Patient advocacy: Healthcare on your side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

Your Healthcare Rights:  Be Informed

The Patient’s Bill of Rights took effect on September 23, 2010. Created as a means to end health insurance abusive and discriminatory practices,  to introduce industry-wide guidelines, and to unify a complex and segmented system, it is implemented, protected, supervised and guaranteed by several Federal and State agencies.

Here is a list: 

1. Protection from discrimination and unfair practices: 

HIPAA (Health Insurance Portability and Accountability Act), ACA ("Obamacare"), and your Civil Rights protect you from discrimination or unfair treatment based on age, sex, race. color, place of origin, disability or religion.  Patients have a right to considerate, respectful and non discriminatory care from their healthcare providers and health plan representatives.

2. Privacy and Confidentiality: 

They are guaranteed under several laws. The Privacy Rule establishes who is legally authorized to review your records. HIPAA  places stiff fines on offenses, and medical providers are obligated to provide their patients with a written notice detailing its implementation in their practice. The Patient Safety Act and Rule established a system for confidential and secure access to patientsʻ medical records in order to ensure quality control and safety. Confidentiality is guaranteed during any discussion with a medical provider about your health information. Your rights also include setting limits on who may see your information, being informed of who was given your information and asking your providers to contact you only in a specific way. 

3. Medical records: 

Patients have the right to review, request a copy of your medical records, or have them forwarded to another medical provider. You can request your physician to amend, update or correct any incomplete, erroneous or inaccurate record. 

4. Choice of Providers and Plans:  

Access to and choice of appropriate high-quality healthcare providers is an essential right. It is your right to receive the care you need when you need it, including seeing a specialist. The ACA also allows patients to choose a PCP (Primary Care Physician, OB/GYN and pediatrician within their healthplan network without prior approval or authorization from another physician. If you are unhappy with your present choice, you may change to another provider. If your doctor leaves your network, you have the right to continuity of care, even out of network, with no penalty. Certain mental health conditions are guaranteed coverage.

5. Access to Emergency Services: 

In cases of "life or limb at risk", or in case of injury, severe symptoms or serious illness, you have the right to seek and receive emergency services wherever and whenever, without the need of a prior authorization, outside of your insurance network and without financial penalty to you. 

6. Participation in Treatment Decisions: 

Your healthcare provider must present options, and include you, and any individual you designate, in any decision regarding your treatment. You may accept or refuse any treatment, surgery or medication. You may seek a second opinion with another professional. 

You have the right to have an Advance Directive on file. If the patient cannot make his/her own decisions, documents such as Power-of-Attorney, Advanced Directive and Do Not Resuscitate forms should definitely be given to every healthcare provider the patient is receiving care from. Forms and information can be found on State government websites. 

InCalifornia:  

http://www.sos.ca.gov/ahcdr/forms.htm  

http://www.emsa.ca.gov/pubs/pdf/DNRForm.pdf

http://www.courts.ca.gov/forms.htm

7. Dependants:

They can stay under a parentʻs insurance coverage until age 26. 

In addition, children under the age of 19 may no longer be denied benefits or coverage based on a "pre-existing condition" (health issue that was present before the child applied for health insurance). 

8. Information Disclosure: 

You have the right to receive accurate information from your healthcare providers and insurance representatives. It must be easily understood, in the language or manner that you best understand. Assistance should be available if you need further explanations, to help you make the best informed decision. You may also request a written description or explanation of your condition.

9. Healthplan regulations:

a. "Lifetime" limits on a policy are no longer allowed

b. The retroactive cancellation of a policy is no longer allowed in case of a "honest" mistake on the part of the applicant

c. Preventative services are to be provided to subscribers free of charge (except if plan is grandfathered)

10. Complaints and Appeals

The patient has the right to a fair, prompt and impartial review of any complaint they may have against a health provider, facility or healthcare representative. Contact the specific office, supervisor or entity for details on filing a complaint. 

You have the right to file an appeal and ask for an Independent Review in case of a denial by your insurance plan of a service, treatment or payment. Steps on filing an appeal are detailed in your policy or can be found on their website. 

More serious offends should be reported to the appropriate governmental agencies. in CA: http://www.cdph.ca.gov/services/Pages/ComplaintsCaliforniaHealthCare.aspx

These are the major points you should be aware of to be an informed patient. It may also explain the significant number of forms your doctor will ask you to sign. Always make sure you read any document you sign, request a copy, and understand that compliance with the signature requirements are mandatory for your provider, and in your best interest. 

More CA links:

http://www.takechargeca.ca.gov/campaigns/health_main.shtml

http://www.opa.ca.gov/Pages/KnowYourRights.aspx

http://www.calpatientguide.org/

http://www.disabilityrightsca.org/about/opr.htm

©  [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 Good Reasons to Hire 
                                       a Patient Advocate 

A growing field in the healthcare industry is that of Patient Advocacy. Though still in its toddlerhood, this profession is starting to spread its message of expertise, service and problem solving to an expanding base of patients. Disclaimer: I am an advocate, providing advocacy, account management, mediation and consulting services. 

You may have noticed that insurance companies, philanthropic patient support associations, hospitals as well as governmental agencies and healthcare organizations are now offering the services of advocates to their patients. 

   
 By all means, use these services when offered to you, usually free. These intermediaries will assist you with financial assistance applications, with navigating their hospital or place of medical care, with providing you with information and support when faced with a serious diagnosis or upcoming treatment, with grievance advise against your insurer. 

These services are however, limited to the advocate's employer. Their scope of service, while beneficial and most helpful, remains confined to a restricted area. 

Here are 5 good reasons to consider for hiring your own patient advocate. 

1. This system is too confusing

  We all find the healthcare system confusing and too complex.

 To learn the system now will require learning some medicine, medical coding, legal requirements, specific insurance guidelines, the Alphabet soup of terms, the art of mediation, your rights, your state and carrier grievance processes, patient assistance and support opportunities with a dash of common sense, a bag of tenacity and ongoing deliveries of patience. 

     A good patient advocate can help you now either fight the system or take advantage of it, depending on your view of the water in the glass. Need someone to explain your insurance benefits? Cannot understand where to turn, who to ask or what your next step is? Need basic information, more education on your rights,  specific material? Need a helping and guiding hand that is on your side? Consider hiring a patient advocate.

2. You need to concentrate on my health and recovery

   When life throws you or a loved one a challenge, your time, attention, energy and resources will be focused on going through the process of reaching a positive outcome. From the serious aspects of a upcoming treatment, surgery, or event to the day-to-day affair of living, you are stretched thin. The financial, emotional, physical, practical and spiritual toll is often overwhelming and life-altering. 

   Hiring an advocate can put assets on your side from the beginning. Working with your medical providers, he/she can verify your coverage, benefits and authorization status, and whether a treatment is standard and established. The advocate can also negotiate reduced fees or a payment plan, help find assistance and make sure you are getting the services you need and that are covered. Some advocates will take you to appointments, advise you on specialized care and facilities, or research treatments and options. 

3. I am not sure what and who to pay

    The easy answer is to match your EOBs to your statements. But this won't help you if they don't, or if a mistake was made. where did it originate? how to correct it? Your advocate will audit your bills as they come in, analyze statements and EOBs, and advise you on paying a bill or file an appeal.

4. My insurance is not paying my claims

   What is the reason? There should be a good explanation as to why an insurer would reject a claim. If you do not have the time, knowledge or inclination to hear one person throw the blame at another with no resolution in sight and growing frustration, let your patient advocate handle the job. Errors will be rectified, records sent, appeals filed and sanity restored. 

5. I cannot pay these bills

   Let me first remind everyone that checking coverage and benefits, getting authorizations and assessing one's likely liability should be done before a treatment or procedure. Preparation is key. But too often we are dealt circumstances out of our control which, added to a lack of understanding of policies and guidelines and an inflexible and uncaring system, lead us to hopeless situations. A patient advocate's expertise and skills may well find overcharged, erroneous or non billable charges. He/she may find ways to appeal for additional benefits or help you get approved for assistance or reduced fees. At least can he/she negotiate on your behalf, arrange for a payment plan or a reduction of your liability. 

A word of caution: 

At this time, it is necessary to point out that not all advocates are created equal. Services, skills and credentials vary from the well-seasoned and experienced to the newly minted and self proclaimed. 

There is no federal or State accreditation process. There are no "official" credentials, certifications or degrees.   There currently are no regulations.

Courses, training opportunities and "certifications" are now offered by a few colleges, associations and  trade schools. While some training and education are better than none, the complexity of today's healthcare machine, the scope of patients' needs and the vast range of required skills and knowledge make it a challenge for novices. Experience in this field, especially specialized, is a must. Ask for credentials based on verifiable resume contents and letters of recommendation, or ask for a referral from knowledgeable and trustworthy sources.

			©  [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