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Acadia Benefits Inc. Blog

  • Tips from Paula: Understanding Balance Billing

    Posted on March 5, 2018

    As Employee Advocate here at Acadia Benefits, I spend a good deal of time helping our customers understand their bills from providers.  It is often confusing and hard to understand these statements.  The first thing we look for on a bill is some sort of reference to a payment or reduction from the insurance company.  This means that the bill has been correctly submitted to the insurance company. If there is no reference at all to this type of activity, there is a good chance that it was either submitted incorrectly (perhaps to an old policy) or not submitted at all.  If still not sure, we recommend that patients compare these statements to their insurance company’s Explanation of Benefits (EOBs) to see if the processing and payments line up.  If there is no record of a claim in the EOBs or in the online account, then the patient should call the provider to be sure the claim was actually submitted, and if not, to be sure they have updated ID card information so the claim can be sent ASAP. There is also a matter of “timely filing”, i.e., there are often time limits placed on how long a provider can wait before submitting a bill, so time is of the essence in these matters.

    In addition, it is extremely important not to pay a bill unless you can confirm that you are not being billed beyond the applicable copay or contracted amount.  Contracted providers should not be billing the patient for the full charge of the visit.  Cross-referencing the EOBs can quickly show if the provider is billing you correctly.

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  • Tips From Paula: Coordination of Benefits Letter

    Posted on January 23, 2018

    Occasionally,  two insurance plans work together to pay claims for the same person. That process is called coordination of benefits. Insurance companies coordinate benefits to avoid duplicate payments by making sure the two plans don’t pay more than the total amount of the claim. They may also need to establish which plan is primary and which plan is secondary—the plan that pays first and the plan that pays any remaining balance after your share of the costs is deducted.

    The carriers will periodically send out letters to the insured, to check on “other insurance coverage”, especially if certain claims appear to be part of an accident, such as a broken leg, hip injury, etc.  If the insured ignores the letter, eventually the claims will be pended, and not processed.  Eventually, these claims may be sent to a collection agency, and it may take several months,  or even a year before the insured receives the collection notice.

    Since it can be difficult to get the claims processed and paid after that amount of time, we strongly recommend that insureds answer these letters or questionnaires as soon as they are received. Many times, the insurance company will take the information right over the phone.  Once they know there is no other insurance coverage on the claim, the claim can be quickly processed and paid.


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  • Tips From Paula: Obtaining Medical Records for Disability Claims

    Posted on August 7, 2017

    I have been very busy this summer working on our customers’ disability claims! One recurring issue I have come across is obtaining medical records for the insurance companies’ review.

    Most large medical practices now “outsource” their medical records distribution to a third party.  These third parties usually want payment for their time and resources.  The process can be extremely time consuming, often resulting in long delays before claimants will receive their disability checks.

    The process begins with the insurance company sending a request for records to the physician’s office, who in turn, sends the request to their third party medical records company.  That company then sends a payment request to the insurance company, who must cut a check and mail it back to them before the records can be pulled and mailed.

    This whole process can take up to 3 or 4 weeks, depending on how quickly each responsible party turns the requests around.  Patients often don’t understand the delays, and will many times complain to the insurance company, when, in reality, it’s the process itself that is causing the delay.

    I am here to help facilitate and track the requests, but patients should know the process ahead of time, and anticipate some delay in the medical records distribution.

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  • Tips from Paula: Understanding your lab work benefits

    Posted on June 7, 2017

    As the Employee Advocate here at Acadia Benefits, I get several calls each month from our customers who are unsure of how a claim for “routine lab work” was processed.  Because their doctor ordered this lab work as part of their routine physical, many people assume the lab work will be covered in full, similar to how the actual physical is covered.

    However, many insurance plans are set up to follow guidelines under the Affordable Care Act.  Those guidelines state that not all lab work is automatically covered in full.  There is a listing available at the following website:

    As we can see, the lab work on this list is limited. Therefore, if your doctor tells you they are ordering routine blood work as part of your annual physical, be prepared to possibly receive a bill for these services, as they will most likely be applied to the plan’s deductible.

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  • June 1st Breakfast Seminar

    Posted on May 10, 2017

    We hope you can join us for a breakfast seminar:


    Healthcare Cost Reduction Initiatives

    and ERISA Compliance Considerations:

    Tips for 2017 Open Enrollment


    Thursday, June 1st

    7:30 – 9:30AM


    Pierce Atwood, LLP

    254 Commercial Street

    Portland, ME 04101



    With the move away from fee for service to value based reimbursement initiatives, employers still struggle with healthcare costs and the shift towards high deductible health plans. Further, employers looking to bring added value to their employee benefits offerings may be doing so at the expense of ERISA compliance.

    Join our expert panel for a discussion on recent trends in health plan design and contracting to address healthcare costs and population health management, as well as tips and traps for employers offering voluntary benefits.

    Mike Burton from Acadia Benefits will be presenting along with John Larrabee from Harvard Pilgrim and Pierce Atwood Attorneys Christine Worthen and Byrne Decker.



    Please email Sara Pinto at to RSVP to this event.

    We hope to see you in person, but if you can’t make it in and would like to attend remotely, please let us know.

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  • Tips from Paula: Who is Responsible for Obtaining Referral Extensions

    Posted on January 31, 2017

    Over the years, patients on HMO plans have learned the importance of obtaining referrals. What we need to remember, however, is that referrals are often written for a certain number of visits, or for a specific time frame. For example, a PCP may write a referral for a patient for three visits to an orthopedic specialist.    Once those three visits are up, it may be up to the patient to check in with the PCP for more referral visits, if necessary.   A good specialty practice may pick up that the number of authorized referral visits have been used up, but we should never assume this will happen. In addition, referrals are not “automatically extended”.  Therefore, it’s up to the patient to pay strict attention to their referrals, for time frame and/or number of visits allowed, and be proactive in following up for new referral visits if necessary.

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  • The Importance of Timely Filing For Claims Paid in Error

    Posted on November 9, 2016

    As we head into a new benefit year for many of our customers, it may be a good time to remind people about the importance of using the correct ID card during the transition time.

    There are occasions where the new ID card may not have been received by a member. In addition, their “old” ID card may not be terminated right at the beginning of the year.  For example, for a January 1 renewal, the new group may still be in the process of being set up, and the former ID card has not been technically cancelled yet.

    A member may be at the pharmacy on January 2nd, and their old card runs through with no problem.  A member may think they are all set, because the Rx ran through. However, the carrier will eventually catch this error in payment, and will send the member a bill for the cost of the Rx that was filled in error.

    If members receive one of these bills asking for the payment to be refunded, it is important to act quickly and not ignore the bill.  There is a window of time to submit to the new carrier (known as “timely filing”).

    If a member misses the filing deadline for the claim, it will be denied by the new carrier and the member will end up responsible for the entire bill.

    Therefore, if you do receive a bill for a claim paid in error, please call your new carrier ASAP to discuss how to submit this to them for processing.  Acadia Benefits is also here to help should any of our customers experience this issue.

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  • Tips from Paula: Establishing A Relationship With Your PCP

    Posted on July 6, 2016

    During our open enrollment presentations, and here on our blog, we often remind our customers of the importance of wellness exams with their Primary Care Physicians (PCPs).  The benefits of these wellness exams are not just health-related.  We are finding more and more that it is extremely important for patients to establish a relationship with their PCP up front, and not wait until services, referrals, or prescriptions are needed.

    For example, many doctors will not write a prescription refill if they have never met the patient. They may also deny writing a referral to a specialist without seeing the patient first.  Conversely, if the patient has a good relationship with their doctor, and the doctor knows their background and history, they may be amenable to waiving the need for an office visit before they will refer a patient on to a specialist.

    Therefore, we strongly recommend that patients book that annual exam with their PCP every year. Not only is it covered in full under the Affordable Care Act, but it will begin to build that necessary doctor/patient relationship for the future.

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  • Know Who Your Vision Carrier Is

    Posted on May 2, 2016

    As benefits advisors, we are always looking for ways to find the best benefits for our customers.   Consequently, we may offer new and innovative ways for employers to cut costs, while still offering plans with viable coverage.

    One of those changes may be seen in vision plans. In the past, several carriers would offer routine eye exams and discounts for hardware embedded into their medical plans.   Members would simply present their medical ID card to the eye doctor’s office, and everything was filed and processed with the medical carrier.

    There are now several separate vision plans being presented to our customers. One example is the Blue View Vision (B.V.V.) plan, through Anthem Blue Cross. Blue View Vision uses a separate network of providers, separate claim forms, ID number, customer service number, etc. In this case, it is very important that members not use their Anthem medical card when obtaining eye care. They should present their Blue View Vision card and ask the provider to bill accordingly. If the provider is not in the B.V.V. network, the patient will have to file the claim themselves.

    By not following this procedure, claims will be held up and consequently denied by the medical side. It is important to note that claims not automatically forwarded by Anthem medical over to Blue View Vision.

    As always, we strongly recommend that employees know and understand their benefits before obtaining services.

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  • Tips from Paula: Billing for DME Items

    Posted on February 2, 2016

    When we are having surgery or other services that are performed by a doctor or hospital,   there are times when medical supplies, also known as Durable Medical Equipment (DME), are dispensed by that doctor or hospital. We should not assume that the doctor or hospital is the actual vendor for those supplies.

    For example, if a person has surgery at an outpatient surgical center, they are often sent home with items such as a walker, crutches, or specialty ice packs. We might assume these items will fall under the general bill from the center, along with the other services, such as the surgery itself, surgeon fees, etc.

    However, we are finding that surgical centers are not always the actual vendor for many of these DME items. They may dispense them, but the bill for these items will come from a third party. And with that third party billing, there are often problems with coding and coverage once the claim hits the insurance carrier’s claim system. If the provider submits with a code that the claim system doesn’t recognize, the claim will deny.

    The vendor may also not be considered “in network”, which, for some plans, can result in higher out of pocket costs for the patient.

    Members should be prepared to review their bills and statements from the carrier. They may always dispute this via the appeal process with the carrier, and/or work with the provider to ask them to submit with a code that the insurance company can recognize.

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