The Commonwealth Fund’s 2010 study found that almost 50% of US adults were either underinsured or uninsured. This is a 7% increase from 2007 for the underinsured population. It used to be that having coverage was simply enough. Today, however, having the right type of coverage and amount are key factors in choosing a plan. What happens when you don’t have coverage for a specific procedure? One forward thinking practice in the Chicagoland area takes the time to explain your options and provides the cash discount rate – up front. Before you even ask. That’s mightily refreshing given the lack of communication in many healthcare organizations. And, it’s a win win for both parties. The practice receives a bill paid in full without expending additional dollars in the collections process and the patient is educated a little bit more on how the billing and insurance process works. Let’s hope that more practices implement this customer service level in the near future.
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According to the AHA (American Hospital Association), 87% of hospitals expect bad medical debt to continue to grow. And it’s no wonder with situations like a very common one experienced by patients across the nation. You are seen by your healthcare provider for a service or procedure that should be covered under your insurance plan per plan benefits. However, when the Explanation of Benefits is received from the insurance carrier, charges have been denied for coverage. What happened?
Reimbursement is based on a few key areas including plan benefits and coverage period, medical necessity, correct patient information, diagnosis code, and procedure/service code (CPT), etc. An incorrect key stroke can cause your claim to be rejected. Or, an erroneous code can result in zero dollars paid. What can you do?
Begin by appealing the rejection to your doctor and the insurance company. As described above, it may have been a simple clerical error that caused charges to be dismissed. In other situations, you want to confirm that the CPT and diagnosis codes are cross referenced. What may have happened is that the CPT code did not support the diagnosis or the reverse. Codes are chosen based on the physician’s notes, documentation, and national coding guidelines. Sometimes, the CPT code may not be specific enough or it may have incorrectly described the level of care. Most insurance companies have their own unique process and timeline for appeal submissions.
If you’ve exhausted your appeal efforts and your claim remains unpaid, you may want to file a complaint with your state’s health insurance commissioner and or enlist a medical bill advocate to navigate the process for you. Whichever route you choose, be persistent, professional, and follow through.
Recent news on the costs of health care, in the U.S. and around the world, is focusing on what experts call “double digit levels” of annual increases. This is bad news for us, and troubling for the country as a whole. What it translates to is annual increases over 10%, where health care costs could conceivably double in a decade. Since this kind of price spike has been going on for a while already, many American families already consider major medical care to be priced above their ability to afford it.
Who Pays the Bill?
Part of the particular desperation that has surrounded the American medical industry in the past few years has to do with who usually pays the bill.
In the past, employer group plans provided coverage for the majority of Americans. A few decades ago, this model was built on stable, long-term contracts between workers and companies, where those who stayed loyal to a business could expect to keep a job for life. Also, employers paid a major part of all premium costs.
In the present, however, we’ve felt the rise of health care prices. First, employers started to lower the premium amounts they were willing to pay. As jobs went overseas, employers laid off workers. Then, as the economy grew weaker, more lost jobs. An unemployment rate of over 10% means much more than lost wages: it means that many thousands of American families are suddenly left without coverage.
Meanwhile, the group plans that are left often do not pay the majority of premiums and often include high deductibles, which are also extremely expensive for the average family. In fact, some employers hardly pay anything toward premiums at all, while others provide “mini-medical” plans or other virtually useless coverage, or move full-time positions to part-time and thus avoid offering plans.
What Can You Do? Read the rest of this entry →
The Affordable Care Act is cracking down on some of the most aggressive ways that hospitals categorized as charitable or nonprofit facilities for tax exemption can seek to shake money out of patients. Reports of the new laws also often offer some of the most common advice to protect you and your family from unfair or excessive medical debt.
Always Talk to Your Providers
One of the biggest pieces of advice is to always ask up front about available charity and financial assistance programs. It’s a great idea to ask about health care costs, and detail payment options, before you sign up for any given course of treatment. But beyond this, dialogue with the provider is also a key to keeping medical bills from showing up on credit reports. It’s true that even with the best back channel dialogue, some hospital administrators will still send bills to collections, but having an open communication with the provider will prevent this in the majority of cases where reasonable financial offices simply ask that patients keep in touch about their debt and pay to the best of their ability.
Make Sure You Are Covered
Essentially, the Affordable Care Act can be seen as a double-edged sword – depending on what side of the table you are on. Read the rest of this entry →
News from the medical industry shows that the American Medical Association or AMA is working with private health insurers to lower the rates of medical billing errors within the American healthcare system. For a while now, the AMA has been talking about a collaborative effort to make medical billing more efficient, and it seems that this initiative is starting to pay off, according to this year’s National Health Insurers Report Card, an annual report released by the AMA to document national trends.
Overall Error Rates for Medical Claims
The new report shows inaccuracies for private health insurer payments dropping from nearly 20% in 2011 to just under 10% in 2012. The AMA claims that this 50% reduction has saved the industry over $8 billion, and that there’s a lot more potential for improvement. In a press release this month, AMA Board Chairman Robert M. Wah is quoted as saying that first-time accuracy in medical claim payments “saves precious healthcare dollars and frees physicians from needless administrative tasks” – that’s the idea behind these sorts of efforts to increase accuracy. These improvements help physician offices manage revenue cycles, while they also help you to understand your financial responsibility and contribute to greater transparency in the healthcare market.
The National Health Insurer Report Card also provide some other assessments of this year’s trends within the medical industry. While the report shows improved response times for medical claim payments, and indicates greater transparency by health insurance companies, it also shows that medical claim denials are now on the rise. The AMA sites a prior decline between 2008 and 2011 that was reversed this year with an increase of nearly 70%. This increase, according to the AMA report, was across the board, as all major insurers declined many more claims than they had the previous year. Denials will be an issue that third party medical advocates and others will continue to evaluate in order to make sure that you are getting a fair shake when it comes to your healthcare costs.
We face a lot of challenges in identifying and controlling our health care costs. Keep informed on what’s happening in the health care industry as it affects you.
June 18, 2012 in Health Insurance
I get a lot of questions about health insurance. Not that I’m any expert. It’s just that my friends and colleagues are desperate for help with their insurance options. Last week a colleague described a dilemma that really made me stop and think.
This colleague is covered by her husband’s health insurance. His employer was switching to plans with limited networks. A lot of employers are doing this to save money. Limited network plans are cheaper because they cut out some “high cost” hospitals or because they guarantee a few hospitals more business in exchange for a lower rate.
So my colleague, who is pretty savvy about this stuff, narrowed her options and weighed the pros and cons of two plans. It came down to this: one plan included all the hospitals she thought she might need except Dana Farber. The other included all the hospitals she might use except Mass Eye and Ear, which also specializes in throat and vocal problems.
Since my colleague, like me, needs her voice to work, the idea of not being able to go to Mass Eye and Ear, or paying a lot more to go there, was scary. But in the end, the idea of a cancer diagnosis and not being able to go to Dana Farber was more disturbing. She chose the network that included Dana Farber.
Many of my friends and colleagues say they won’t try a limited network plan because they want to be able to go wherever they want for care. Sometimes when they I hear this I say, come on, there are lots of good docs at all the hospitals in Boston. But I think this colleague has a point.
Being Your Own Advocate
In case you haven’t been paying attention to changes in America’s health care system, there’s a general idea that needs to get out to as many people as possible: the gist of it is that, in most cases, today’s consumer needs to be much more engaged in their care and ready to act as their own advocate in order to get the health care and treatment that they need, no matter what their health is like.
You may have heard something like this already: from all corners of the health related media, patients are hearing that they need to “be their own advocates” and get vigilant about not just what they pay for health care, but what kinds of health care they receive and whether or not it fits their specific needs.
But what does it mean to be your own advocate? Looking beyond the cliché, you can obtain good, concrete ideas of how to go about interacting with a family doctor in ways that will help you get better access to the health care you need.
Patient Engagement: What it Involves
The good news on this front is that you may already do a lot of what you need to do to advocate for yourself in a healthcare environment. Read the rest of this entry →
My family is luckily very healthy and we like our primary care doctors. I have not had any reason to see a doctor who is not on the list approved by my health plan. But now my daughter needs to see a counselor who is connected to a hospital where she make get treatment. The counselor is not in my insurers’ network, so I’m filling out the “Out of Network Request” form – any tips?
A recent story from Dayton, Ohio, caught our attention, where according to news reports, some patients remain responsible for emergency room charges when a hospital happens to ‘subcontract’ doctors who may not accept health insurance at all. This adds another layer to the oftentimes confusing in network vs. out of network debate. In many cases, especially in an emergency situation, patients who visit a local hospital or facility may experience unexpected costs after they are cared for by a doctor who may not be ‘in their network’, even if the facility itself is listed as an in network provider. There’s been a lot of discussion whether this, which may seem deceptive, especially to those without specialized knowledge in the medical billing and health insurance field, is fair. In fact, state officials, like in New York, are looking to pass legislation which mandates better transparency for out of network charges. Taking the time to understand your health insurance plan and what defines a covered provider or facility can save you hundreds if not thousands of dollars in non-covered charges.
It seems providers tend to respond to these scenarios in two ways: Some indicate they will change their policies to include more transparency while others claim to be bound by federal laws that do not allow them to reveal to patients whether an on-call doctor or a physician on shift will accept their insurance or not.
We find the second argument to be completely unacceptable at face value. In fact, it’s reasonable that consumer advocates would expect state regulators to crack down on these well documented examples of seemingly unfair provisions in delivering medical services. It’s not outside the realm of possibility that a patient facing bankruptcy after a bill like this would have a basis for legal appeal, especially as new legislation is introduced and passed. It’s vitally important that you discuss your options and ask questions before treatment to minimize impact to your financial future. How prepared are you in the event of an emergency room visit?
Balance billing occurs when a healthcare provider bills a patient for some or the entire amount that should have been declared an insurance discount (contractual allowance). The fact that Prime Healthcare Services in California recently settled a suit for $1.2 million and discontinued the practice suggests that this is a problem. In fact, several states have statutes that prohibit balance billing.
How do you tell if you’ve been balanced billed? First, you have to determine if your treatment was performed by an in or out-of-network healthcare professional. Then, you have to check your EOB (Explanation of Benefits).
Check an erroneous charge simply by seeing if the bill for the service exceeds the amount on the EOB. If it does, let your insurance company know and let them handle it.
There are two scenarios:
- If you have an OON benefit, the OON deductible and co-insurance will apply first. The insurance company pays the balance above that like always. However, if the provider billed you for more than the deductible and co-insurance you may be the victim of a scam. Check the EOB. Did insurance pay the provider? If so, report it. It’s a scam and it is wrong.
- If you do not have an OON benefit and accidentally got treated by the provider, tell them you want to be treated like an uninsured patient. A standard discount will be applied.
When in doubt, check with a medical bill advocate.
Have you received a medical or hospital bill with no clear due date? This can be because of how bills are laid out or because of design issues. Typically, a bill or patient statement will show medical debt as 30, 60, or 90 days past due, providing the kind of urgency that can make you drop a check in the mail. Bills may also be labeled “second notice” or “third notice” to show that the biller has already tried to contact you. But, all of that doesn’t always tell you what you need to know: how long you have to pay before the bill goes to collections. There are several reasons you may choose not to pay your medical debt right away including having a lot of bills or long-term debts to juggle. Prioritizing which ones to pay can take precedent to stay afloat. And, some billing statements require real, actionable steps while medical bills seem to be written in some strange, esoteric language.
Medical Debt Collection: Common Practices
Every medical provider has their own system for handling past due bills. Some are quicker than others to send a past due bill to collections. Many have different billing systems that represent debt in different ways. Some may be explicit about a due date, others will not. In some cases, when patients call, the medical office admits that they don’t even know the exact date when a bill will go to collections. That’s what motivates many experienced consumer advocates and others to recommend “playing it safe” and promptly paying all past due medical bills aged longer than 30 days, which is a common grace period for payments.
Some patients, though, will make active attempts to talk to providers. Those who pick up the phone can often get on payment plans that will make due dates and everything else much clearer, while allowing for deferred payment according to the patient’s finances. Some can even qualify for charity. In many cases, it’s this direct communication which can yield benefits for both parties: you know where you stand and your provider receives data on how and when you are likely to pay a particular bill. It’s a win-win, and that’s why when it comes to vague patient statements, the direct approach is often best. How do you promote open communication with your provider on past due medical bills?
Nine physician specialty societies are each reporting a top five list of commonly used procedures that are often unnecessary. These societies represent 375,000 physicians across the country.
Some of the procedures cited include:
- Brain scan after fainting (without other relevant symptoms)
- Antibiotics for sinusitis (while typically resolving itself in two weeks, 80% of patients are prescribed antibiotics. CT scans are also usually unnecessary.)
- Admission and pre-operative chest X-rays (routine X-rays are not needed.)
- Colonoscopies (not recommended but once a decade.)
- Cardiac stress tests (they do not need to be part of a checkup for a healthy adult.)
- Lower back pain (unless another ailment is suspected, X-rays are not needed in the first six weeks.)
Unwarranted testing can lead to stress, over treatment, higher medical bills, and even unneeded invasive procedures.
In fact, the natural tendency to screen for heart disease prior to having any symptoms, like getting a stress test as a 50th birthday present, hasn’t “panned out,” according to a preventive cardiologist at Northwestern Memorial Hospital.
Study members suggested that patients and doctors have to thoroughly discuss any tests/procedures even if they are suggested by patients because they are not always needed.
As current government initiatives wrestle with the issue of millions of uninsured Americans facing potential medical bankruptcy, new studies are revealing that it’s not just the uninsured who are at risk. The issue of underinsured American individuals and families is becoming a major part of today’s healthcare conversation and alerting many more Americans to the dangers that they face, even if they have access to affordable health insurance policies.
Current statistics show a startling trend, where being underinsured is becoming a common way to fall into extreme medical debt and eventual bankruptcy or bad credit situations. Research by the Commonwealth Fund that appeared in recent industry journals shows that America’s underinsured community has doubled in the past four years to over 25 million people. While the highest number of underinsured Americans are in the income range below the poverty level, research shows that middle and upper income families are being affected in larger numbers each year. Research also shows that some individuals with what others would consider healthy annual incomes are still very likely to become underinsured in the immediate future.
In general, being underinsured has to do with the cost of one’s medical bills against that person’s annual income. Read the rest of this entry →
Just watched ”U.S. Health Care: The Good News” (Episode: The Good News in American Medicine, with T.R. Reid) on PBS. I was flipping through the channels and it caught my attention. I watched ”Sicko” when it came out in movie theaters and before I finished my Coke I was convinced that we needed a major overhaul in medical care in the U.S. It just doesn’t seem humane that people could die because of insurance loopholes or die because they don’t have enough money to pay for their healthcare.
Obviously nothing in life is free. Everything requires energy- which always equates to money in some way or another. Since energy (and money) are finite resources, the only solution seems to be in overhauling the entire system to make it cheaper to get and stay healthy. And when I saw the part of the show’s title that said ”The Good News in American Medicine”, I had to watch. Good news. What is that?
I was very pleased to see there is good news out there. Many communities are doing a lot to overhaul the system and provide care to everyone, regardless of coverage, while bringing the costs way down. It was refreshing to see that people are trying and finding ways to succeed in this area.
I’d recommend watching this show and passing the link along to friends. The more people know about this, the more we have a chance at getting medical care costs down to manageable levels (and be a more humane society). The full video is here:
I’m in Texas visiting my darling sister Elizabeth who is going on 20 years with ALS. GO ELIZABETH! My mom hands me a stack of paper. It’s the latest round of reimbursement roulette. Someone is refusing to pay for something that my sister uses a lot of every day and I need to figure out why.
I grimace but then remember, hey, here’s my chance to check out Medicare’s BLUE BUTTON. My Savvy colleague Adrian Gropper talks about how great this thing is. Let’s find out. (Turns out Adrian wants an enhanced version of the Blue Button more on that below).
The Blue Button, takes any member into their own private Medicare world. You see claims for office visits, hospital stays and supplies. I spent an hour trying to figure out why Medicare wouldn’t pay for the syringes that push food into my sister’s feeding tube and why they won’t send as many absorbent pads as her doctor says she needs.
I didn’t get anywhere when I started the search last Sunday. The claims database is down on weekends. But I was impressed by how much I can find online. My insurer, Blue Cross, has similar feature but it isn’t quite as user friendly. In the end, my mom has to appeal the denial of the syringes and we’re appealing for more pads through Medicaid.
I imagine that some of you wonder why Medicare and Medicaid should pay for these items. It’s a fair question. Read the rest of this entry →
As Americans continue to absorb the healthcare reform and projected modifications, the federal government is updating the way that medical services are coded and billed to consumers. The first mandate is HIPAA 5010, which is an update to the existing HIPAA format and the healthcare information processing systems. 5010 compliance is currently set for July 1, 2012. This will be followed by implementation of an updated coding system, ICD-10, which is to be effective October 1, 2013.
The existing coding system has approximately 13,600 codes while the updated system will have approximately 69,000 codes. The detailed coding system will allow for better analysis and treatment outcomes while providing payers with an initial claim submission that is much easier to understand. However, you may find interpreting your medical bill to be even more confusing as you may see more line item charges.
An example of this was recently reported in a Pennsylvania’s Fox News story. The patient was charged for an office visit and on top of this, she received a separate charge for a “consultation” when the doctor advised her to quit smoking. Read the rest of this entry →
Looking at Medicare- vs. “usual and customary”-based reimbursement
By Robin Gelburd
Many Americans with private health insurance have plans that reimburse for out-of-network care. But consumers often don’t realize the wide variation in reimbursement rates among insurers and the implications for their wallets.
At FAIR Health, the independent not-for-profit corporation dedicated to bringing transparency to healthcare costs and out-of-network reimbursement, we have noticed that differences in formulas can make a big difference in reimbursements. A number of private health plans are now basing out-of-network reimbursement rates on a percentage of Medicare fees – as opposed to the usual, customary and reasonable (UCR) standards that reflect actual provider charges. Read the rest of this entry →
Locked out of medical care, that is. Who? Individuals with pre-existing conditions. Now, 50,000 of them have healthcare coverage via the Pre-Existing Condition Insurance Plan (PCIP) in their state. This is a temporary high-risk health insurance program that makes healthcare not only available but much more affordable.
For example, a patient named Deborah fell victim to a back injury. It left her unemployed and unable to afford health insurance premiums. However, when she discovered the Michigan PCIP plan, she was able to enroll in it, receive the back surgery she needed and get on the road to recovery.
PCIP makes a difference. It has allowed many Americans to get connected to health insurance and receive the medical care they sorely need. That’s because PCIP enrollees can receive that care immediately.
The Affordable Health Care Act has also helped students up to age 26 receive coverage and assisted seniors by allowing access to more affordable prescription drugs.
You can see how your state administers PCIP by clicking here.
By Robin Gelburd
Recent survey reports have shown that current economic uncertainty and continued unemployment are compelling millions of Americans to delay or forgo medical and dental treatments.
Consumers concerned about healthcare expenses should be able to find out the cost of procedures or treatments in advance of seeing a doctor – regardless of whether or not they are insured. And, if consumers are insured, they should be able to determine if their doctors are in their insurance plans’ networks.
This is where the not-for-profit organization, FAIR Health, comes in. FAIR Health was created to bring transparency to healthcare costs and out-of-network reimbursement. FAIR Health created a free tool that gives consumers access to estimated costs of medical and dental treatments based on insurance status, level of insurance, and geographic area.
How does FAIR Health do this? FAIR Health maintains a database with records for more than 13 billion de-identified, private healthcare procedures from the last ten years. The database reflects the healthcare claims experience of more than 125 million people covered be private health insurance, making it the largest such data resource in the nation that is owned and overseen by an independent, third-party organization. Read the rest of this entry →
The web has been full of stories recently about Mitt Romney turning 65 March 12 and “turning down” Medicare.
Many pundits claim Romney made an unbelievable political mistake and has most likely just lost the senior vote. I don’t necessarily agree because I have not seen enough information on any web site to explain the whole situation. I have seen a whole lot of misinformation.
So what we have here is what some like to call teachable moments. Here are at least five: Read the rest of this entry →