As a parent of a child with medically complex conditions, I’m good at handling health emergencies. My child is tracheostomy dependent, which means that several times a day, his breathing tube gets blocked and I have to act quickly to clear it. When my son’s ventilator alarm sounds, I know how to troubleshoot and figure out what went wrong so he can keep breathing. Handling medical emergencies isn’t hard for me anymore, it’s just a part of life.
But handling all of the paperwork that the medical emergencies create? That’s an entirely different skillset.
Unlike with medical emergencies, parents get no training on how to deal with health care approval paperwork and bills. They must figure it out on their own. This used to be a huge source of stress for me, until I changed my mindset. Now, I’m no longer a frustrated mom sorting through bills and insurance denials — I’m a health care detective and I’m solving health care billing mysteries.
In my first career, I was a police officer. Being a mom to a medically fragile child is actually very similar. There are moments of life-threatening danger where I have to act quickly and decisively … followed by hours of paperwork. Being good at emergencies keeps my son alive. Being good at paperwork means my son gets the care he needs and the bills get paid. Some bills do end up being my responsibility — but understanding the terms and the rules of his three health insurance programs (Medi-Cal, California Childrens Services and our private insurance) means that I don’t panic when I get a stray bill for more than my car is worth.
Thinking of myself as a health care detective who is solving a mystery makes a frustrating process feel a little bit more interesting. You have to figure out the motive, gather the evidence, interrogate the suspects, and put together a case. Every health care paperwork problem is slightly different — so any advice on how to solve these problems has to be broad. But if you can think like a detective, you too can solve medical billing mysteries.
Here are my six steps for tackling medical paperwork like a detective:
To figure out how to fix a medical bill, you have to figure out why the bill exists. Providers are trying to get paid for the care they’ve already provided — that’s their motive. Insurance companies and Medi-Cal managed care plans have conflicted motives. At first glance, it might seem like they’re trying not to pay claims to save themselves money. But on an individual case level, it’s more likely they’re not paying the claim because the paperwork isn’t quite right. Never attribute to malice what can be adequately explained by bureaucracy. The people denying the claim don’t personally profit off of not paying your claim — they just need someone to send them information that they don’t have yet.
Gather and examine the evidence
This means sitting down at the kitchen table and spreading out all the paperwork you can find related to the bill. When you receive a health care bill, you can match the information on the bill to the claim that was (hopefully) filed with your insurance company. If you’re being asked to pay, it’s a bill; if the insurance company is being asked to pay, it’s a claim. If a claim wasn’t filed it can be an easy fix — just call the number on the bill and make sure the agency sending the bill has your correct insurance or Medi-Cal information. If you have private insurance, every claim that is filed generates an explanation of benefits (a document that explains what insurance is going to cover). You can usually access this through your insurance company’s online portal, or you can choose to have them mailed to you. If you have Medi-Cal, you’ll receive a different document called a notice of action for any claim that is denied, but you generally won’t receive anything if the claim is paid.
As you scour the evidence, keep in mind that, if you have private insurance, you are generally responsible for copays, deductibles and coinsurance for covered, in-network services. Every policy is different, so you’ll need to look at the rules for your specific policy. The explanation of benefits paperwork will tell you why you are being asked to pay. If you’re confused by their reasons, you can call and ask for more details. If you understand their reasons but you still disagree, you can file an appeal.
Interrogate the suspects
Once you’ve examined the evidence, you’ll probably have an idea of why the bill hasn’t been paid, but you’ll need to confirm your theory. In order to solve the mystery, you’re going to have to interrogate the suspects and try to get a confession. There are a lot of suspects: Separate bills can come from hospitals, doctors and laboratories for things that happened at the same visit. In California, the bills could legally be the responsibility of private insurance, Medi-Cal or California Children’s Services. They’re all going to blame the problem on each other. Use this to your advantage. For example, if you suspect the insurance company ignored a fax sent over by the doctor’s office, instead of accusing them of doing this, use your best customer service voice to ask if they can check to make sure the doctor’s office actually sent the fax. In the end, all you need the insurance company to do is admit that they got the fax — by giving them the option of blaming someone else for the mistake, you get the problem solved.
Make your case
To resolve your claim, you have to put all the information together and make your case. The provider may have submitted their claim wrong or sent it to the wrong agency. Children with medically complex conditions frequently have multiple agencies covering their care — private insurance, Medi-Cal, California Children’s Services and Regional Centers are all potentially responsible for a bill. Sometimes the problem is that the agencies were billed in the wrong order. For example, if Medi-Cal is the secondary insurance, then private insurance needs to either pay or deny the claim first. Sometimes the problem is that two agencies — commonly Medi-Cal and California Children’s Services — each say that the other agency is responsible for the bill. Once you’ve figured out where the claim went wrong, you can usually find a way to fix it either by making some phone calls or filing an appeal. The appeal can be intimidating – but when you’re a health care detective you’re not intimidated by paperwork.
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 Services. 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 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.
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.