Monday, October 27, 2014

Patient Advocacy: Healthcare on the Side


www.advimed.us    October 28, 2014  Issue 61
Patient Advocacy: Healthcare on your side

    a weekly blog by Martine Brousse, 
Healthcare Specialist, Patient Advocate, Certified Mediator
Founder, PRES.  AdviMed


  Billing Disputes: avoid costly mistakes*

It has become all too commonplace to receive overinflated, incomprehensible, erroneous, unexplained medical bills, sometimes from mystery providers. After all, if all bills were correct and justified, I, and other billing advocates would be checking job posts.

The usual reactions are discarding the statement as a mistake, placing it on the to-do list (or is it the never-to-do pile?), waiting for a miracle, appealing the insurance, getting upset at the phone representative or asking nicely for an explanation or a discount which may never come.

Before you give up, or worse before your account goes to collection, consider these steps.

1. Use your right to question

Medical providers are considered, under state and federal consumer laws, in the same category as other purveyors of services. It is your right to ask for justification and explanation of a statement, or proof services were rendered.

Just as you inquire about a charge on your credit card statement, or an item on the store receipt, so can you for medical bills.

2. Contest in writing

You should contest a balance or request clarification in writing. Address your complaint to the office manager, billing manager or physician. Knowing the name and contact information for the person in charge often translates into prompter responses and better outcomes.

Confirm with the billing department, preferably in writing, that your account is on hold and will not be reported to a collection agency until this grievance has been addressed, as per the Fair Debt Collection Practices Act.

Specific insurance appeal forms are usually required. These can be found on the website. 

Sending your documents certified mail, or via any way that can confirm its receipt, is best.


3. Share the news

If your grievance is with your insurance company, you must inform the interested parties of any delay in payment on your part. You may ask a representative to contact the billing department and request for your account to be placed on hold, as it is not done automatically. This step should be in addition to your written notice.

If a medical provider uses an outside billing service, both offices must be contacted. Communication between both parties is all too often infrequent. Avoid costly misunderstandings by mailing two letters.

4. Keep the account current

While the insurance works hard at finding ways to deny your appeal, or when waiting for the facility to mail you an itemized bill or review the charges, you must make small monthly payments to keep your account current. Sending a small monthly remittance shows good faith, confirms your acknowledgement of the outstanding balance, and buys you time.

Remember that it is much harder to get a bill reduced once it is in collection. Unless you have confirmation that your account has been placed on hold (and the date it expires), the countdown is on.

5. Give updates

Billing people love hearing from patients with unpaid balances (trust me, I know!). It reassures them that you are neither a deadbeat nor trying to pull a fast one. Regular updates will prompt more understanding and patience on their part.

6. Keep good notes

From the first call on, keep a log of calls made and received, the content of the discussion and subsequent results. Keep a copy of every written correspondence as well. Some providers are more eager to use the collection tool, and this evidence will work in your favor. Insurers keep notes one every call or letter you make, so should you.

This documentation may also come in handy if you are forced to go up the corporate ladder, need to escalate the issue or eventually file a grievance with a government agency.

In conclusion:

Delaying may end up costing you dearly. Other bills may wait without harmful consequences; medical statements should preferably be looked at promptly.

Timeliness may also become an issue if you decide to file an appeal with your insurance, as a deadline of 90 days is usually the norm. Check the website or your policy for more details.

Nobody likes to wait to get paid when the job is done, and your doctor or hospital are no different. Prompt, precise and courteous communications will be appreciated.

* Previously seen on NerdWallet

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

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


Quote of the week

"If you want to go fast, go alone. If you want to go far, go together" African proverb


AdviMed        (424) 999 4705 or (877) 658 9446       fax (424) 226 1330
                                www.advimed.us            contact@advimed.us

Monday, October 20, 2014

Patient Advocacy: Healthcare on your Side



www.advimed.us    October 21, 2014  Issue 60
Patient Advocacy: Healthcare on your side

    a weekly blog by Martine Brousse, 
Healthcare Specialist, Patient Advocate, Certified Mediator
Founder, PRES.  AdviMed


A few Tips about

Medical Bills Management*


I am often asked about how best to manage mounting medical bills. This is often due to the difficulty many patients experience when facing serious health issues, managing appointments and maintaining their daily activities. Who has the energy and will to deal with financial paperwork under such circumstances? Who has the time to call medical providers and insurance carriers? How do you negotiate a bill or even know for sure that a statement is correct?

While patient advocates specializing in billing matters or accountants can assist in this task, they can only do so based on the documentation they receive. Here are some tips that may make a difference for you and for them.

1. Be mindful of time limits

Patients usually have 30 days to make a payment on their account, or inform the office of their intention to contest a balance. Delaying may mean collection action (sometimes in as little as 60 days), or paying added interest. If you need more time, make a small payment to keep the account current and to show good faith. If you need clarification, make your call early. If you disagree, indicate so in writing as soon as possible.

Insurance companies place time limits on policyholders filing a first grievance or second-degree appeal. Ninety days from the date on the Explanation of Benefit ("EOB") or the determination letter are the norm.

2. Communicate!

Remember to report any arrangement, payment plan or settlement you have in place to your advocate to avoid misunderstanding and wasted efforts.

It is of the utmost importance to follow the policy guidelines about filing written appeals. You usually only have two: use them well!
A phone call asking for an explanation may count as strike one, even if you are unclear with the representative about your intention. Asking the adjuster to reprocess the claim "because the insurance did not pay enough" is a sure denial in the making. 

3. Play the matching game

Your advocate, accountant or family member handling the bill are not the only ones looking for correct information and exact figures, so does the IRS. Keeping accurate records will prove worthwhile when filing for medical expenses tax credits or seeking reimbursement from your HSA account.

I recommend matching every statement from providers with the corresponding insurance EOB. This will allow you to verify that the amounts billed to you are justified, and that every medical service has been submitted to your insurer for payment. Discrepancies, errors or issues should soon become apparent.

Using an Excel spreadsheet is a great tool to keep track of statements, EOBs and amounts paid. Keeping it updated on a weekly or monthly basis costs little effort, with great reward. This is the way I keep track for my clients, and strongly recommend it as a managing tool. You need to itemize every charge, but each date of service and provider should have an entry.

4. Details count

Small details make the difference success and wasting time and $ on losing efforts. Winning an appeal may well depend on their reporting or explaining.

Some examples: an error on the hospital's part caused you to have to stay longer; the provider was in network but canceled his contract with your insurance in middle of treatment; the patient signed a financial agreement while still under the influence of anesthesia or without an interpreter; the office sent your samples to an out of network lab because the Dr needed the results ASAP.
All of these are routine denials, yet each one can be the reason for winning your appeal. 

In conclusion:

Managing medical bills, establishing the best course of action and getting to the best outcome depend on basic matching and minimum organization skills. While hiring a billing advocate can mean peace of mind, not every patient can afford this service.
A small investment of time can save you money by recognizing errors, missteps or even fraud and having them reversed.

Blindly paying every bill you receive, or sticking them on the growing pile until you can (or want to)  get to it are neither cost-efficient nor advisable.
  
* Previously seen on NerdWallet

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

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


Quote of the week

"It always seems impossible until it is done"  N. Mandela


AdviMed        (424) 999 4705 or (877) 658 9446       fax (424) 226 1330
                                www.advimed.us            contact@advimed.us

Wednesday, October 8, 2014

Patient Advocacy: Healthcare on your Side


www.advimed.us    October 14 , 2014  Issue 59
Patient Advocacy: Healthcare on your side

    a weekly blog by Martine Brousse, 
Healthcare Specialist, Patient Advocate, Certified Mediator
Founder, PRES.  AdviMed


Medical Necessity:

Filing Successful Appeals*

As explained in last week's blog, "medical necessity" takes on diverse meanings, based on who claims it.
Eventually the final word rests with your insurance, its guidelines, the terms of your health policy and the documentation supporting your claim.

Here are some tips to help you conquer those hard-to-win appeals.

1. Standard medical practice appeal

In general, you (and your physician) must show that the normal, well established standard of care has been followed. In a nutshell, you have been prescribed the gentler, cheaper, usual, normal course of treatment, and this is not working.

Let's say your prescription is brand name, and over the counter alternatives are available. You are liable for a higher or total share of cost when purchasing it. Medical necessity would be justified if the OTC version or generic prescriptions had been tried over a certain amount of time, resulting in no improvements, a worsening of the condition, a serious side effect, or were counter-indicated.

When a surgical or invasive intervention is recommended, proving medical necessity requires records that show prior conservative, pharmaceutical or non-invasive therapies have been tried and are no longer or never were effective.

2. Insurance guidelines appeal

This appeal will be more difficult to win, but all hope is not lost. Because the terms of a contract are at play, the room to maneuver is tight.

Medical necessity would be established if conservative measures have been used and become ineffective to the point of causing irreparable damage to your health. Detailed explanations of the negative impact on your daily life, professional activities, and/or on your mental or emotional state if the prescribed treatment were not administered must be presented.

Let us say that you have intense back pain due to an old injury. Your policy will not cover surgery as your condition is neither acute nor hazardous to your life. It will cover pain management modalities, physical therapy and supplies such as a brace.
Exposing potential risks (addiction to pain pills), reduced quality of life (loss of mobility), inability to do your job (can't sit or drive) or onset of new related conditions (depression) would have a chance of success. The medical records would need to clearly unusual and serious circumstances justifying the prescribed approach.

3. FDA based appeal

We are now entering a world where cooperation from your physician is indispensable.
If your treatment has been denied as "off-label" (not approved by the FDA) or inappropriate for your diagnosis, you are unlikely to win an appeal unless highly technical clinical documentation is presented. Many specialized sources in the US are only available to physicians, while looking for supportive information elsewhere will test your research and linguistic skills.

If a prescribed treatment has a proven and effective off-label use abroad, in US drug trials (at least stage II) or as part of peer reviewed studies, it might be up for consideration. If literature supporting the physician's decision has been published in medical journals, can be located from reputable sources or is listed in the drug NCCN compendia (the "Bible of medications"), your insurance may be convinced to cover it.

Your physician must have the justification and be ready to hand over details, articles and research papers. His reasoning, supported by established facts and reasoning, should be extensively detailed in the medical records as it is out of established and standard guidelines. If not, ask yourself: on what medical grounds was the treatment prescribed?
This type of appeal is rarely done by patients, due to the complex nature of the evidence and the restricted access to resources.

In conclusion

Records from other physicians, demonstrated impact, detailed past treatments and their results should be on file in your chart. The Medicare rule for payment is: " if it is not in the medical records, it did not happen". Every other insurance follows this reasoning. Unless a member of the medical profession noted it, or unless you have written proof, saying it means little. Old explanations of benefits would do, as would a history print out from a pharmacy. A letter from someone in the office, or unsigned by the physician have no value.

But remember: filing an appeal requires two things. State exactly why a claim should be reprocessed or a denial overturned, and prove your point with as much relevant, legitimate documentation as you can get. 

* Previously seen on NerdWallet

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

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. 


Quote of the week

"Speak only when your words are more beautiful than the silence"     Arabic proverb


AdviMed        (424) 999 4705 or (877) 658 9446       fax (424) 226 1330
                                www.advimed.us            contact@advimed.us