Monday, September 29, 2014

Patient Advocacy: Healthcare on your SIde    September 30, 2014  Issue 57
Patient Advocacy: Healthcare on your side

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

Five Tips about Medicare Advantage *

As a billing manager, I often found many senior patients were misinformed about their Medicare coverage. A lack of basic understanding would translate into delays, higher costs and added stress. Understanding five basic points could help such patients obtain appropriate and prompt care, and save them money and sanity.

1. There is more than one

At the beginning was Medicare. Called "straight" by those in the medical field, this Original Medicare (OM or MCR) consists ofPart A: hospital, nursing and hospice care
  • Part B: physicians, labs, tests and Durable Medical Equipment
  • Part D: prescription drugs (dispensed out of a hospital or office)
Patient involvement is minimal. Healthcare providers render services, send a bill and get paid quickly, a perfect example of the "Fee for Service" (FFS) process so discussed lately. The Federal Government administers OM. 

Created a few years ago to lower costs, Medicare Advantage (MA) plans are administered by private insurance carriers. This is also called Part C. 

2. Is it MCR or MA?

Knowing which coverage you have is essential. Assuming and telling the office that you have "Medicare" is incorrect if you have a MA plan.  In the industry, "Medicare" means Original Medicare, it NEVER means Medicare Advantage.

Once enrolled in a Medicare Advantage (MA) plan, you turn your Original Medicare (OM) benefits over to a private insurance company, which in turns provides coverage, administers your plan and pays your claims. You now have the equivalent of a commercial policy, subject to specific guidelines, requirements and limitations. Your doctor may need a direct contract with this insurer, or authorizations required before services are rendered.

Your Medicare card (with your social security followed by a letter) is no longer valid for payment of claims, only the one issued by the private insurance carrier is.

3. Conditions of coverage vary

MA plans are not based on the same easy "get-paid-easily-as-long-as-you-follow-basic-and-well-publicized-guidelines" protocol used by MCR, although they are required to cover the same benefits (doctor visits, in and outpatient services, emergency care, some preventive services, tests and labs, mental health care, some physical therapy, limited home, nursing and hospice care, some supplies and drug/alcohol treatments).

Vision, dental and hearing coverage are not covered under OM. You may purchase these options separately if they are not included in the MA policy.
Note that MA plans may cost more than the premiums you already pay to Medicare. 

There are 2 basic MA plans:
  • ·      HMO patients must receive services through an exclusive network. Subscribers are assigned to a local IPA (Medical Group) and a PCP (Primary Care Physician) who oversees your overall care and issues mandatory authorizations. Part D coverage must be purchased from the same HMO.
  • ·      Non-HMO (FFS or PPO): this type of plan seems to indicate that restrictions do not apply. Beware: your final liability may increase if your medical provider has no contract with your health plan or if an authorization was not obtained. Because a provider is a PPO provider does NOT imply he is willing or able to accept MA patients. PPO plans are by definition commercial, caution is warranted when using the term "PPO" or "FFS" in the Medicare context. 
4. It may cost you

Too many patients switch to a MA policy only to discover that they cannot continue seeing their physician or have significantly higher financial liability in January. While prescription discounts, no 20% copay and a limit on the yearly share of cost are great reasons to choose a MA plan, other financial concerns may unexpectedly and negatively affect your bottom line.

Most of the MA plans carry office copays, deductibles and out of pocket limits, which must be met before claims are paid in full. Certain services may be subject to unlimited co-insurance liability.

5. Help is available

To learn more about Medicare choices, costs, coverage and options, visit:
In California, free counseling and information on Medicare is available at:

In conclusion:

MA plans work well for a large number of seniors, but doing research prior to enrolling remains advisable, as your choice is locked in for the next year. 

Remember: You can join, switch or leave a MA plan during the Open Enrollment Period between Mid-October and Early December. You may only join a MA plan during the year if it has a 5 star rating, or if you just qualified for Medicare coverage. You may only request disenrollment and return to OM between January 1st and February 14th each year. 

* previously published 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
"What we think we become"   Buddha      

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

Tuesday, September 23, 2014

Patient Advocacy: Healthcare on your Side    September 23, 2014    Issue 56
Patient Advocacy: Healthcare on your side

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


The major cause for the high cost of cancer treatment often is that of chemotherapy drugs, oral or infused. Many treatments, also called regimens, include generic options, but the promising outcomes of new patient-directed therapies, and the growing use of leading-edge targeted drugs often come at a hefty price.

The cost of one or two brand name drugs can often meet your deductible and/or out of pocket liability at the first cycle (the time between your first chemotherapy treatment and the next one). The facility or office providing the drug will appreciate your prompt payment ... in full, as drug purchase is the number one expense in an oncology practice.

Solutions are available but getting approved is not enough. Unless certain conditions are met, the largest grant will not help you pay the oncologist or the pharmacy. Here are some tips:

1.    Whats out there?

There are three major sources of financial assistance:
   no-cost donations from drug manufacturers: office-dispensed free samples and free doses of infused drugs for the uninsured. Patients with insurance policies that do not offer coverage for the treatment may also qualify. 
   Copay assistance from those manufacturers for insurance patients with high shares of cost, in the form of direct payments to your pharmacy or oncologist, discounts cards or reduced fees.
   Grants from charitable organizations to help cover your cost.

Please note: Medicare and government-issued insurance policy holders are prohibited by law from receiving direct assistance from manufacturers, so apply directly with private organizations.
The off-label (non FDA-approved) use of a drug is rarely eligible for donations or financial aid from any entity.

Get the  list of your prescribed brand name drugs and the associated diagnosis code, then check the list of available programs at: or or

Start with the manufacturer, as most offer specific assistance, then contact charitable organizations. Genentech and Amgen have exceptionally well-run and generous programs, as do Healthwell and CancerCare.
Eligibility guidelines, documentation requirements and application forms can be found online, or by calling the toll free number.

2.    Apply early

You may apply for financial assistance covering your specific diagnosis, or specific drugs or both. Many private funds routinely run out of money, it is best to apply between the first and 5th of each month (or ask about a waiting list). Make sure you attach all required documentation with your application. If you financial circumstances have changed this year, add a letter of explanation as most applications are based last years tax return and income.

Apply, if possible, before you first treatment. If you deductible or out of pocket are met before you are approved, you are wasting your time.  Grants are NOT retroactive, except for CancerCare (60 days).

3.    Separate Diagnoses

You should apply for each diagnosis and/or drug separately. One program is unlikely to cover expenses related to another prescription or condition.
A good example is Neupogen or Neulasta, expensive drugs used for chemo-induced neutropenia (low white blood count). These are not considered chemotherapy, and always require a separate application from a different fund.

You may apply for assistance for the same drug or condition from more than one entity.

4.    Talk to Billing

It is imperative you inform the billing manager about your grant. The billing process will need to be radically altered in order to accommodate your situation, causing an insurance denial, payment delays, additional work and stress. This sounds complicated because it is! But unless an Explanation of Benefit from the insurance showing the liability applied toward the drug charge is provided, no payment can be made by the assistance program. This is the time to become best friends with the Billing department staff. Your financial fate literally depends on their good will!

5.    Keep on top of things

Grants expire after a certain number of months or $ amount. Keep track of and renew your application as needed. Dont assume you will be notified, this is your responsibility, as is that of notifying all parties of any changes.

Because available funds have decreased, and demand growing, do notify the program when you no longer need your grant money. It can then be dispersed before the year is up or the limit reached. Someone in a needy situation will be grateful!

* 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:
"In the middle of every difficulty lies opportunity" A. Einstein

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

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