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

Patient Advocacy: Healthcare on your Side


www.advimed.us    October 7 , 2014  Issue 58
Patient Advocacy: Healthcare on your side

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


THE 411 ON "MEDICAL NECESSITY"*

In the realm of insurance denials, few are more frustrating that those issued for "lack of medical necessity". If your doctor prescribed a treatment or procedure, it must be medically necessary, right?

It depends. "Medically necessary" has different meanings. Understanding which one applies to your case determines your appeal options.

1. Standard medical practice says

The most common definition is that "the service/procedure/treatment is reasonably expected to prevent the onset of a condition, reduce or ameliorate the effects of an illness or condition, or help an individual obtain or maintain maximum functional capacity".

From the insurance point of view, the most economical, least invasive, most efficient way of achieving the above is the preferred option.

Let's say your prescription is brand name, but over the counter or generic alternatives are available. In most cases, medical necessity for the more expensive drug would not be justified.

When a surgical or invasive intervention is recommended, medical necessity means no other pharmaceutical, more conservative or non-invasive therapies are indicated.

2. Your insurance (policy) says

Visiting one's insurance website can be enlightening. Coverage of the same procedure or drug may vary from insurer to insurer. It is advisable to always confirm a service or prescription is covered under your policy to avoid costly surprises.

Restrictions are often found on procedures that have cheaper or less radical alternatives, or those deemed "elective". If the insurer can argue that the life or welfare of the patient are not in immediate danger, or that the condition can be managed via a more conservative approach, the medical necessity for more drastic measures is often rejected.

A good example is knee replacement: your physician may recommend immediate replacement surgery, but your insurer may impose physical therapy and pharmaceutical pain management until the condition turns more serious or for a certain length of time without improvement.

3. The FDA says

If it is not FDA approved for use or not indicated for your specific diagnosis ("off label"), it is not medically necessary... unless accepted exceptions apply.

The most important is the listing in the drug NCCN compendia (the "Bible of medications"). If an off-label use is published there, your insurance may accept to cover it. Though not FDA approved, it indicates that it has become an accepted use within the medical community.
 
4. The physician says

Based on professional experience your treating physician might prescribe a stronger prescription than the over the counter version, bypassing the standard protocol. He might also disregard a longer-term approach for a quicker but more drastic solution based on medical and other criteria.

5. You say

As a billing manager, I have seen my share of cases where convenience and personal preferences were the basis for requesting a specific prescription or treatment.
While a young mother choosing to undergo a gentler but longer type of chemotherapy when the norm is a less costly, shorter but debilitating treatment can be justified, requests based on marketing ads, advise from friends and family members or indiscriminate internet research will not.

Medical providers might be tempted to prescribe a certain drug, or order a test or scan to please (and keep) their patient. Relying on unverified statements by the patient, they may be led to advise serious interventions when not truly indicated.

Unsupported by sound, appropriate medical records, it will be difficult to prove medical necessity in such cases.

In conclusion:

Depending on the point of view, medical necessity takes many forms. It usually follows established protocols. When your insurance issues a denial, it does so based on specific reasons, published policies, FDA guidelines or standard medical practices. Other valid explanations include a lack of medical records, insufficient justification or a missing authorization.

Until evidence is given supporting the need for an out-of-the-norm service in your specific case, expecting a change of decision might be a lost cause.

* 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

"The flower of consciousness needs the mud out of which it grows." Eckhart Tolle



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