Patient Advocacy: Healthcare on your side: 2014-07-20

Monday, July 21, 2014

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

by Martine G. Brousse,

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

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 hospital or office 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. Ask the office for an application form.

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 safely 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

© [2016] Advimedpro.

© [2016] Martine G. Brousse.

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.

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

www.advimedpro.com contact@advimedpro.com

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

by Martine G. Brousse,

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

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? Were your benefits verified 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 ID 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 as the law states. 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.

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