HealthcareWhisperer
HealthCare Whisperer
Tips to Understanding Medical Bill Negotiation
You recently received a bill from a provider, hospital or medical supply company stating your insurance either has paid their part or is not going to pay anything. Or you may be without insurance and have received the final bill for services which is being charged at the highest rate possible. At the bottom of the bill it states that if you have questions or need financial assistance, call the listed number. In a panic, you call the business office. You wait anywhere from 10-30 minutes to get a customer service representative in a large institution or a voice mail in a smaller institution. When you finally get a live person, you are given two options, fill out the financial aid papers or set up a payment plan. Your greatest concern is your bill will go to collections and your credit will be ruined.
Here is what you can do to facilitate what you need.
1. Fill out the financial aid papers if it is appropriate. In some states, it has to go through the medicaid system especially if it is a public hospital. The business office expects you to have assets like a home, car or savings account. What they are looking for is to make sure you don't have several million stashed and could make payment. It will get rejected by medicaid and the business office will make a determination. It can often be up to 100%.
2. Without any serious negotiations, you can expect at least 20-30% reduction. This is standard. You can get more.
3. If you have a coinsurance or deductible payment, it will be difficult to get any reduction. The contract with the insurance company generally does not allow for any reduction in cost. It is rare but a compassionate business manager may give 20% discount.
4. Speak with a supervisor when possible. Business offices make it difficult to get to the supervisor but be persistent. Customer service representatives can not make final determinations. Ask for the name of their supervisor and if necessary, fax a letter. If you get no response, call the business manager or CFO office. You will get a response.
5. Business offices have their own time schedule. Two days usually is five days or more. Do not think they are ignoring you. They want their money. Call to follow up so everyone knows you want to work this out. I like to remind the office, I am waiting and can be patient. It can take months.
6. Always ask to have a note put in the computer stating you are working on a resolution. This way your bill will not be sent to collections. I verify each time I call, the bill is not going to collections. You will continue to receive bills but don't panic because it is automatically computer generated. I also recommend you pay a small amount to show good faith. it can be as low as $25.00.
Know the Insurance Lingo
Knowing your insurance policy starts with understanding the terms used to describe the parameters of coverage. Having a clear definition of terms will allow you to look at any policy and understand what it means. Let's review the terms.
In Network is the term used to designate which hospitals, doctors, pharmacies, diagnostic centers and labs have a contractual agreement on reimbursement with the insurance company.
Out of Network is the term used to designate which hospitals, doctors, pharmacies, diagnostic centers and labs that do not have a contractual relationship with the insurance company.
Deductible is the amount you pay before the insurance company starts reimbursing. Deductibles can start at $0 and go as high as $10,000.
Coinsurance is the per cent you pay for any treatments. For instance, a policy may state the insurance pays 70% and you pay 30%. It will be shown as 70%/30%. There is a difference between the in network vs the out of network ratio of cost. The out of network is a higher per cent usually 50/50. Some policies have no coinsurance.
CoPay is the amount you pay for some medical visits like primary care, specialists and sometimes hospitals and radiology. These payments can range from $10 to $50. Hospitals copay can be as high as $1,000.
Out of pocket maximum is the total amount you have to pay before the insurance pays 100% of cost. The CoPay is not included as an out of pocket expense. It is generally the coinsurance amount. Some policies include the deductible as part of the out of pocket maximum but most do not. There is a separate amount for all out of network costs. It is usually higher.
Explanation of Benefits or EOB is the insurance explanation of the reimbursement break down. It will let you know which part goes to deductible or coinsurance. You receive this after the doctor or facility send the bill to the insurance company and a reimbursement determination is made.
It is easy to confuse copay and coinsurance which are not the same. Many policies have both. It means that when you go to the doctor you pay up front with a copay. If you have a coinsurance, you will find out the amount you need to pay from the insurance EOB.
I advise clients to recheck every year their policy to make sure coinsurance or copay amounts haven't changed.
How Medicare Advantage HMO's Limit Senior's Options
Today a friend of mine got a rude awakening about her father's medicare HMO advantage plan. She is the healthcare proxy and oversees all things medical. She hasn't had any problems until today when she was trying to get her father in to see the leading surgeon for a very specific rare surgery in Boston. Her father was suffering from compromised breathing problem of unknown etiology. Three doctors in the HMO network said it was nothing and would resolve with inhalers. My friend's sister working at another Boston hospital took the CT Scan and showed it to colleague who showed it to the specialist. Both immediately saw the cause and recommended surgery. There should be a big sigh of relief right now but the surgeon is out of network. The policy with Medicare Advantage HMO is no out of network. However, after my friend called the insurance company, she was told that if the PCP advocated for the second opinion and/or surgery, it would be approved. Another sigh of relief except when she called the primary's referral designee, she was told it was not possible and she should stay in network. In a panic, she called me and asked what her options were. This is what I told her.
1. Medicare law allows for a second opinion.
2. The reason the PCP office was not being supportive was by sending anyone out of network, they lose money from the insurer.
3. It is not the decision of the provider but yours. You can firmly continuing to insist on a referral.
4. Call the insurance company for further clarity. Take the name of the person you speak with and write down the answers. If you do not get a good explanation ask to speak with a supervisor. Always take the name and write down the answers.
5. Get a list from the insurance of alternative surgeons. Call these offices and ask how many of these specific surgeries have they preformed. This is way to show the insurance company why a specific surgeon is needed because of experience and training.
My friend did as I suggested by first calling the PCP and the referral person who continued to feel it was not going to be approved. She called the insurance company and ended up speaking with the supervisor. She was told to speak directly to the PCP and request he/she advocate for the referral. She verified the reason PCP's don't jump at the chance to be advocates is because they lose money with any out of network visit.
She is headed in the right direction but it took several hours on the phone and much anxiety. There is hope for her father. She was most concerned that three physicians from three specialties had misdiagnosed her father and didn't want to stay in network. Are seniors at risk from the rigidity of medicare advantage plans? Was "live with it" the prescription because of possible out of network loss? I believe seniors also deserve the very best care if available. I understand cost containment is important but denying a person the proper care for financial gain is not good medicine.
The Rocky Road to Healthcare Reform
It isn't going to be easy getting healthcare reform to happen. Let's start with the lawsuits by some of the states. The premise is the federal government can't tell people or states that everyone has to have insurance. Most of the constitutional scholars on both sides do give it much of a chance. What it does is stir the fires of emotion and fear while continuing the misinformation of reform being socialistic or even communistic. If having health insurance is socialistic, then why isn't mandatory car, mortgage, or home insurance also socialistic?
Then there is the battle of the insurance company vs the state of Massachusetts. The insurance companies wanted to raise rates as they do every year and they wanted the usual pass. Given the current climate, the state flexed its muscle and said no to any rate increases. The insurance companies fought back with putting a freeze on new enrollees. In Massachusetts, you are fined already if you don't have insurance. The insurance companies stated they needed time to assess the damage from no rate increases and how they could proceed. They filed suit in court and asked for an immediate review. The courts ruled at this time that the state was in its right to deny rate increases. The insurance companies said they would start taking new clients again. Last week, they sent out letters to current members that all rates would stay the same as last year through 2010. In the meantime, the insurance companies have filed with the Department of Insurance to allow the increase in rates.
Another issue with the healthcare reform is it doesn't solve as many immediate problems as hoped. For instance, I have a client who will be coming off COBRA and has a pre existing condition. COBRA is considered a creditable insurance coverage. Her state has a high risk pool but the cost is prohibitive. The new risk pools to be set up for June will be equal to the market cost of regular health insurance plans. The law states there has to be six months without any credible coverage for a pre existing condition. My client will be left without any insurance because of her pre existing condition. Maybe she will be able to get regular insurance but it is not hopeful. Will she have to wait six months to get insurance? No one seems to have an answer.
Between the insurance companies, the false rhetoric on the bill and the loopholes, health care reform has a rocky road ahead. Keeping up with the maneuverings is going to be more work than I planned for!
A HIPAA Hiccup
My mother-in-law was hospitalized at Lutheran Hospital in Brooklyn, NY, a level one trauma center for a fall in her house. My sister-in-law is the healthcare proxy for making medical decisions. On the way to the hospital, I reminded her to put my name on the HIPAA release form so I could speak with all the involved parties if necessary. Later, that day she called with an update and I asked her if she had remembered to put my name on the form. She told me, the hospital personnel had refused to allow my name on the form. I asked why and she said it was because I was not there and they wouldn't speak to me on the phone. I told my sister-in-law, the hospital had picked the wrong person to refuse. I knew they couldn't refuse and I, of course, could speak on the phone with all involved parties. I also knew who to call. I told my sister-in-law not to worry, I would fix it tomorrow during hospital business hours.
The next day, I called the administrative offices and asked for the HIPAA compliance officer. I explained why I needed to speak with someone and was transfered to the correct person. I calmly explained the situation of being refused by the hospital to allow my name on the form and requested the situation be changed immediately. The officer took my information and said she would call the floor and find out what happened. Within an hour she had called me back. She had spoken with my sister-in-law who verified my name be on the form and also spoke with the doctors and nurses telling them to speak with me.
Don't let anyone in a hospital or medical office tell you "no" to the name you want on a HIPAA release. It is the right of the patient to decide not the hospital. I find hospitals have started holding HIPAA releases hostage and denying patient's their rights. It is important to have someone on the form who can be your voice when you need it. If you have a problem, contact either patient relations or the HIPAA compliance officer. Don't back down because it is YOUR right to decide not the medical facility. HIPAA was designed for the patient NOT the hospital.
The Making of an Empowered Patient
I talk to people about being an empowered patient. I tell them it's about being in control of your healthcare and partnering with the medical profession to get what you need. I think the key is understanding the role of each of the players in the game of healthcare and keeping your expectations realistic of what each can provide.
I witnessed a client finally grab on to the idea of being an empowered patient after months of decline, no answers and feeling battered by the system. Here is his story. I was called by a family member when hope was beginning to fade. The situation was complications related to a surgery and repeated trips to the emergency room. This young man was declining physically and becoming depressed. His work and personal relationships were suffering. At this point, the surgeon was the only medical provider involved because of the unresolved surgical complications. When I first met my client in the hospital after another emergency room admission, I saw a young man, sad and exhausted. His life was spiraling out of control and he couldn't see any possibilities. As an advocate, I saw the possibilities immediately. It was clear a new medical perspective was needed. Luckily, that process had begun right before I had been contacted and an appointment was set. He didn't make that appointment because he had to go to the ER again but we went to the ER where the new doctor was associated. This time the reason for his complication was determined, treated and he was sent home.
All should have been good at that point, but his local support was not in place. He saw his surgeon as the main player and expected all answers and follow up to be from him. I knew this was not going to happen because specialists only relate to their area of concern. We went to a follow up appointment with the surgeon who was thorough, patient and kind but it was clear to me, he was not going to provide the continued support now that the issue was identified. My client was near tears and feeling abandoned during the appointment. I saw the moment as a critical turning point. I sat him down and said it was good what happened. Now he can be the driver of his care. Only he knew what he needed now from nutritional, primary care, counseling and local specialty services and support. I was determined to switch this situation to empower him to know he could move forward. He agreed I could begin making other appointments for him.
And then several days later, I received a long email explaining to me how he was going to change his live, stop the spiral, try to make the changes he needed and rebuild his life and relationships. I knew the empowered patient had arrived and there was no turning back. His new mantra is "Let's get the healing started". Since that time, he is feeling better, getting the appointments he needs and enjoying his life.
The Mammogram
Today I went to get my annual mammogram. I wasn't really thinking about it until I checked myself in and was sitting in the waiting room. Usually, there are only about three women in the waiting room but today there were ten. All the chairs were taken. And you could hear a pin drop. The fear, apprehension and anxiety in the room was palpable. I knew some of the women were in the room receiving their first test post treatment while others were hoping this was another year clear. Then there were those of us who had never had an abnormal exam or test.
Here we were a community of women, all needing support and no one could talk. No words of encouragement or support. I am generally very chatty but I felt a profound respect for those who needed to be inside themselves to get through the moment. I couldn't even respond when my name was called. I felt mute. Isn't there something the hospitals can do to make the experience more supportive? I don't really think having someone walk me into the dressing room is enough. Music? Shoulder massage? A room for silence and a room to speak? Someone in the room to engage with? I like hearing people's stories and if a woman wanted to share it, I'd like to listen. Where is the human element?
I felt today gave me an opportunity to imagine what it might be like if I got a positive result. How would I feel? What would be my reaction? I let me mind wonder to the unimaginable diagnosis of breast cancer and what it might mean to me. I knew for sure I could never do it alone. I say a big heartfelt thank you to those who have walked the path, both survivors and those past. I can not truly imagine what it would mean. Your work, commitment to stop this epidemic has gotten me to this room today for my annual mammogram.
A Story to Make You Laugh and Cry
I received a call from a young man who was asking about an insurance problem for his father. He told me last year he had gotten insurance with Blue Cross NJ. His father has high blood pressure which he put on the application. He was enrolled and covered for all illness at the onset. One month later, he was having vision problems and went to the eye doctor. The eye doctor sent him immediately to the ER where a brain tumor was diagnosed. Successful surgery was done the next day. He recovered well with no further problems. A year later, a bill was received from the hospital stating the insurance was not paying for treatment due to pre existing condition. The insurance is saying high blood pressure is a pre existing condition for a brain tumor. Needless to say, the son was in a panic.
Here is where we have crossed into the twilight zone. There is no data supporting this premise. What we know is, high blood pressure may be a result of a brain tumor but not the opposite. The father had high blood pressure for a long time. If this is the premise used by insurance , high blood pressure may be the cause of all things medical. Dare I say lucky for us, pre existing conditions may be history very soon. Here is a prime example of the insurance companies making decisions not based in science but dollar value.
Unfortunately, it will now take time and effort to get the insurance company to reverse on appeal. There is so much research refuting this decision. I do think it is a decision that will need to go to an external appeal. In the interim, I have advised the family to gather all the medical notes, letters from doctors and begin the appeal process. When in a situation like this, I advise people to speak with all involved providers, let them know you are appealing and sometimes it is necessary to make a small payment on the bill. As long as it is in the computer files of the billing office, you won't go to collections. Billing offices like to know you are trying to work it out. I also advise to get the financial aid papers filled out as a back up.
So hold on everybody. The ride to implementation of healthcare reform is going to continue to be bumpy.
How to ask for a Second Opinion
Second opinions are important and I have mentioned it before. I know many people are apprehensive to ask the doctor for a request or referral. There is a feeling the provider will hold it against them or take it as a slight about their care. Sometime I hear, I trust the provider and I can't be bothered. Other times people are just too overwhelmed and scared by the diagnosis and looming treatments to seek a second opinion.
A decision to get a second opinion is not necessarily a reflection of your distrust or dissatisfaction of a medical professional. I believe it is a way to gather more information, verify the diagnosis and suggested treatment, and to be empowered to have options. It can seem like a huge step to say to the provider, I want a second opinion, especially if you have a good relationship. People ask me how do I say it? Here is what I suggest. Write down what you want to say to the provider before the visit or phone call. Let the provider know you are going to get a consult for a second opinion. You believe it is important before you move forward with treatment so you know your options. Express your appreciation for your relationship and you would like to review with him/her what new information you may discover.
I cannot say 100% the provider will be supportive. More medical professionals are understanding the value of the second opinion. We as empowered patients have been given the opportunity to help train the medical professionals to value the patient who wants a second opinion. I hope it becomes standard of care for providers to suggest a second opinion.
With any major purchase or decision in life, like buying a house or changing a job, we take time to assess options. The same should be for major medical decisions. If there is a window of time to get a second opinion without causing any life threatening problems, I encourage it. It is my belief everyone deserves optimal medical care which includes knowing your options.
Need Help: An undiagnosed neurological disease
I have a patient I have been advocating for since September. I was hired by the family. Joe (not real name) 44 yr old started having dizziness and balance problems 2.5 years ago. Fast forward to NOW. Joe is in a wheelchair with extreme dizziness and balance problems ( cerebellar related), decreased hearing, constant nausea, visual problems which include severe abnormal eye movements, double vision, ataxia, intermittent headaches, decreased feeling in left hand and muscle weakness. He has been to several neurologists in his local area and in a major city. Every lab and radiological test has been preformed. Nothing is positive. The last neurologist was hopeful and ruled out paraneoplastic syndrome and Multiple Sclerosis. Joe recently spent 10 days in the hospital receiving plasmapheresis treatments with no change. Internet , medline and NIH searches have been done. The doctors are now calling it idiopathic. Meaning no diagnosis, no available treatment, and no hope. Joe was an active husband and father, worked to provide for his family and now spends his days in a wheelchair hoping the day won't be too bad.
There was so much hope with the last neurologist who admitted he was stumped. He was the first one to try anything. However, where to now? I am searching for suggestions as to options, centers, and any known wild and crazy neurologists, neurophysiologists, researchers who like to think outside the box nationally and internationally. What is experimental out there and where to look? Any ideas?
