Tuesday, August 12, 2014

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse
Healthcare Specialist, Patient Advocate, Certified Mediator


If your situation is an emergency or dire, or your life is at risk, do seek immediate treatment.
Getting a second opinion is an option that should be considered when your immediate survival and wellbeing are not threatened.

Provisions of the ACA ("Obamacare) give patients with right to a second opinion, though insurance companies may interpret this as only for serious conditions. Restrictions may lead you to providers within a specific network or medical group. But patients should remember this option is available, even recommended in particular cases:

a. Your diagnosis is uncertain

 Why has your diagnosis not been confirmed? If the tests results are inclusive, or if the doctor is unsure about their significance, you may want to ask another opinion.

b. Your physician is intransigent

 When only one treatment is offered, if you are told "this is the only way", or if your physician refuses to discuss alternatives, it could be time to make that other appointment. Basic internet research should help you determine if a prescribed treatment, therapy or intervention is the only option. 
Asking about other treatments is your right. Your doctor should explain what criteria his decision is based on, and why one treatment is better than another. No alternative or explanations? Get information ... elsewhere.

c. You don't trust the doctor or diagnosis 

Many years ago, an ER doctor misdiagnosed my symptoms. Despite my strong intuition he was incorrect, I did not dare ask for another opinion, nearly costing me my life. I could have avoided surgery and lifelong side effects if I had listened to and expressed my gut feelings, and requested to be evaluated by someone else.
If you feel, deep down, that what you are hearing is not right, or does not make sense, seeking an outside consultation may be wise. Trusting your physician is essential to a positive outcome.

d. Your insurance says no
Lack of coverage on your policy for the prescribed treatment or intervention may drive you to seek another physician's evaluation. Another red flag would be in the form of an insurance authorization denial, especially labeled as "not medically necessary".

While insurance companies deserve some bad press about denying prescribed services, they mostly base their determination on FDA recommendations and guidelines, scientific information and performance or outcome data. The insurance case manager can guide you through to a second opinion, appeal or external medical review process.

e. It's not working

When the prescribed treatment is not translating into improvements, and especially if your doctor is unwilling to address or recommend a change without a good explanation, consider getting another opinion. Seek a specialist if your unresolved condition is currently managed by a general practitioner, or if you locate a medical provider more familiar with your specific diagnosis.

f. The cost is an issue:

If you are self-pay, or if your policy has a high deductible or share of cost, getting another opinion may save you money in the long run. While this is less a medical second opinion than a financial one, a similar intervention or treatment may be more affordable around the corner. If you are quoted a price and have a detailed list of covered items and services, why not consult somewhere else and potentially receive the same for less?

g. Your insurance policy says so 

Before any treatment, surgical intervention (even outpatient) or imaging, contact your insurance to find out if (1) an authorization is required and/or (2) if a second opinion is necessary. Some cases, mostly those considered elective, not medically necessary or experimental, require additional supporting medical documentation from another professional before it is covered.

In conclusion:

Involvement on the part of your insurance is usually required in order to be paid. Contact customer service before making any appointment, especially with a HMO policy.

Ask for a referral outside of the medical group or office where you are currently a patient. It is quite unheard of for one physician to contradict a colleague in the same practice or group. Go up the administrative ladder if such request is denied by your insurance, or ask your state's department of insurance for assistance.

If your insurance will not cover the cost, pay cash. Negotiate on the price ($ 350.00 to $500.00 depending on the severity of the diagnosis) and forward all records before your appointment so that the time allotted is best spent going over options and discussing treatment options.

©  [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

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