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

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

(Or how insurance allowances are killing us)*

This is the story of Y.L., a patient stuck with an outrageous liability, all legal, yet unconscionable and unjustifiable. This is due to the contract rates between the facility in Walnut Creek, CA where Y.L. received services and Anthem Blue Cross CA, her insurance company. These contracted rates were set by the patient's employer, a national bank (known by its old-time carriage logo). Apparently, money is no object there.

While the patient is eager to pay her share, the excessive allowances she has been made responsible for, prompted her to seek a patient advocate to negotiate them down.

Her story is the story of so many others in this country. A spotlight should be placed on these practices, as they add to the burden of patients, as well as that of companies and the healthcare system in general.

Consider the simple lab called the Comprehensive Metabolic Panel. Usually reimbursed at around $ 15.00 to $ 20.00 by Medicare and commercial carriers, it is as commonplace and basic as they come, and is widely and easily performed.

Why then would Anthem issue an allowance of $ $808.99 in this case? Why would this hospital even charge $ 1,244.60 for this test? Why would this patient be required to pay over $ 800.00 for something the corner lab or doctor's office could have run for 40 times less?

Next is the shocking $ 42.02 allowance by Anthem for 1 dose of Zofran, a common (generic) drug. Billed $ 64.65 for one dose/unit, the Medicare reimbursement is $ 0.16, that of commercial carriers a few pennies more. Again, a shocking discrepancy.

Whether such excessive rates may be in violation of Consumer laws has been asked. I am definitely not an expert on the subject, but settling the patient with $800.00 for a service that only costs $ 15.00 might seem a bit suspect to some.

This bill has more similar charges. Yet this hospital is inflexible, categorically refusing to even consider adjusting balances down or extend commonplace discount (such as "prompt pay") that other facilities (legally) routinely offer to their customers. It is not the only one in this area, and is not a specialized care center.
Billing representatives and supervisors brandished "the policy" as a shield, while higher executives never responded to messages. The media department proved unable to accept phone messages, not responding to online inquiries. Even Anthem's representative phone request for a review and a possible discount, was rejected.

The sad truth reflected by this case, is that self-funded employers, the ones with final decision about the benefits and reimbursements to be included in their insurance contracts, may not have much experience in setting those prices. Maybe they don't have or understand the financial limitations their employees face, or care because the company can afford such rates. Do all employees enjoy the size of salary allowing them to pay such bills without a second thought? 
After all, if this bank can easily afford to get fleeced for $ 42.02 on a $ 0.16 pill, should its voiceless and powerless employees?

Management should scrutinize such financial matters as long as employees have deductibles and out-of-pockets, Linking contract rates for a self-funded group to those of the average contract in a specific state is often done. Calculating reimbursements based on existing data, such as Medicare rates, ASP rates for drugs, Usual and Customary used by commercial carriers is not an insurmountable task. As a long time billing manager, I know that unions and smaller self-funded groups are well aware of all allowances on their plan. When money counts, one pays better attention.

In the end, I had  to give up. The Explanation of Benefit is a legal form, used to bill the patient according to the terms of the policy. There is no arguing that the facility acted within its rights. 

The patient will now make small payments over 60 months. What is the cost to send so many statements? What about burdening the books for 5 years? Would a prompt pay settlement not have saved operating costs? Would this not be a smart business move, embraced by many others?

I wish someone at J.M. Hospital had answered my multiple requests for a talk. I hope the patient will follow through with openly and visibly exposing these practices, letting public opinion make its own mind. Good luck to her.

* As 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