In the Words of Our Founder
Back in 2007, a close family member had been diagnosed with a debilitating disease, requiring extensive medical treatment and resultant medical bills. She was being inundated with medical invoices, and I had agreed to audit the bills to ensure compliance with her health insurance benefits package. She had been told that the medical bills were “covered”, yet she was being held responsible for the majority of the charges. While investigating, I had found that the insurance company were not all that knowledgeable about medical necessity in treatment, and the medical providers were confused as to their rights as a benefits assignee. I began advocating for the patients, to relieve them of this unexpected financial burden. The result was additional payments to the provider, and a settlement being reached where the patient was not held financially responsible.
After becoming a Certified Professional Coder, I identified many gray areas in the industry. No one seemed to be able to explain non-covered services, surgical code bundling, retro-active claim denial, medical necessity, etc. It seemed the providers were relying on the insurance companies to inform them of how to bill and what they shall be reimbursed for. The provider would then blame the insurance carrier for the large balance, and the carrier would accuse the doctor of over-billing. This is particularly true for highly specialized out of network surgeons, who were increasingly aware of the health law changes with the passing of the Affordable Care Act. We set out to bridge the gap, and hold the insurance company to a standard, in that the eventual reimbursement correlate with the expectation of payment prior to service.