Monday, July 21, 2014

Patient Advocacy: Healthcare on your Side


www.advimed.us    July 29, 2014    Issue 50

Patient Advocacy: Healthcare on your side
  
  a weekly blog by Martine Brousse, 
Healthcare Specialist, Patient Advocate, Certified Mediator
OWNER, PRES.  AdviMed


Paying for Prescription Drugs
Part I: Infused or Injected *

Infused or injected treatments are common, ranging from a 32-cent B12 injection to thousand-of-dollars chemotherapy infusions. Due to medical and liability reasons, these are mostly given in office or facility settings, and are billed to Medicare under part A(inpatient) or B (outpatient or office), and to commercial insurances under the Medical benefits portion of the policy.
Many such treatments use brand-name drugs, often associated with prohibitive costs. These medications are not covered or payable under the Pharmacy benefits of your policy when administered in those settings.

There are options to lower your costs. Here are some tips:

1. Visit the Manufacturer's website

Almost all manufacturers offer so-pay assistance programs to self-pay patients, or those with a high share of cost. While income maximums may be in place, they are not mandatory. Grants can be generous ($ 24,000/yr for Herceptin from Genentech for example), but will not cover off-label (not FDA approved) use. Most offices will have application forms or documentation, but may not offer it unless prompted.

Self-pay or cash patients might qualify for free drug donations, based on criteria specific to each product.

Medicare, Medicaid or Tricare patients are prohibited by law from applying directly for funds, but may qualify for indirect assistance (see below)

2. Public & private Organizations

Every disease or condition has likely created an organization dedicated to its education and support. Cancer patients, for example, have access to various general federal agencies, as well as numerous private societies.There, should be listed general and focused charities, offering financial assistance and free resources. Healthwell or Copays.org are such well-known programs.

Please note that private funds often run out of funds early each month; applying the first week is best. Grants are not retroactive so requests should be made before a treatment starts.

3. Do it at home

Some infusion treatments, including those less complicated such as IV iron, IVIG, zoledronic acid for osteoporosis (Zometa, Reclast), etc, can be administered at home by a visiting nurse. Although the first regimen will be given in the office or facility to rule out any allergic reaction, subsequent home treatments may be cheaper.

Take too into consideration these hidden costs: time taken off work to go to the office, parking fees, the risk of infection in crowded waiting rooms, or the discomfort of leaving home when not feeling well (especially after a chemo treatment).

Injections such as growth factors for anemia (Procrit, Aranesp) or for neutropenia (Neupogen) for example, can safely be self-administered (syringes come pre-filled and require no medical background). Others like B12 injections can be administered at home via a home health agency. In these cases, your pharmacy benefits, or Part D will be responsible for the authorization, delivery and payment of the drug. 

Calling your insurance carrier to compare costs, verify coverage and work the set-up is a must. As this option creates more paperwork for your doctor, and extends his legal liability beyond his active control, he is likely to be more supportive if most details, such as locating an in network home health provider, have already been worked out.  

4. Use specialized mail order pharmacies.

If you are self-injecting at home without the help of a health agency, your prescriptions will be filled at your local or mail order pharmacy. Try contacting TNH or US Bioservices in such cases. They may not be contracted with your insurance, but their staff is trained to locate and apply for financial assistance on behalf of patients. This service can save you $ and efforts.

5. Question your physician

Convenience and habit may lead to prescribing costly regimens and medications when cheaper or generic alternatives are equivalent. Less expensive treatment options are often available, with the added advantage of having proven their value and effectiveness.

An active dialogue with your physician, especially when explaining your financial situation, can benefit both sides. After all, the office has an incentive to help you in order to get paid promptly in return.

In conclusion:

There may be more help out there for you than you may realize. I specialize in oncology, and know that for a fact for cancer patients. Asking the office staff is the first step, doing basic internet research is next. For those who are not computer-savvy, your local library, church or teenage neighbor may be helpful.

* as seen on NerdWallet

Next week: Part II: Oral Prescriptions



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:
"Detachment is not that you should owe nothing, but that nothing should own you" Ali Ibn abi Talib

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


Patient Advocacy: Healthcare on your Side



www.advimed.us    July 22, 2014    Issue 49

Patient Advocacy: Healthcare on your side

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


4 Tips for Successful Insurance Appeals

In the mysterious world of insurance appeals, final determinations are based on the merit of your grievance, your insurer's policy and your plan benefits. Following these tips may lead to better outcomes.

1. Know the Facts

Providers should be initiating the vase majority of appeals. They have the medical, coding, and technical knowledge to do so.  If they refuse, or are unable to do so, you should, at a minimum, receive all relevant supportive documentation. 

If a claim was rejected for billing errors (incorrect codes, diagnosis ID, etc), filing an appeal is a waste of time as only a processed and paid claim can be appealed. Your doctor's billing person should resubmit corrected charges, or provide your insurer with any requested documentation. 

If a charge is rejected as "non-covered, not a benefit of the plan, not reimbursable under the insurance guidelines, experimental, off-label, not medically necessary or out of network", a talk with the office manager at your office is in order. Was this info known to the office but not communicated? Was your policy checked before services were rendered? Is it a simple clerical error?

Answers will determine whether this is now appeal material, an financial issue between you and the provider, a third party responsibility (i.e. an incorrect dx given to the lab whose claim was rejected) or your own error (i.e. you did not share your new card). 

2. Who should appeal?

If the office is responsible, it should take immediate corrective steps, send records, or update information.

Billing mistakes made by secondary providers (labs, imaging centers) are common. Call them to give your new insurance ID or address. Many denials occur when invalid or non-payable diagnosis codes are forwarded with the order or prescription. Your MD cannot be expected to know each payable dx for every outside service. Updating the order in your chart must be completed before the appropriate biller can resubmit the charges with a payable code. 

If information was withheld from you, either deliberately or by ignorance, insist the office appeal to your insurer with comprehensive explanations and detailed clinical justification from accepted sources. Best undertaken by both the patient and the provider, this process calls for payment due to "medical necessity".

If you had no choice or option, and are being billed for services considered "out of network" or "non covered", do file an appeal, especially if these were rendered under emergency conditions.

When in doubt, go ahead and file. You are within your rights to ask that your claims be reviewed, and your financial responsibility confirmed. 

3. Be Clear and precise

Why you are requesting the review of a charge? Asking your insurer to reprocess a claim just "because they did not pay or not enough" almost guarantees a denial of your request. Computers process claims, not people. They seldom make mistakes (computers not people!). As an actual person will review your appeal letter, the exact reason(s) of your request should be clear. 

Invoke your right to a "continuation of care" level of coverage if your Dr cancelled his/her contract in the middle of treatment and claims were paid "out of network". Demand payment of non-contracted charges based on your emergency hospitalization. Demonstrate that "medical necessity" was met for a prescribed treatment or procedure by using your medical records, and supportive industry or Medicare guidelines. Ask for a reversal of a denial based on specific and unusual circumstances. Brand drug manufacturers offer ready-made sample letters to appeal coverage of their products.

4. Attach relevant documentation

Documentation is essential to any appeal. No or little documentation = not much hope of success. 
While I would not recommend sending truckloads of papers to the reviewer, ask the staff to provide the most appropriate clinical records to make your case. Ask them to direct you to related websites, significant studies, important links and online resources to add supportive documentation.
You may need to request records from a third party, usually the physician who ordered a specific lab, test or imaging service, in order to get medical justification and prove medical necessity. Remember to include the original order or prescription with your attachments.

Mail a copy of the appeal to the related provider, and ask for the financial responsibility to be shifted back to the insurance during this process. If the provider refuses, make small monthly payments to keep your account current, show good faith and avoid collection action.


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:
"A man sees in the world what he carries in his heart" Goethe



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

Wednesday, July 16, 2014

Patient Advocacy: Healthcare on your Side



www.advimed.us    July 14, 2014    Issue 48

Patient Advocacy: Healthcare on your side

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



5 Tips to get the Medical Office Staff on your side

The medical office staff member: they can be uncooperative, unfriendly and even seemingly uncaring. How can you reconcile your needs and rights with their schedule, training, orders...and attitude? Cooperation and a little give-and-take are key!

As the healthcare system is transforming under ACA ("Obamacare") implementations, medical providers have had to adapt to a dizzying number of new requirements, technological upgrades, legislative mandates and compliance deadlines. Sweeping changes are apparent: clinical staff spend much face-to-face time typing away on tablets, automated appointment recall messages are the norm, phone calls rarely lead to a live person. 

Cost-cutting measures brought on by the economic turndown, the ongoing drive toward leaner financial operations, finding additional resources to cover the price tags for new technology and lower insurance reimbursements have prompted offices to employ fewer staff, while workloads have increased in complexity and size.

Healthcare workers are too often overworked, understaffed and overwhelmed. As a billing manager and primary patient contact for 20+ years, I understand their frustrations and limits, but this is the career they chose. Here are some tips to turn these employees into allies.

1. Politeness goes a long way
The old standard way of being demanding, using abusive language, "showing who you are" may get you a result in the short term. But a bit of caution: you will be tagged as "difficult". Under a coat of cold professionalism, you'll wait a little longer next time, and your calls might go straight to voicemail as no one wants to answer them. Perceived abuse of one staff member (let alone many) gets around, and passive collective resistance grows in the face of divas and pains in the b---. 

2. Required: a little patience
Understand that the receptionist has no power over the doctor falling behind on his schedule, or that your labs can't be drawn without a MD signature. Pushing staff around will not get the doctor out of another exam room faster. Electronic Health Records orders take more time to generate than a scribble on a piece of paper. 

Unless you witness employees playing CandyCrush or chit chatting about their latest date, why not limit asking "when will I be seen?" to once in a while rather than every 3 minutes?

Do reschedule if the wait is so long as to cause you problems at work, anxiety or excessive anger. As this is not your fault, the office should be receptive. 

3. No finger pointing please!
As the saying goes, if I had a dollar every time a patient yelled at me "it's all your fault, you always make mistakes", I would definitely be writing these words from some sunny beach in the 50th State.

Because another office mismanaged your claim/info/labs/orders do not mean this office did or will. Incompetent billers and uncaring individuals abound, but maybe not here. It is very aggravating to be condemned before being given a chance to review and possibly correct. After all, the misunderstanding may be yours or have originated in another office. Your sincere apology would then be much appreciated...

4. Mistakes happen
Reporting a clinical error to the physician immediately is crucial. Bring ongoing or un-rectified administrative errors to the attention of the office manager.  An occasional blunder should be corrected, blamed on a temporary but uncommon lapse in efficiency and forgotten.
   
5. Do your share
At your first visit, bring your ID and insurance card (legally required to be copied into your chart). Give an up-to-date medication list and the name of other treating physicians. Indicate the contact info of your preferred pharmacy. Bring a translator if necessary, and one support person to take notes and help you remember your questions. More is a crowd, and too disruptive.

Consider booking the first appointment of the day or after lunch for follow-up visits. Fridays are usually lighter days; your wait time will be shorter. Report any changes to your medication list, insurance coverage or health history. Follow up on authorization requests, labs results or prescription orders; waiting for a call may cause unnecessary delays. Confirm any new physician you might be referred to, contracts with your insurance network. 

Collaboration is one of the Cs in Success (or is it cooperation??). Helping the staff, with a minimum of effort on your part, will pay off, especially when you ask for a favor or expedited action. But don't forget your rights and stand by them!


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:
" Nothing is impossible. The word itself means "I'm possible"! Audrey Hepburn



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