Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

  Should you trust (and pay) statements  

                     from your medical providers? 

In my professional career, I have observed that patients tend to fall into two opposite categories. The "trusting" types always pay whatever amount is indicated, while the "questioning" ones rarely do so until a final or collection notice is sent to them.

The common excuses of the latter types are their lack of trust in the amount billed or their waiting for explanations (they usually do not request). The former trusts the billing staff as they do their doctor. 

Here are some guidelines to help you determine when to pay and when to wait.

1. Check your insurance policy

Each January, find out what amounts you can expect to ultimately be responsible for in the coming year. What is your yearly deductible (the sum you pay first before your insurer starts issuing payment)? What is your yearly out of pocket (your percentage of the cost before your insurer pays 100%). Do you have an office co-pay (set fee)?

Contact your insurance if the terms of your policy are unclear or confusing. 

2. Verify and compare

Every amount listed on your provider's statement (doctor, facility, imaging center, lab etc) should match your insurance Explanation of Benefit (EOB). You can also go online to check whether a claim has been paid, and what is your total liability. If the statement's balance matches the EOB's: you owe this amount.

A spreadsheet at the time of matching statements and EOBs is a great visual help for you, and for your tax person during tax season. 

3. If  you have not received an EOB

Further research may be required. 

Has the claim not been sent? More medical offices no longer handle claims, leaving it to patients to mail them. If you have been handed a claim form or an itemized bill, make sure to forward it to your insurance for processing. 

A first statement may just be a notification or description of services rendered. Confirm a claim has been processed before paying such a "notice".

Does the provider have your correct information? If you received a new card, forward a copy to the office: an identifying number or claim address may have changed. Charges may have been denied for the incorrect info.

4. If your EOB does not match

Is the claim pending by your insurance for additional information? The EOB will indicate what is needed. It could be required from you (info regarding another possible primary coverage, verification of a dependent status, or return of a health questionnaire or from your medical provider (address update, medical records). In this case, forward a copy of your EOB to the billing department and demand prompt handling. 

Consider calling the billing person, to verify contractual adjustments were correctly applied, or ask for justification. After all, mistakes happen. You may also contact your insurance for explanations. 

Is the provider "out of network", meaning not within the contractual network your policy covers? If this is the case, you will need to negotiate a settlement as you are liable for whatever amount is billed to you.

However, if services were rendered to you by an out-of-network provider at an in network facility or setting, especially if you had no choice, an appeal to your insurance should be fruitful. Your insurer, once informed you are being billed for the full amount, would likely propose a financial settlement or issue additional benefits to reduce, or cancel, your balance. 

5. What are your rights? 

In case of any conflicting or unclear paperwork, you are entitled, as a patient, to receive concrete explanations from your insurance carrier. You may also file an appeal, and ask for a review or reprocessing of any charge. Detailed steps and specific forms are available in your policy booklet or online.

As your creditor, the medical office has the burden to detail and explain any liability billed to you. Although many do not, by choice or lack of understanding or training on the part of their staff, do not give up. A call placed to an office manager or doctor will usually resolve such issues.

Filing complaint to the insurance company, a grievance to your state commissioner's office or medical board is next.

In conclusion:

While ignoring a bill from your medical provider is never a good idea, paying up without checking the amount billed to you is not recommendable either.

Your insurance should be your primary guide when determining if a bill is owed, and how much. Discussing charges with the billing department is a right to exercise whenever appropriate.

©  [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

Brown/White Bagging: A disturbing trend

Over the last few years, a disturbing trend on how insurance companies manage infused or injected medications has been spreading within the healthcare industry. Aimed at saving costs (theirs, not yours!), it is affecting patients undergoing treatments as easy and inexpensive as B12 injections to pricey, complex chemotherapy infusions, and anything in between. 

The American Medical Association and various patient-centered organizations has decried this business move, and are sounding the alarm. Some of the main concerns include patients' access to treatments, safety, legal liability and costs. 

1. What is this trend?

Insurance companies are now shifting the financial burden of many infused or injected medications from the "medical" benefit portion of policies onto their "pharmacy" benefits. While access is usually still available, it is more complicated, expensive and possibly unsafe for patients to obtain office-based treatments. 

Until recently, any medication which the nurse injected or infused in an office (or outpatient) setting was purchased by that medical practice and billed, along with the clinical services, to your insurance under your "medical" benefits. Reimbursed to the clinic or office, these medications were bought from a few reputable companies, and were shipped under appropriate conditions, guaranteeing safety and provenance. 

Now, more and more insurance companies are forcing medical offices to stop this practice, and obtain drugs through specific mail-order companies they contract with ("white-bagging"). In some cases, patients must receive these drugs at home ("brown-bagging") then deliver them to their doctors. 

2. What is the big deal?

There are many unsettling aspects to this new business model. 

• Administrative hurdles: instead of requesting one authorization for one course of treatment, offices now are required to do so for the general treatment aspect (from the "medical" utilization management unit) and one for each individual drugs (from the mail-order company or "Pharmacy" authorization unit). This creates delays, chances of errors, or potential denials.
• Pay up now! Before a shipment is sent out, the mail order pharmacy will require the approval and full co-pay remittance from the patient. Whereas your doctor allows monthly payments on expensive treatments, and bills you after the facts, the pharmacy will not extend such niceties. No can pay? no delivery!
• Complicated scheduling: your next treatment may not occur on the scheduled date if the shipment your doctor is waiting for has not been made. Coordinating the ordering, receiving and administration of your prescribed drugs may test the staff's (and your) patience. 
• Provenance: a big issue with the AMA, the origin of drugs cannot be traced further back than the mail-order company. Where, when and from whom were the drugs purchased? Neither you nor your doctor will know. 
• Source of Manufacture: your doctor may choose a certain manufacturer for a certain generic drug, based on experience or preference. In this scenario, he will not have any word in the matter, and may have to use drugs manufactured abroad rather than ones made and inspected in the US. 
• Shortages: a serious and growing issue, certain drugs of limited or focused use are in short supply. Offices are on alert for such instances, and either "stockpile" whenever possible or purchase more expensive alternatives to avoid delaying or canceling treatments. With mail order companies, any backorder will take as long as it takes to get filled, with obvious disregard to patients' needs
• Labeling: even if you are not required to play this game by your insurance, nothing can assure you that your personal treatment is done being given using drugs which were meant for another patient, but, for scheduling purposes or due to improper labeling, are now given to you. Many offices don't have the manpower or workflow to track every delivery. Similar drugs (office-bought and insurance-delivered) are stored together, and given "as needed" not "as assigned". 
• Safety: any shipment delivered to your home wile you are not there can be stolen, delaying your next treatment. What about a box full of sensitive drugs sitting on your front porch, in a warm day? Any ice will have melted, potentially compromising the contents...and your health. And how about storing it? Whereas your doctor's drug storage unit is at the appropriate temperature, and sounds an alarm if it is not, your fridge might be too cold or not enough, questioning drug stability and effectiveness.
• Handling: transporting any shipment from your home to the office also requires appropriate and safe conditions. Did you leave the package in your car while running errands? Is it packed in dry ice or just in the original package? 
• Liability: your Doctor is legally responsible for any procedure rendered in  the office, and for any product injected into you. In such cases, where does his responsibility start or end? Having lost control of the process, will he be covered by his malpractice insurance in case of a problem? Who can now determine whose fault is responsible for a negative outcome?
• Costs: even if you already have met your deductible and/or out of pocket liability for the year, you may have to pay additional fees for those "pharmacy" products. Your share of cost might be higher too, as many of these drugs are brand and therefore reimbursed at the lowest level. 

3. What can you do? 

Your options might be limited. Based on your policy, you may be required to use a mail-order pharmacy to cover certain treatments or drugs. Appeals can be filed, and in case of a negative response, you may request a review by an outside medical doctor. 

If you are being asked to receive and handle very sensitive or unstable drugs (such as chemotherapy agents) without training or proper knowledge, this could negatively affect your health and safety. Ask if a shipment can be sent directly to the office, that is better than a home delivery. Threatening to hold your insurance liable may help. 

The medical office may also request a waiver due to specific circumstances. Drug manufacturers can often help in this process, as legal liability might ultimately be traced back to them. So might your HR department.

In some cases, paying cash might be the way to go. A B12 injection, for example, costs less than $ 1.00. Paying the office for it will save time and efforts, and will be gladly accepted by the grateful staff. 

In conclusion:

Be aware when your doctor prescribes a infusion or injection. Call your insurance to find out what are the requirements when using specific drugs, and whether the office can use their own stock. 

Talk to the staff about any authorization requirement, or if they will even accept any brown or white bagging. Many office do not, citing legal liability and malpractice insurance guidelines. An alternative administration arrangement, at home or at an infusion center for example, will need to be made.

* 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

Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

Five Tips: when someone you know 
has cancer

Despite medical victories, millions of survivors and a sharp decline in mortality rates, the C word still causes one of the most visceral fears in the human community. We all breathe easier after a negative scan or exam.

We all know someone batting or who had cancer. When we are close to the person, how best to help is not in question. But what about a friend, co-worker or distant relative we don't know so well?

When the news is shared, how to react, how engaged to become, or what to do? The generic statement: "call me if you need help" makes us feel better, but how likely is the person to do so?

Without much information, we could assume difficult treatments are in the near future. So might emotional turmoil, financial worries and a reassessment of priorities.

I propose five tips to guide you when you care enough about a cancer patient, but don't know enough.

1. Offer concrete, specific help

Based on your skills, aptitudes, experience or habits, you might propose your services in one or a few specific areas. Detail what your assistance would consist of, and how extensive it would be. A good example would be to say: " I will do your grocery shopping every week on Saturday mornings for the next month but could not make runs during the week".

Other examples of useful services are medical billing support (go through the bills, verify what is owed), running errands, bringing complete meals, paying a cleaning lady, taking over carpool duties, or having your teenage daughter babysit or help with homework.

2. Be silent

Because there are many aspects of your friend's journey you don't know about, avoid giving well meaning but possibly unhelpful (or even offensive) advice unless prompted.

Your uncle Joe's cancer experience or the article on alternative treatments you just read, are only relevant if your friend asks for them. Do assist with research if needed, but refrain from expressing your opposition or disagreement at a decision. This is not your life or health, and if you were to do things differently in the same situation does not make you right.

3. Offer true friendship

Friendship has many meanings, but one I find very appropriate is that of non-judgmental listener and supporter. Allow a dialogue to go where it is needed, not where your agenda leads it to. Be aware of the mood and of the best response, as they will change. Some times will call for humor and laughter, others for reflection or inspirational words.

Be there, only if as a strong shoulder for your friend to cry on. Or be the leader she requires today to take her mind off things.

4. Offer neutral gifts

If your involvement revolves turns general gift giving rather than time, remember that changes in sensory sensibility are common. Pass on flowers with a strong fragrance, on scented candles or perfumed body or bath items as they will likely be discarded or go unused. Going scent-free is the best way, or give a store credit instead.

Selected self-help or cancer-related books may not be welcome, but a gift certificate to a major or online bookstore probably will.

Consider giving a gift of "escape": movie or concert tickets, a few hours at a botanical garden or beach, a visit to a museum, a drive to a favorite place or store.

5. Be kind and understanding

Even the most responsible, emotionally stable person experiences changes during such difficult times. Remember that emotional mood swings, memory lapses, mental "flakiness" and changes in commitment or plans might occur. Do not take outburst or late-minute cancellations personally. When body and mind undergo such an out of control roller coaster, there might not be any better alternative than just wait for it to pass.

In conclusion

Forgiveness and understanding, along with patience and kindness, are valuable gifts.

Often, small gestures are as appreciated as large-scale ones, coming from the heart and not from a sense of obligation. Extending help involving a personal connection or time donation because one wants to, not because one has to, conveys respect and truthfulness.

Keeping this in mind may direct you to a less personal (but appreciated nonetheless) gesture such as a gift certificate. While not everyone is able or willing to offer direct support, at least resentment or misunderstanding will not be added to an already difficult situation.  

©  [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