The Alliance of Claims Assistance Professionals (ACAP) is a nationally recognized association of independent Claims Assistance Professionals (CAP). Our members provide medical claims assistance and patient advocacy to individuals and businesses across the country. We are each independently owned for-profit businesses whose services are fee-based. All members undergo a rigorous application and vetting process and provide multiple professional references in order to be invited to join the organization. Our membership provides a broad array of assistance that ranges from local and regional focus to national and even global representation.

May 2025

Medicare Part A (Hospital) When Turning 65 and Continuing to Work

I was recently asked, “Do I need to sign up for Medicare Part A when I turn 65 if I’m planning to continue working full time and my employer provides health insurance?”
The answer may seem to be a simple, “No”; however, Medicare enrollment involves more than just age and working status. And prompt sign up during the designated Medicare enrollment periods is important to avoid gaps in coverage or late enrollment penalties.
While Medicare Part A is free for most individuals because they’ve worked for over 40 quarters/10 years and paid social security taxes, late enrollment penalties can result in higher premiums for Part B (Medical coverage) and Part D (Prescription coverage) that continue for life. For Part B, the penalty is typically an extra 10% added to the monthly premium for each year the individual could have signed up, but didn’t and it escalates along with the cost of Medicare since it is a percentage of the premium.
Here are some criteria that must be considered. If…

• the company you’re working for has less than 20 employees, Medicare is necessary.
• the insurance your employer provides is not considered “credible coverage” by Medicare (coverage is at least as good as Medicare), Medicare is necessary. Your Human Resources (HR) department should be able to advise of this.
• the insurance your employer provides doesn’t include prescription drug coverage, Medicare Part D is necessary and requires Part A for enrollment in Part D.
• your spouse or other dependent(s) require your coverage, Medicare won’t cover them. It is for individuals only.

In the case of the individual who asked the question, none of the criteria above impacted him and Medicare Part A was going to be free so he elected to enroll. while this is not an exhaustive list of conditions for all circumstances, it illustrates how Medicare enrollment rules involve more than age and working status.

-Marion Gottlieb from Marion Gottlieb Consulting

April 2025

Scary bills!

“Help, I’m getting a $30,000 bill from the hospital and they keep telling me my insurance won’t cover my recent hospital stay!”
This is the call I received from a client who is on Medicare and didn’t understand why he was getting such a large bill. My first response to my client was to NOT pay that bill. He had Original Medicare A and B and a secondary plan through his employer retiree benefits, there’s no reason for an out-of-pocket expense of $30,000.
After doing some sleuthing, I found that there were some problems with the hospital billing. His stay to Medicare Part B instead of Part A. Medicare part B covers outpatient hospital care, yet it includes overnight observation. Medicare part A covers hospitalization. There was some confusion over his employer retiree health insurance coverage, which fell in the category of acting as secondary plan to Medicare. It was not a Medicare Advantage Plan and was not a true Medigap/Supplement plan.
There were claim denials from his secondary, because it was billed as primary. The list went on, and on. I was able to resolve the problem and get the hospital to bill his stay correctly to Medicare Part A. After that the remaining coinsurance and deductible was filed to his secondary insurance that was provided through his retiree benefits. It required many calls to the hospital billing department, Medicare and his secondary insurer. After all the corrections, his out-of-pocket expense was $0.00.
The best part is that my client wasn’t alone in this and had an advocate to help him resolve this scary incident for him; thinking that he was on the hook for $30,000 for his recent hospital stay. No one should ever feel this kind of dread, so if you get a scary bill for medical services, call a Claim Assistance Professional (CAP) and have them help you navigate this crazy world we call health insurance.

-Nicole Blair from Health Insurance Claims Assistance

February 2025

Health Insurance Policy Renewal

It is a common practice to ignore notices each year regarding open season for health insurance. However, regardless of one’s satisfaction with their health plan, it is important to confirm your providers haven’t left the network. Providers come and go and sometimes, entire medical groups or hospital systems will leave your network.
This can pose problems. Such as it was for Bob when he required an urgent procedure for his condition, Hypertrophic obstructive cardiomyopathy. This condition required a special procedure called Alcohol Septal Ablation. As Bob lived part time in a foreign country, he was missing notices that his medical group had left his network and he needed to choose a new primary physician. When it came time to set up appointments at his hospital of choice for the cardiac procedure, he no longer was assigned to a primary physician at that hospital.
An ACAP stepped in and contacted the insurance to request that Bob be reassigned at his hospital of choice in order to have continuity of care and providers he chose. The action was expedited due to the urgency of Bob’s condition. If you can’t stay on top of your health plan, a CAP can step in to ensure you are covered with the care and providers you expect.

-Mary Lavery from Transparency Healthcare, LLC

January 2025

Self-pay discounts have increased as well as the individual’s bargaining power.

The portion of health expenditures by direct consumer payments is growing. The increase in 2022 was 6.6% while third party payer spending has declined by 10.2%. The consumer is feeling the larger brunt of the financial burden. For this reason, and the advent of transparency laws, individual consumers have more negotiating leverage and market power compared to health plans and insurance companies.
A Forbes article titled “Why Are Cash Prices Lower Than Health Insurance Negotiated Prices?” points out this interesting trend. The Forbes article explains that most hospitals set self-pay prices at rates lower than median insurance price. And 20% of hospitals set self-pay equal to or lower than their lowest insurance rate.
In the past, health plans with the largest market share received the largest discounts. Unless the individual qualified for financial assistance, the individual was only offered a minimal discount. Today, individual consumers have better negotiating leverage and pay rates lower than rates commanded by large insurance companies. As a result, most hospitals offer self-pay discounts at rates significantly reduced from billed charges.

-Richard Lacy from Health Claims Resolutions LLC

May 2024

Medical Claim Denial

Insurance denials of medical claims are commonplace. Insurance companies deny payment for multiple reasons. It could be a medical necessity, a coding error, edits, and many more. Insurance companies get very creative to find confusing explanations for why a claim is denied.
The good thing about a denial is that it lets us know the claim is unpaid. Careful reading of the Explanation of Benefit (EOB) gives clues and directions on what to do next. Unfortunately, those instructions are not always clear or even true.
The best thing to do is call the insurance company and find out what the problem is. Ask as many questions as you can think of and ask for clarifications and step-by-step instructions to get the claim paid. There are times when the insurance representative offers to correct a small problem or offers to call the physician to get the correct information. It is a good idea to let them help.
It is most definitely frustrating and very personal. Try to separate emotions during the call and try to understand what needs to be done. If all your efforts fail, do give us a call to help you get that claim paid.

-Katalin Goencz from Medbillsassist

April 2024

Balance Due After Insurance Payment

A client came to me for assistance with an air ambulance balance of over $4,200.00 after payment from their insurance. He was severely injured resulting in being in a wheelchair and not able to work. The client was fortunate to have an insurance policy that significantly paid on the hospital and provider bills; one of the largest balances due was the air ambulance. I sent a letter to the air ambulance company that described the client’s injuries, ongoing rehab and financial situation asking for a reconsideration of the balance due. About a month or two later the air ambulance company sent their response. They did consider the client’s eligibility for financial assistance and wrote off the remaining balance.
Air and ground ambulances are not necessarily in-network with insurance companies because they would have to sign a contract and then accept the amount paid by insurance. When you receive a balance due, call the company to request their financial assistance form(s). Don’t be afraid to ask them to negotiate with you or even offer a final amount for full and final payment.

-Ann Rowland from ASR Medical Billing Consultant

March 2024

International Claim

An 80-year-old woman contacted me about an issue with her Medicare Advantage (MA) plan. She fell and fractured her pelvis in Mexico, was hospitalized there for about a week, and then moved to a rehab program, also in Mexico. She had filed her paperwork with her California-based Medicare Advantage plan, and they never responded. She asked me to follow up with them and see why they were not paying for her out-of-country claims. Her MA plan was contacted, and they finally reviewed the claim.
The family had spent about $10,000 for her medical care in Mexican Peso before she was transferred back to California. At first, the Medicare Advantage plan paid about $3,000 to her. I contacted the plan several more times, and they reviewed the paperwork and the payments again. Part of the difficulty was that the payments were on a credit card, and they had trouble with the conversions, which should not have caused a delay, but it did.
After about 6 months of follow-up, they paid my client about $9,000 in total, and she agreed that it satisfied her. When the claim was initially filed, there was no clear listing of all the services provided; the Medicare Advantage plan could not easily reconstruct what medical services she received and when. Had my client had contacted me sooner, I would have organized the filing for her and made sure there was adequate documentation.

At the end, the client received most of her money back that she spent and she was pleased with the outcome.

-Patricia Stone from Stone Ortenberg Support

February 2024

What Have You Got to Lose??

A client recently reached out to me. He had just received a $39, 935.23 bill from the office that had provided their son with ABA (Applied Behavior Analysis) Therapy & PT (Physical Therapy) 3 and 4 years prior.
The family’s health insurance had paid his claims until this time. In fact, some months they paid and then randomly decided not to pay claims the other months; sending letters stating the provider was out of network (NOT SO!); or the patient did not have this benefit. (NOT SO!).
Three (3) months later, I succeeded in reducing the family’s financial responsibility to $5, 038.12 (less than 13% of the debt). Based on their in network benefits, this was the patient’s deductible & co-insurance over 2 years.
It took much determination & a dose of persistence, but I accomplished what we set out to do with cooperation from the health insurance company, the provider’s office & the family.

This certainly was worth pursuing!

-Karen Weiss from ABC's 3R Solution

January 2024

Charity Care…Don’t be Embarrassed to Ask

Most hospitals offer assistance with medical bills through charity care, or financial need applications. While the existence of these funds is often not actively publicized by the facilities, they are available and accessible to patients at varying income levels.
In a recent case, a client with more than $10,000 in hospital and related-provider bills reached out to us, to help reduce their financial liability. After successfully navigating the patient through the financial need application process, we were able to erase $8,000 in charges and are now finalizing the same process with the affiliated providers who are recognizing the hospital’s determination of financial need for the patient.
We recommend that the first step that patients with excessive hospital bills should take is to investigate what funds might be available for those in financial need. Keep in mind, don’t be afraid to hear “no” as the answer.

You are no worse off than if you didn’t ask, but you will frequently hear “yes,” and this, after all, is your goal.

-Robert Berman from SysteMedic, Inc.