitedHealthcare Oxford when he signed up for a rehab facility in Arizona in 2010. He paid for the cost of the treatment up front knowing his insurance covered it, but when he tried to get them to pay, they gave him the run around.
If you want the money from the person and they don’t have it, how can you get blood from a stone?
— Adria Goldman Gross
“They would stone wall me and say ‘We’ll give this to a committee to review, this is an appeal process, and it will take 30-60 days for them to review and then we’ll let you know of their decision. Sure enough, [in] 30 to 60 days—’Mr. Ziolkowski, we cannot honor the claim because of X,Y, and Z,’” he said in a phone interview.
He thought he was pretty savvy with medical claims, but he was about to give up when he came across Goldman Gross online. She worked on his case for over six months and after writing a letter to New York’s attorney general, was able to get the $37,000 claim not only paid, but paid with interest.
Not all have been so lucky though. Goldman Gross said there are people she simply can’t help. Sometimes it is because a person works for a company that self-insures, or she simply cannot reach the people she needs to to resolve the case.
“The only time I’ll ever get to that point is when we have gone to the state, and we have gone to the doctor, or the hospital, and we’ve gone to the politicians—that’s when I give up,” she said.
She has also worked with people who simply don’t have the money to pay for their treatment. In those cases, she has negotiated with the healthcare provider to have them pay less, and in some cases they write will it off completely.
“If you want the money from the person and they don’t have it, how can you get blood from a stone?” Goldman Gross said.
One trend that Goldman Gross is seeing in the healthcare industry is that doctors are joining hospitals or larger organizations to make more money and for protection from malpractice lawsuits. This means that a doctor can be in-network one visit, and not in-network the next, which happened to a woman she worked with who needed regular I.V. infusions.
“This woman who was going to the same hospital, she was in the same room, the same doctors, the same infusion, but the bills went from no more than $660 to almost $20,000,” she said.
One thing that hospitals are required to do by state law now is to notify a patient before a planned procedure, like a surgery, how much they will be charged. The law, called the “Surprise Bill Law” went into effect at the end of March, and says “if the patient requests, they [the healthcare provider] must disclose the anticipated cost, warning patients that costs could go up if unanticipated consequences occur.”
“I know that they’re not doing it. People are telling me this,” Goldman Gross said.
Health care providers, she said, will also try to make more money by scheduling a procedure that could be done in one day, over two.Because of how the billing works, they make more money from this.
She recommends always looking at the fine print, getting everything in writing, knowing what the insurance policy will cover, and if possible, never going out of network to avoid large medical bills.
She has expanded on that advice in a book she co-authored called “Solved! Curing Your Medical Insurance Problems,” which she expects to be published in the next few months.
After talking at length about what she has seen in the industry, Goldman Gross acknowledged, “It’s a mess.”
“I’m thinking about when I go to book signings … I’m thinking about what to write in my book,” she said. “Maybe ‘Never get sick.’”
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