Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

Tips on Five Common Labs 

As a Patient Advocate, I often encounter bills and statements showing commonplace labs performed in various settings (office, outpatient, inpatient). I keep getting surprised, and often outraged, by the differential in pricing for those simple tests.

Patients should realize that these are the some of simplest tests, often requiring minimal clinical experience to interpret and very inexpensive. Yet they routinely overpay. Even if the price is considered "acceptable", chances are they were  overcharged anyway. 

Here are some basic information on 4 common labs and their usual reimbursement rates. If your Dr sends your samples to a non-contracted lab, or if you are out-of-network due to unforeseeable circumstances, you will now be better informed when negotiating those fees down. Hint: never pay the full price unless it amounts to your insurance allowable and you are directed to do so by your Explanation Of Benefits. 

1. CBC (Complete Blood Count) Code 85025

This is probably the most common lab test, routinely used by General Practitioners and Specialists alike. This test gives the clinical staff an overview of the health of your blood, and can detect certain underlining conditions (anemia, neutropenia) or acute needs (infection). 

It usually covers these readings: 

• hematocrit
• hemoglobin 
• mean corpuscular volume (MCV) 
• mean corpuscular hemoglobin (MCH) 
• mean corpuscular hemoglobin concentration (MCHC); 
• red cell distribution width (RDW) 
• percentage and absolute differential counts 
• platelet count (RBC) 
• red cell count 
• white blood cell count (WBC)

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003642.htm

The average reimbursement rate is around $ 15.00 to $ 30.00. You should never pay more than 
$ 40.00 for this test if you are paying cash. 

2. CMP (Complete Metabolic Panel) Code 80053

This test is more detailed and provides your physician with a clearer picture of your organs' health. These are tested: 

• Alanine aminotransferase (ALT/SGPT); 
• albumin:globulin (A:G) ratio; 
• albumin, serum; 
• alkaline phosphatase, serum; 
• aspartate aminotransferase (AST/SGOT); 
• bilirubin, total; 
• BUN; 
• BUN:creatinine ratio; 
• calcium, serum; 
• carbon dioxide, total;
• chloride, serum; 
• creatinine, serum; 
• eGFR calculation; 
• globulin, total; 
• glucose, serum; 
• potassium, serum; 
• protein, total, serum; 
• sodium, serum

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003468.htm

The average reimbursement rate if $ 20.00 - 40.00. You should never pay more than $ 50.00 for this test if you are paying cash. 

3. PT (Prothrombin Time) Code 85610

Those patients on blood thinning medication such as Coumadin or Warfarin are well acquainted with this test. It does not require blood to be drawn, and many patients can test at home via a device that sends the results to the lab and your physician. Used to monitor your blood's speed of coagulation, its long-term and regular use is necessary to adjust your medication dosage. 

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003652.htm

The average reimbursement is $ 10.00 to 20.00. You should not pay more than $ 35.00 for this test if you are a cash patient.

4. Lipid Panel with LDL/HDl ratio (Cholesterol) Code 80061

Used as a screening tool for various conditions (hyperlipidemia, heart disease, obesity, renal or liver disease, and many others), this test is invaluable in evaluating risk factors as well as the effectiveness of a prescribed treatment. While they are more complex lipid tests, this is a most commonly used. 

To learn more about this test, visit: http://www.nlm.nih.gov/medlineplus/ency/article/003491.htm

The average reimbursement for this test is $ 25.00 to $ 40.00. You should never pay more than $ 60.00  for this test is you are a cash patient. 

5. Urinalysis (urine test) Code 81005

The most basic urine test, it uses special strips to detect bilirubin, and to screen for possible billiary, liver and other abnormalities and diseases. 

Learn more about this test at: http://www.nlm.nih.gov/medlineplus/ency/article/003579.htm

The average reimbursement is  less than $ 10.00. As a patient paying cash, you should never pay more than $ 20.00 for this test. 

NOTE: You may also be charged for a venipuncture (code 36415). Although most commercial insurance carriers deny payment as it is considered part of the service, Medicare allows reimbursement in the $ 4.00 range. You should not pay more than $ 10.00 if paying cash. 

Some of these tests do not require a MD to immediately review the results. For example, the ProTime test is routinely interpreted by nurses or medical assistants, who only consult the physician if the test results are out of the range that was determined at the time of the prescription of the medication. 

In any case, patients should not be put in a position of refusing or postponing a basic test such as those listed because of an exhorbitant pricing. Other labs can perform the same service, and many offices have the appropriate lab machines. Your PCP (Primary Care physician) may be able to perform a test prescribed by a specialist at low or no cost to you. It might be a good idea to ask when you are seeing that needle. 

©  [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

CONCIERGE MEDICINE: 
                                   IS IT FOR YOU?

Now that the ACA ("Obamacare") and its requirement that every American be covered for healthcare services by an insurance policy are established, the relevancy and future of concierge medicine could become a question mark. 

If self-insured patients become a thing of the past, and access to affordable medical care is not only available to all but guaranteed, why would Concierge Medicine still exist let alone expand? After all, transitioning from the current fee-for-service platform to a more efficient, cost-saving, safe,  fee-for-result system should provide patients with quality of care, more personalized services,  and preventive measures ... just what concierge medicine advertises. 

Reactive and therefore more costly care is still more the norm than the exception. Preventive medicine or screenings are not routinely performed, as, until 2014, they were expensive or not covered by insurers. Nutritional and lifestyle advice are often only addressed once a chronic or serious condition has been established, causing a change of habits harder to accomplish and making a full recovery difficult and distant. 

Because of high deductibles and share of cost, visits to the doctor were done mostly in case of acute illnesses or uncontrolled symptoms. While the new implementation of healthcare laws encourages (and in some cases provides for free) early intervention, prevention, screening and personalized care, we must keep in mind that doctors' schedules are already full, that there are not enough physicians available in some regions or specialties, and that time spent with the patient will remain at a minimum for economic reasons. 

Keeping visits short, seeing a maximum of patients in a day is what pays the bills and keeps a practice going. Unless other means of income are devised, and until the new quality and result-based fee structure is firmly in place, quantity will remain essential for the financial viability of medical practices. 

So, while the idea of signing up as an "exclusive patient" may seem elitist and unnecessary to many, more and more patients are looking more closely at the advantage/cost frame, and finding it to their advantage. 

1. Better care considerations

Concierge medicine is based on old-fashioned principles: personalized, quality and direct care. These have come, over the years, to be stripped to their essential, delivered in 15-minute office visits and expensive treatments.  

Squeezed in the usual consultation are: review of the medical chart, analysis of tests or labs, reason for the visit, physical exam, establishment of a diagnosis, setting a line of treatment, referral to other medical providers, report writing, signature of orders for the medical staff, prescription of meds all while explaining the condition to the patient, advising on the treatment and possible side effects and answering questions. 

No wonder so many physicians feel they are not practicing the medicine they signed up for, and so many patients feel unheard and hurried. No wonder also, so many mistakes are made and costly waste is rampant. 

Concierge patients (usually a few hundreds per physician rather than the typical thousands) are guaranteed 24/7 access to their physician, "on demand"  appointments, an in-depth following, extensive screenings and preventive measures, emotional and other forms of support, as well as the longer office visits required for serious conversations and a deeper sense of caring. Most physicians remain General Practitioners or Internists, but more specialties are being represented. 

For those with conditions requiring frequent follow-ups, or those whose schedule do not allow for inconvenient appointment times or long delays in the waiting room, paying the extra fee is worthwhile. Patients who prefer less aggressive measures, or need more guidance and support may well be interested too. If having a more meaningful, personal and mutually respectful relationship is very important, considering a concierge physician may be in order. 

If seeing a physician and getting a prescription without much involvement is your preference, Concierge Medicine may not be for you. People who rarely need medical advice or those who need a specialist's care such as oncology may not benefit as much from this arrangement. 

2. Financial considerations

Concierge medicine is not free but it can be an affordable option. Consider using your HSA or HRA account to cover its cost. 

Those in favor consider the monthly or yearly fee (usually around $ 1,500.00 to 2,500.00), in addition to any insurance co-pay, a worthwhile investment. How much are convenience, longer time one-on-one with a physician, personalized service and direct access worth? 

Depending on the usual number of office visits, calls or emails a year, this cost may break down to a smaller figure per encounter than you might think. 

However, many exclusive practices no longer hold contracts with insurances, including Medicare, and are considered "out of network". Depending on your insurance policy, this may mean large $ in liability. 

Medicare will pay you their usual allowance minus 5%, and let you settle your bill directly. PPO plans routinely apply a high (and separate) deductible and out-of-pocket amount to such claims, or pay very little. HMO plans would deny any claims are "non-authorized", leaving you with the full cost (including Medicare Advantage plans). 

Making financial arrangements at the time of signing up is recommended. 

Additionally, outside tests, labs, imaging services and referrals may be deemed "out of network" and denied or underpaid as they were ordered by a non-contracted provider. Those costs can also quickly add up. It is advisable to discuss these issues before expensive and unexpected bills arrive. 

3. Pro or Con?

While Concierge Medicine is not for all, and will likely remain a small part of the healthcare system, there is no denying its ongoing attractiveness to both clinicians and patients. 

Physicians, burnt out by stress, the expanding scope of legislative implementations and deadlines, more complex and restrictive insurance contractual requirements and growing concerns for financial survival, now practice a medicine that often loses its caring and healing aspect in the name of expediency and business. 

Delivering simpler, pro-active, quality care could bring back a sense of service, fulfillment, and a more balanced lifestyle while making a more significant and direct impact on the well-being of patients.

It should be noted that  the ACA is addressing this matter, and is imposing regulations and restrictions which may impact this growing trend. 

As for patients, it seems that the benefits would outweigh the cost, especially when a physician remains "in network", or agrees to reduced insurance payments. 

However, in the long run, this is the type of care that the ACA is working on implementing. 

Quality care, affordable measures, easy access to providers, personalized treatments, elimination of wasteful or duplicate services, lowering of errors, reduction of costs, emphasis on prevention and early intervention, integrated lifestyle-changes advice and support, are all part of this major overhaul and sweeping changes the US system is undertaking. 

Available to every patient, it might eventually render Concierge medicine obsolete.

©  [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