Wednesday, September 17, 2014

Patient Advocacy: Healthcare on your Side    September 10, 2014    Issue 55

Patient Advocacy: Healthcare on your side

  a weekly blog by Martine Brousse, 
Healthcare Specialist, Patient Advocate, Certified Mediator

Reduce your Out Of Network Bills *

Scenario: You recently had surgery, or ended up in the ER. One (or more) physician evaluated you. Not all are part of your insurance network, and you are now receiving outrageous fees. You did not choose them or directly request their services. How can you get out of paying these bills? 

This is routinely happening in our times of restricted insurance coverage, smaller networks, reduced choice of in-network providers and growing trend among physicians of opting out of all contracts. 

Appeals made by patients are often rejected. Reasons range from "it is the patient's responsibility to use in network providers" to "the policy has a strict exclusion for all out of network services". 

Understand that you may have to pay something for the services rendered to you. But know that you do have options, and rights, at your disposal before taking out your credit card.

1. Get the insurance to pay

If the hospital is "in network", but the insurance paid a provider at the out of network rate, file an appeal and demand they pay the higher contracted rate based on the preferred contracted status of the facility. Other arguments should include: You had no choice in the matter, you went to the correct facility, services were medically necessary, this was the only specialist available, or none of the specialists on call were providers (often the case with anesthesiologists). 

Ask that the insurance attempt to sign a one-time agreement with the physician. Inform the office: such deals are routinely (and gratefully) accepted. 

2. Invoke your rights

Your patient's rights include the rights to receive timely, appropriate, adequate, qualified care. If the in-network or preferred provider could not render the service soon enough, lacked the necessary qualifications, expertise or training, was too far away from your location, or if you could not trust him for specific reasons, your insurer must cover the out-of-network cost of the provider you chose.

If a service was rendered under emergency conditions, specific policy guidelines and regulations kick in. Public Health Service Act (PHS Act) section 2719A and the ACA ("Obamacare") impose on health insurances to fully cover emergency services in an emergency department of a hospital without regard if the provider is out of network, and requires insurers to apply the same financial liability to the patient as would have been if in network. 

3. Call your State's Insurance Commissioner

If your appeal is still denied despite using these arguments, consult your State's Insurance Commissioner's website for information on how to submit a grievance against the health plan. Include a copy of all relevant documents when filing. Some states offer free phone consultations to determine whether you have a case. 

4. Deal with the provider directly

A provider may refuse an insurance agreement or to write off your balance after an "in network" payment. Request to meet the office manager to negotiate. Meanwhile, send small monthly payments to avoid collection action. 
Your insurance representative may be able to help you determine an acceptable settlement, as would a billing advocate. Remember that a one-time "paid in full" remittance is more attractive than monthly payments. 

5. Ask the referring physician

If all fails, contact your surgeon, explain the situation and ask for assistance. A non-contracted provider, counting on more referrals and work from his colleagues, may have to learn to be more flexible and less greedy. Another physician is the best placed to explain this delicate situation. 

The referring physician, or his office manager, may be able to use his contacts with the facility's officers to get a bill reduced or an application for financial assistance pushed through.

If the provider belongs to a medical group, as anesthesiologists and ER physicians often do, file a request for a review of your case and ask for a fee reduction directly with the managing director. They often are more sensitive to negative comments and potential backlash, especially if you indicate a copy is being forwarded to the referring physician and to the administrator of the facility.

In conclusion:

A negative response to an insurance appeal or the initial refusal of a reduced fee should not deter patients from seeking other avenues to get a better outcome. Patient satisfaction and the threat of public exposure are growing factors forcing medical providers to "play nice".  Knowing your rights and demanding they are respected are powerful incentives, as are hiring a patient advocate or going up the corporate ladder. 

* A seen on NerdWallet

Any comments or questions? Contact us!

 My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
©  [2014] AdviMed.
©  [2014] Martine G. Brousse.
All rights reserved.

Quote of the week:
"Nature always wears the colors of the spirit" Ralph Waldo Emerson

AdviMed          (424) 999 4705 or (877) 658 9446       fax (424) 226 1330

Friday, September 5, 2014

Patient Advocacy: Healthcare on your Side    August 26, 2014    Issue 54

Patient Advocacy: Healthcare on your side

  a weekly blog by Martine Brousse, 
Healthcare Specialist, Patient Advocate, Certified Mediator

Medicare Advantage Plans:
Unpopular with Medical Providers

Created a few years ago with the goal of improving efficiency, care and overall cost, Medicare Advantage plans (part C) claim uneven success. While enrollment is higher in some parts of the country, efforts at increasing the number of subscribers have been met with obstacles, such as a low number of contracted providers, or difficult access to care.

Before blaming the cause on medical providers' greed or lack of caring, let's look at things from their perspective:

1. Straight Medicare is great

Consider "regular Medicare": render service, send a bill, get paid. Follow well published, simple instructions, and your payment will make its way into your bank account within 14 days.
Advantage plans are less transparent, more complex and obstructive. More resources, time and manpower are needed for the same 30 days... maybe.

Disputed claims, in general, are a minor reason for rejecting Medicare Advantage patients. But there is no doubt that for each single appeal made to Medicare, there are dozens made to Part C carriers.

Even if the payment is eventually the same, the cost of the added paperwork, stress, processes, appeals, calls and staff time bites through any profit, quickly throwing a practice into losing money territory.

2. It's complicated

The tedious and often-delayed authorization process remains a major drain on resources and staff time. Losing money (and patience!) on that end is common.

Fee for Service or PPO (a misnomer as patients think providers are contracted with Medicare when in fact it is with a specific plan administrator) plans are more widely accepted. Less resources or staff time are required.

HMO plans are disliked throughout. Any service, visit, treatment requires prior authorization. This routinely takes 3 to 5 days (if no emergency) and the patient must return to receive care. Schedules are burdened, diagnoses and treatments delayed, frustration rampant. The exceptions are plans like Kaiser, autonomous and self-contained.

Because of cost and unrelated contract requirements, simple tests or labs must often be performed by an outside provider. An authorization must be requested, paperwork sent to the lab (for example), blood drawn, reports sent to the office, before the patient can be notified of results which may have taken a few minutes otherwise. This waste of time causes hardship and anxiety for patients, while the added office administrative costs are not reimbursed.

I worked with cancer patients whose HMO plan forced them to receive chemotherapy at home. With no way of supervising the treatment, the stress on staff, doctors and patients was crushing. Saving a relatively small amount of $ seemed the only reason for the insurance to impose such a risky and potentially disastrous decision.

3. Unpaid patient balances

Another element has become important in the decision-making process of medical practices: straight MCR patients usually have a secondary insurance. Patient liability, though growing in recent years, remains low and easily collected.

Medicare Advantage policies often come with much higher deductible and out-of-pocket costs. Some plans have no patient limit for certain items (chemo drugs for example), causing patients to either forgo treatment altogether or drain their savings. Without secondary insurance, many cannot afford to pay their bills, causing doctors to lose more $.

4. Unclear policies

Straight Medicare offers a vast range of guidelines, policies, webinars, educational materials and contact methods to help offices determine whether a specific item or treatment is covered, under what conditions, and at what price.

Commercial carriers, the administrators of Part C plans, must offer equivalent coverage. But they may impose which treatment to order (cheaper, non-surgical or less drastic first), which drugs to prescribe (generic only), where and how patients get treated, etc. Pre-authorization requirements vary, so calls must be made before any treatment or service can be recommended or prescribed.

5. Patient Responsibility

If an office bills incorrectly, or provides a non-covered service to a straight Medicare patient, it must absorb the loss. Not always so with part C. Patients are more likely to be hit with unpaid balances, especially if they see a non-contracted provider or receive non-pre-approved care.

In Conclusion:

Seniors are caught in the middle. Between restricted access to medical providers, billing surprises, treatment delays, widespread confusion and impositions of all sorts, they are too often left to fend for themselves, with no way to change their plan until the following January.

If you are a Medicare Advantage patient, check and double check. Not doing so could lead to bad and expensive surprises!

Any comments or questions? Contact us 

 My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.

©  [2014] AdviMed.
©  [2014] Martine G. Brousse.
All rights reserved.

Quote of the week:
"The world is changed by your example, not your opinion." P. Coelho

AdviMed          (424) 999 4705 or (877) 658 9446       fax (424) 226 1330