How to sort through your maze of medical bills

April 08--See if this sounds familiar.

After surgery to save his eyesight, Richard Crestani of Boca Raton began to receive a series of confusing bills. Before long, they amounted to a stunning $18,000. How could that possibly be -- considering he had health insurance?

Frustrated, the 47-year-old Crestani turned to Kenneth Klein, who operates Human Health Advocates in Boca Raton. Klein came to the rescue, getting the bill whittled to $1,600.

"Ken was able to get to the right people," Crestani said. "Ken was a savior."

Many patients have experienced the same thing as Crestani: a dizzying pile of bills from a system that Klein says is stacked against them.

"It requires someone with knowledge and patience to deal with it," said Klein, who opened Human Health Advocates in January 2015, using the tagline "Helping People, Not Corporations."

A former lawyer and mediator, Klein has several pieces of advice for people dealing with doctors, hospitals and insurance companies:

--Realize that under Florida Patient's Bill of Rights, you're entitled to an itemized bill and an explanation of that bill. Never pay a doctor's initial bill until you have looked at your insurance company's Explanation of Benefits, or EOB document, which spells out what already has been paid. Check for any double billings, which Klein said are common.

--To avoid denial of benefits, always obtain pre-authorization for diagnostic and other procedures. Verify not only with the doctor's office and diagnostic center, but also the insurance company itself. " "The common belief is that if one has insurance they are 'covered.' Not necessarily so," Klein said.

--Keep good records in case of a dispute. "Always obtain a reference number, name of the person with whom you spoke, the time and the date," Klein said.

--Often, when bills are denied, inaccurate coding is the culprit, Klein said. "There's a code for every procedure. If someone puts in the wrong code, the insurance company may not recognize it," he said. Coding also can be a tip-off to double billing. "If you see the same code showing up, you can challenge the hospital on it," he said.

Client Paige Coburn of Pompano Beach began getting thousands of dollars in bills from a treatment center for her 18-year-old daughter after she had been told it accepted payments from her preferred provider organization, or PPO.

She went to Klein, who recognized that the treatment center's billing company had failed to optimize the coding and that reduced the percentage of claims that were covered. Coburn's $60,000 bill ultimately got settled for $6,400.

--Patients who are insured through a PPO often fall victim to a practice called "balance billing," Klein said.

To explain, Klein cites the example of patient "John," who goes to the emergency room in his insurance network for a broken leg. But little does he know that he is being seen by an emergency room physician who is out of network and the hospital is using an anethesiologist who also is out of network.

Once back to work, he receives extremely high bills from the emergency room doctor and anesthesiologist. His insurance company pays the doctor $350 and the anesthesiologist $425 -- rates they would have paid in-network health professionals.

But the emergency room doctor still sends John a bill for $1,450 -- the balance between what the physician initially charged and what the insurance company paid. The same thing happens with the anesthesiologist.

Florida law prohibits balance billing when the patient is in an HMO and for emergencies and covered services provided in an in-network health center. But members of PPOs can end up with a bill from a doctor that's beyond the rate the insurance company has agreed to pay, Klein said.

Many physicians' billing offices are willing to negotiate reductions in the amounts, he said, with some accepting the negotiated rate paid by the insurance company or the Medicare rate.

Crestani, a former chief financial officer and business owner, knows how to read financial statements. But he couldn't understand why he was being billed $14,000 by the hospital and $4,000 more by the surgeon for eye surgery that had been pre-approved by his insurer. And he couldn't seem to communicate with the hospital or insurer about it.

As a teenager, he suffered a retinal detachment and developed glaucoma, an eye condition that can cause blindness if not corrected. So when he bought his own insurance as an adult, it came with a rider that prohibited treatment for his pre-existing condition.

But in 2014, he developed another eye condition that had nothing to do with glaucoma. In a previous surgery, a small hole was made in his lens to improve his vision. But then cells began to form and close up the perforation in his lens.

"I needed them to go in and open this passage up," he said.

Even though the new surgery had been pre-approved by his insurer, his hospital bills were denied, citing the glaucoma rider.

Klein urged him to get a letter from his doctor stating that the condition was not related to glaucoma. Klein filed an appeal with his insurer, consistently following up.

The process "took 60 to 90 days, but I won the appeal," Crestani said.

Much of Klein's work revolves around preparing appeals of denied insurance claims and discovering errors that are making the bill higher than it should be.

Usually, "someone comes in with a box full of bills -- they're overwhelmed," he said. "Patients are wholly unprepared to deal with the onslaught of unexpected bills that follow."

Human Health Advocates offers a free consultation. If Klein accepts the case, he charges an hourly fee depending on the amount of research and time required. Klein said his fee is higher for an insurance appeal than for the individual who brings in a box of medical bills and needs help determining what to pay. He also offers a 45-minute educational session for $75, for either an individual or a couple.

Phil Scruton, consultant with the Small Business Development Center at Palm Beach State College in Boca Raton, is helping Klein market his business. He said Klein's understanding of detail makes him especially good at being a patient advocate.

Klein "knows when he's being stonewalled and knows how to get around it. And he seems like a genuinely compassionate person," Scruton said.

But don't call Klein if you have a problem with Medicare. He only takes clients age 65 and younger -- insured or uninsured.

With Medicare, "there are so many specific rules. I don't want to venture into that," he said.

[email protected] or 561-243-6650

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