BIP Fall 2024

“The Middle Man ”

deductible in place. “Because there were so many bills related to the procedure, everything piled up and looked like he owed money when, in fact, he didn’t because the main claim, the surgery, had him hitting his deductible,” says Caban. “Because I knew he was going to continue to receive bills, I had to stay on top of it to make sure all his EOBs [explanation of benefits] matched and that all his claims from the surgery were reprocessed.” The real work It took 30 to 45 days to ensure that everything went through the system properly. To keep track and ensure nothing slipped through the cracks, Caban set calendar notifications for herself to follow up on bills and claims. She kept meticulous records of: 1. What did he pay versus what he should have paid? 2. Did every EOB add up? 3. Will he receive the discount he was promised? In the end, the plan participant received a reimbursement of $1,127.51. The likelihood of the employee being owed a reimbursement was very high. You have to stay on top of it. “ ”

M Mickie Caban spent years honing her skills in the claims sector, from service to implementation. While some can find the intermedi ary role between plan members, providers and carriers challeng ing, Caban embraced it. “I loved claims. There’s a challenge behind it, but there’s also a huge reward of helping someone,” she says. Now, as an account manager at Ethos Benefits in Waverly, Tennessee, Caban draws upon that experience to ensure plan participants get the most out of their benefits. One recent instance put more than $1,000 back in a Florida man’s pocket. The employee In the lead-up to surgery to remove a mass from his forehead, the provider’s business office told the plan participant he would owe nearly $5,000 for the procedure but gave him the option to prepay $975 instead. Confused about the large bills, the participant contacted his employer, who contacted Ethos. “Because I’ve been doing claims for quite some time — and it’s probably my favorite thing to do — the first step in my process is to see if a PA [prior authorization] was needed and whether or not it was done,” says Caban. The carrier and provider Sure enough, Caban discovered through a phone call with the

Mickie Caban navigates complex claims to secure reimbursements

carrier that the claim was denied because there was no PA for the surgery. The carrier had contacted the provider multiple times requesting the needed information without luck. “At this point, I decided to take this situation into my own hands,” says Caban. “I contacted the provider’s office, contacted the carrier, and then facilitated a three-way call for everyone to speak and get what they needed.” Once the carrier had the PA in hand, the surgery-related claims were reprocessed with the plan participant’s $1,500

TIP: “There are so many times that something’s missing between the carrier and the provider, so we always ask employees, don’t pay the first bill.”

52 bip magazine Fall 2024