Healthcare: Patient Advocacy on your side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

Save on medical costs: 
 Alternative Options* 

As I negotiate down expensive facility bills for my clients, or fight insurance companies for higher reimbursements, I am often struck by the number of patients who thought the ER or the specialist's office were their only choices. Minor episodes end up costing thousands of dollars, when more affordable options were available.

Consider these options:

Please note this is given for informative purposes only, does not intend to provide or constitute medical care or advise. It neither endorses nor promotes any mentioned service or provider.

ALWAYS call 911 or go the Emergency Room if you are having a life-threatening emergency or if your health may be at serious risk by delaying care.

1. Urgent Care Centers

Staffed by MDs, they treat less severe emergencies that require immediate attention. Services include sutures, prescribing medications, chronic condition management, health evaluations, imaging, stabilization until your next doctor appointment and more.

Urgent care centers are found in many cities and neighborhoods. Appointments are not necessary.

2. Retail Health Clinics

Addressing minor concerns such as allergic reactions, minor infections, wound care and skin conditions, they are staffed with nurse practitioners licensed to prescribe medications and perform simple medical procedures. This is a good alternative to a doctor's visit for general and school health exams or for vaccinations.

Located in drugstore chains (i.e. CVS) or retail stores (i.e. Wal-Mart), they contract with most major insurers. Their services are fairly priced.

3. Nurse helpline

This free service, staffed by nurses 24/7, from your insurance can save you the cost of a doctor's visit. Find the number on your card or on the insurance website.

Call to determine if you need to go to the ER, to find the nearest "in network" urgent care, to ask what remedy is best for minor symptoms, to treat an illness or to get first aid steps that do not require the ER. These nurses can provide answers when the office is closed, help coordinate medical care if you are away from home, or order urgent prescription refills when your doctor is unavailable.

4.  Free or low cost clinics

Offering a variety of services, they should not be your first choice in case of an emergency. Administered by the County, privately run or belonging to teaching universities and hospitals (services are rendered by students under the supervision of fully-experienced doctors), waits can be long but prices worth a look.

Some specialize in a specific illness (HIV/AIDS clinics) or services (women's health clinics). Exams, prescriptions, tests and more are provided at significant savings.

5. Labs

Depending on the test, you may need to consult your Dr first. Many common tests can be obtained without a prescription, or at a lower cash cost than in the office, directly from these labs:

·      http://www.saveonlabs.com/

·           https://www.directlabs.com/

·           http://www.questdiagnostics.com/home/patients/get-results.html

6. Chiropractors

If you have a minor sport injury or joint pain, or want to avoid surgery, consulting a chiropractor is a less costly option than an orthopedic MD. Specializing in bones, muscles and joints, they use more conservative, less drastic treatment methods (spinal manipulations, physical therapy, medical massages) to get you back in shape. They can order scans and limited labs. Expect to pay $ 50.00 to $ 100.00 per visit (including all modalities). This is often a covered insurance benefit.

7. Pharmacists

Ask the pharmacist at your local drugstore or pharmacy for a recommendation on what over the counter remedy is best for minor ailments, to check on possible negative interaction with current prescriptions, or advise on a minor allergic reaction.  Local and chain pharmacies also offer low cost flu shots, and other vaccinations.

8. Online  

An increase in the number of online MD visits has been observed, and is likely to continue this upward trend. Sites such as www.memd.me, www.interactivemd.com or the-online-doctor.com propose virtual encounters for set prices, and at convenient times for patients.

In Conclusion:

Remember to ask any healthcare provider or clinic you may consult if they are part of your insurance network. Choosing one who is contracted with your insurer will significantly lower your cost. You may need to send the bill directly to your insurer; getting a "superbill" (specialized medical bill) is essential. If you are self-pay, this receipt or statement will be useful come tax season.

Never jeopardize your health by denying yourself access to urgent or necessary medical care whenever necessary. Though more limited after the facts, solutions can still be found to help lower high medical bills.

* Previously seen on NerdWallet

©  [2016] Advimedpro.

©  [2016] 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. 

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

 

Medical Bills Management: a few tips*

I am often asked about how best to manage mounting medical bills while patients must face serious health issues, undergo treatment, keep their job and maintain their daily activities. Who has the energy, time and will to deal with financial paperwork?  How do you negotiate a bill or even know for sure that a statement is due?

While patient advocates specializing in billing issues 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 they contest a balance. Delaying may mean collection action (sometimes in as little as 60 days), or added interest. If more time is required, make a small payment to keep the account current and to show good faith. Make your call early for clarification purposes. If you disagree with a balance, indicate so in writing as soon as possible.

Insurance companies place time limits on 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!

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

Always 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

Keeping accurate records will prove worthwhile when filing for medical expenses tax credits with the IRS or seeking reimbursement from your HSA account.

I recommend matching every bill with the corresponding insurance Explanation Of Benefit. Confirm 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.

I recommend an Excel spreadsheet 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. You don't need to itemize every charge, but each date of service and provider should have an entry.

4. Details count

Small details make the difference between success and wasting time and $ on losing efforts. Winning an appeal may well depend on them.

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 strategy 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 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 published on NerdWallet

©  [2016] Advimedpro.

©  [2016] 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. 

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

Medical Necessity:

  Filing Successful Appeals*

"Medical necessity", used so often in denials of claims or athorizations 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

It is imperative that 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, most common course of treatment, and this is not working.

Let's say your prescription is brand name, but over the counter alternatives are available. You are liable for a higher or total share of cost for the brand name. 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 demonstrate prior conservative, pharmaceutical or non-invasive therapies are not longer 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.

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 list 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 industry's 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 holds no value.

Filing an appeal requires two things: stating exactly why a claim should be reprocessed or a denial overturned, and proving your point with as much relevant, legitimate documentation as you can get. 

* Previously seen on NerdWallet

©  [2016] Advimedpro.

©  [2016] 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.

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

                                         www.advimedpro.com           contact@advimedpro.com