Patient Advocacy: Healthcare on your Side

Patient Advocacy: Healthcare on your side

   by Martine G. Brousse, 

Healthcare Specialist, Patient Advocate, Certified Mediator

ADVIMEDPRO

The 411 on Patient Refunds*

As a billing manager for many years, and a patient advocate, the subject of overpaid accounts has come up all too often. If patients were truly aware of how much sits, not refunded to them, in the books of medical providers, they might gather pitchforks and descend onto offices to reclaim their money. 

This is a ugly yet common practice in the industry. While it has worked well for many providers, it is time to let the public in on the deal, and come clean with patients who are, after all, customers. Does the clerk at the supermarket, or at any other business, require your formal request to hand over your change? Does your credit card company not send you a statement indicating you have a credit balance? 

1. Why is it happening? 

Unlike any other business, insurance reimbursement will take a couple of weeks at best, months at worst. Paid charges may be appealed or disputed, payments recouped or claims denied or pended. Account balances remain fluid until fully settled, yet patients are usually billed after the first insurance notice. Even if the error or the fault for a denial lies with the medical provider, the patient will receive a statement of insurance non-payment. Threats of collection action will prompt your writing a check. 

The other major side to this sad story is "office policy". Though rarely advertised (and for cause!), many practices have a "refund on demand" rule. Don't ask? Don't get!

The administrative burden of processing refunds as soon as a positive balance is noted is often cited as the main excuse. While it is a valid reason, a good compromise would be "refund on demand for sums under $ 50.00 or $ 100.00", and automatic reimbursements for larger overpayments. 

2. Common reasons for credit balances:

• Premature payment: your claim had not reached final processing before you received a doctor's bill.
• Pre-Payments: the office demands your payment up front, to cover a deductible, or if out of network. 
• Double coverage: If you have two policies, especially primary, overpayments are more likely.
• Double payments: an assistance program may have made payment on a charge, or you may have paid the same bill twice. 
• Billing error: an erroneous adjustment may have been posted or an inaccuracy in the billing process may have occured. If you have a common name, expect such errors. 

3. What can you do?

Keeping track of your bills, insurance explanations of benefits ("EOB") and payments is crucial. Any statement not matching an EOB should be questioned, and a call placed for confirmation or clarification. 

Request a copy of your ledger, or itemized bill, at the end of each year, or after your last visit to a medical facility. Useful for tax purposes as well, it will allow you to scan for errors and check the balance. 

Get receipts for any payments, especially if paying cash. At the time of payment, indicate on it whether this is an advance on a future liability, partial payment or payment in full. 

Decline to make a payment in advance, even if you have not met your deductible or yearly liability. A contractual adjustment will reduce your bill, but it often is difficult to know how much before a claim is processed. If the facility is in network, they should not ask for any up front payment except for the set office co-pay.

At any suspicion or knowledge of an overpayment, contact the billing department and ask for a refund. While it is certainly unprofessional and deeply disrespectful of patients, expect to wait a while before a check is cut. Many offices are on top of billing patients but are reluctant, if not outright combative about  refunding them. 

Do not hesitate to contact the office manager or physician if you are given the run-around or further delay is unacceptable. A complaint to your insurer might be helpful too. 

In conclusion:

A French saying proclaims:" Good accounting makes for great friends". This goes for your medical providers and health practitioners. If you cannot trust the staff or the practices they follow, can you really trust the practitioner? 

If transparency and patient satisfaction are two important cornerstones of the ACA ("Obamacare") reforms, then surely this practice must be ended. 

* 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

  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