Deep Knowledge of the Industry

Benefit: You can have the security of knowing that you have the level of protection that you want, need and can afford.

After obtaining a new client a couple of years ago, we learned from the Executive Director of the group that he personally was very frustrated with their current carrier.  He had some health issues that required numerous hospitalizations and had been saddled with some large medical bills that, according to what he was told by the carrier’s Customer Service Representative (CSR), would be paid as in-network services.

The Executive Director was under the assumption and had been led to believe that the group was covered under a PPO plan, when in fact their plan was actually an HMO.  He had played by the rules – obtaining referrals, seeking second opinions and consulting with the carrier’s representatives.  After seeking services, he was left with thousands of dollars in unpaid medical bills because the benefits received were processed by the carrier as out-of-network services.

In reviewing the coverage that had been in place when the services were rendered, we determined that their plan was actually an HMO.  Although it looked, smelled and tasted like a PPO…it was an HMO.  Even the carrier’s CSRs that had advised our client throughout the ordeal thought it was a PPO.  Our client was totally frustrated, feeling like he had exhausted all possibilities.  He needed some “inside” help.

Feeling his pain and having observed first-hand the complexities and “red-tape” that are so common in handling claims issues, we were more than willing to take on this challenge.  With our client’s authorization, we immediately contacted the carrier and requested claims data as well as supporting documentation.  It quickly became apparent to us that our client had a legitimate and valid argument.

After dissecting the claim and repeatedly challenging the information provided by the carrier, we escalated the issue with the carrier to the director level.  After building the case for our client and having several discussions with the carrier, it was agreed that they would re-process the claims and pay them as in-network services.  The final resolution, which ultimately required special approval at the most senior level of the company, resulted in additional carrier-paid claims that would no longer be owed personally by our client.  Here are his words:

“I had a horrible situation with one of the largest providers in the country and Judy mentored me through the process where I probably ended up saving , out of pocket, $80,000…And it was all because the insurance company didn’t do their job.  But unless you’re behind the scenes, or unless you have some connection with this work, you probably wouldn’t have understood that.”

Lou Nisenbaum, Executive Director, The Nemasket Group

Another of our customers described the advantages of working with someone who has industry knowledge and experience:

“It’s awful hard to coach a sport when you’ve never played the game.”

Michael Shea, Superintendent, Greater New Bedford Regional Voc-Tech