Insurance Problems
maneuvering the maze
Put Your Hospital Bills Under a Microscope
By Jane E. Brody : NY Times : September 13, 2010
In times like these, the last thing you need is a hospital bill that can wreck an already fragile budget. This is often the fate of elderly patients who incorrectly assume that Medicare will cover everything.
Not so, as my aunt discovered early last year after a two-night, two-and-a-half-day stay at a for-profit hospital in Florida. There is a lesson for all of us from the following tale: no matter who is footing the bill, hospital charges should be carefully vetted by someone who, with the Internet and perhaps professional help, can decipher the codes and uncover unreasonable and erroneous charges.
My aunt, then 88, had fainted in her apartment and was taken to the hospital by ambulance. After an evaluation in the emergency room, she was admitted to the hospital for what turned out to be a side effect from a new medication.
Five months later, she received a bill stating that of total costs of $18,865 (which included $5,874 for a justifiable CT scan of her head and brain), she still owed $992.60 after Medicare and secondary insurance. The sum seemed prohibitive to my aunt, who lives on Social Security and a small pension.
$457 for Eye Drops?
But that is not what prompted her daughter to question the bill and carefully review the itemized charges. “What leaped out at me was a charge of $456.67 for the eye drops she uses once a day,” my cousin told me. “My mother pays $85 for her prescription, which lasts about 40 days, and she had her own drops with her.”
Further perusal revealed that each baby aspirin, each multivitamin, each 500-milligram tablet of vitamin C and each dose of stool softener was billed at $4.07, for a total of $40.70. She was also billed for six doses of a heart medication ($10.81 each), only two of which should have been administered.
When my cousin called the hospital to question the charges and explain her mother’s limited finances, she was told that financial assistance is offered only if the bill exceeds $1,000. Instead, the hospital suggested an audit but warned that such investigations often leave the patient with a larger bill. My cousin refused to be intimidated and requested the audit, which resulted in the removal of nine erroneous medication charges and a bill reduced to $500.
And when she replied that this was still more than her mother could afford, the hospital lowered the bill to just $200 — as long as she paid it that day. There are reasons beyond greed that hospitals typically charge what look like outrageous prices for goods and services. Reimbursement rates are negotiated with insurers, and some are considerably less than what a patient without insurance would be charged. And hospitals rely on insured patients to make up for those who fail to pay their bills — and for the rates paid by Medicaid, which may be considerably lower than actual hospital costs.
Uncovered Expenses
In recent years, hospitals have introduced a new source of potential financial disaster. To avoid federal penalties for the costly practice of readmitting patients after discharge, hospitals assign some patients to “observation” status, even if they occupy a hospital bed. Without formal admission, Medicare (and often private insurance as well) charges patients a 20 percent co-payment and does not cover the cost of post-hospital nursing care or rehabilitation.
Observation status, which theoretically should last no more than a day or two, has been on the rise for longer stays. Patients often don’t know they were never admitted as inpatients until they leave the hospital and are slapped with a huge bill. For one 76-year-old Connecticut man “observed” in a hospital room for eight days, the charges not covered by Medicare were $36,000, and he was not covered for three months of rehabilitation services, Bloomberg Businessweek reported in July. Before an unmanageable hospital bill forces you or anyone you know into foreclosure or bankruptcy or into the clutches of an unrelenting collection agency, there are remedies worth knowing about. In fact, even if you can afford to pay the bill, a careful review is a good idea, if only to disclose errors and excesses that drive up the cost of medical care for all of us.
Errors are commonplace in hospital bills. A doctor may request a procedure or medication that is subsequently canceled or that the patient refuses, but it still goes on the bill. An entry error may result in a misplaced decimal point or an extra zero or two in the number of treatments, multiplying the cost 10 or 100 times. Check the dates for all procedures and medication; some may be listed as happening on a day or at a time you were not even in the hospital.
Listings of medications and treatments you don’t understand can nearly always be found on the Internet, but mysterious codes — like “obs unit tell per hour,” found on my aunt’s bill — should be explained by the hospital’s billing department.
Negotiation Tactics
As my cousin found, it is nearly always possible to negotiate a smaller bill as well as a payment plan of a certain amount each month. Hospitals will often reduce the bill by 40 percent or more if it is paid in cash within 30 days. But be sure to remain civil in your negotiations. Berating the institution or its agents can be counterproductive.
If negotiation by the patient, a family member or a friend is not possible, there are commercial services like Insnet that will do it for about a third of the ultimate savings. Other companies, like Medical Billing Advocates of America, can help with bill review.
Another useful tactic, if your hospitalization is not an emergency, is to comparison-shop beforehand. Even within the same ZIP code, hospital charges for various procedures and room rates can vary greatly (get free cost information at Health Care Blue Book’s Web site.
In general, the costs at for-profit hospitals are greater than at nonprofits, and charges to patients at facilities outside the insurer’s network will be much higher. And don’t forget to check what the doctor and, if needed, the anesthesiologist will charge. Find out whether your insurance will be accepted and how much the co-pay is likely to be.
But whatever you do, don’t ignore a medical bill you are unable or unwilling to pay. If it ends up in the hands of a collection service, it will damage your credit rating and could ultimately result in a lien on your property.
By Jane E. Brody : NY Times : September 13, 2010
In times like these, the last thing you need is a hospital bill that can wreck an already fragile budget. This is often the fate of elderly patients who incorrectly assume that Medicare will cover everything.
Not so, as my aunt discovered early last year after a two-night, two-and-a-half-day stay at a for-profit hospital in Florida. There is a lesson for all of us from the following tale: no matter who is footing the bill, hospital charges should be carefully vetted by someone who, with the Internet and perhaps professional help, can decipher the codes and uncover unreasonable and erroneous charges.
My aunt, then 88, had fainted in her apartment and was taken to the hospital by ambulance. After an evaluation in the emergency room, she was admitted to the hospital for what turned out to be a side effect from a new medication.
Five months later, she received a bill stating that of total costs of $18,865 (which included $5,874 for a justifiable CT scan of her head and brain), she still owed $992.60 after Medicare and secondary insurance. The sum seemed prohibitive to my aunt, who lives on Social Security and a small pension.
$457 for Eye Drops?
But that is not what prompted her daughter to question the bill and carefully review the itemized charges. “What leaped out at me was a charge of $456.67 for the eye drops she uses once a day,” my cousin told me. “My mother pays $85 for her prescription, which lasts about 40 days, and she had her own drops with her.”
Further perusal revealed that each baby aspirin, each multivitamin, each 500-milligram tablet of vitamin C and each dose of stool softener was billed at $4.07, for a total of $40.70. She was also billed for six doses of a heart medication ($10.81 each), only two of which should have been administered.
When my cousin called the hospital to question the charges and explain her mother’s limited finances, she was told that financial assistance is offered only if the bill exceeds $1,000. Instead, the hospital suggested an audit but warned that such investigations often leave the patient with a larger bill. My cousin refused to be intimidated and requested the audit, which resulted in the removal of nine erroneous medication charges and a bill reduced to $500.
And when she replied that this was still more than her mother could afford, the hospital lowered the bill to just $200 — as long as she paid it that day. There are reasons beyond greed that hospitals typically charge what look like outrageous prices for goods and services. Reimbursement rates are negotiated with insurers, and some are considerably less than what a patient without insurance would be charged. And hospitals rely on insured patients to make up for those who fail to pay their bills — and for the rates paid by Medicaid, which may be considerably lower than actual hospital costs.
Uncovered Expenses
In recent years, hospitals have introduced a new source of potential financial disaster. To avoid federal penalties for the costly practice of readmitting patients after discharge, hospitals assign some patients to “observation” status, even if they occupy a hospital bed. Without formal admission, Medicare (and often private insurance as well) charges patients a 20 percent co-payment and does not cover the cost of post-hospital nursing care or rehabilitation.
Observation status, which theoretically should last no more than a day or two, has been on the rise for longer stays. Patients often don’t know they were never admitted as inpatients until they leave the hospital and are slapped with a huge bill. For one 76-year-old Connecticut man “observed” in a hospital room for eight days, the charges not covered by Medicare were $36,000, and he was not covered for three months of rehabilitation services, Bloomberg Businessweek reported in July. Before an unmanageable hospital bill forces you or anyone you know into foreclosure or bankruptcy or into the clutches of an unrelenting collection agency, there are remedies worth knowing about. In fact, even if you can afford to pay the bill, a careful review is a good idea, if only to disclose errors and excesses that drive up the cost of medical care for all of us.
Errors are commonplace in hospital bills. A doctor may request a procedure or medication that is subsequently canceled or that the patient refuses, but it still goes on the bill. An entry error may result in a misplaced decimal point or an extra zero or two in the number of treatments, multiplying the cost 10 or 100 times. Check the dates for all procedures and medication; some may be listed as happening on a day or at a time you were not even in the hospital.
Listings of medications and treatments you don’t understand can nearly always be found on the Internet, but mysterious codes — like “obs unit tell per hour,” found on my aunt’s bill — should be explained by the hospital’s billing department.
Negotiation Tactics
As my cousin found, it is nearly always possible to negotiate a smaller bill as well as a payment plan of a certain amount each month. Hospitals will often reduce the bill by 40 percent or more if it is paid in cash within 30 days. But be sure to remain civil in your negotiations. Berating the institution or its agents can be counterproductive.
If negotiation by the patient, a family member or a friend is not possible, there are commercial services like Insnet that will do it for about a third of the ultimate savings. Other companies, like Medical Billing Advocates of America, can help with bill review.
Another useful tactic, if your hospitalization is not an emergency, is to comparison-shop beforehand. Even within the same ZIP code, hospital charges for various procedures and room rates can vary greatly (get free cost information at Health Care Blue Book’s Web site.
In general, the costs at for-profit hospitals are greater than at nonprofits, and charges to patients at facilities outside the insurer’s network will be much higher. And don’t forget to check what the doctor and, if needed, the anesthesiologist will charge. Find out whether your insurance will be accepted and how much the co-pay is likely to be.
But whatever you do, don’t ignore a medical bill you are unable or unwilling to pay. If it ends up in the hands of a collection service, it will damage your credit rating and could ultimately result in a lien on your property.
Demystifying the Emergency Room Bill
By Lesley Alderman : NY Times : August 6, 2010
During a snowstorm last winter, my 6-year-old son fell and cut his chin — not outside on the ice, but inside on the tile bathroom floor. My husband walked our son, Charlie, through the knee-high snow to the local emergency room.
Charlie’s gash was small, less than half an inch long, but deep. The hospital called in a plastic surgeon, who put 14 tiny stitches into his chin.
Charlie called the incident “the worst day of my life” — mostly because he had to spend hours in a hospital instead of throwing snowballs. Weeks later, when the bills arrived, we had our own bad day.
The total charges for his minor spill came to $5,398. The largest single charge was a shocking $4,950 from the plastic surgeon.
Emergency room bills are notoriously high and perplexing; patients often are left feeling like captives who have few alternatives. It is impossible to know how much the services will cost when you walk in the door. The hospital bill, which arrives weeks later, may include seemingly inflated charges for things like Tylenol or an M.R.I. Doctors who treated you may send their own separate bills, further complicating the payment process.
The first step toward managing this expense is understanding what goes on in the hospital’s billing department.
NOBODY PAYS RETAIL
The majority of hospitals are required by law to treat any person who walks into an emergency room whether that person has insurance or not. To make up for those who cannot or will not pay, a hospital sets its so-called gross charges very high.
At the same time, hospitals negotiate contracts with managed care and commercial insurance carriers that specify prices much lower than the gross charges. Medicare and Medicaid dictate lower rates for medical services to hospitals. In virtually every instance, “we get paid a lot less than we bill,” said Michelle Leone, senior vice president for revenue cycle operations at Continuum Health Partners in New York City.
You may receive a statement that shows your E.R. visit totaled $3,000, for example, but your insurer may agree to pay just $500, which the hospital will accept. Depending on your plan, you owe either a portion of that $500 — say, 20 percent, after a deductible — or a co-payment.
People without insurance end up with bills that are much higher than those for covered patients, because the uninsured are charged the hospital’s gross rates.
“People don’t realize that the prices on the bill are just a starting point,” said Dr. Jesse M. Pines, an associate professor of emergency medicine and health policy at the Center for Health Care Quality at George Washington University. “Prices listed on the bill often don’t represent what the insurer or the patient will ultimately pay.”
The prices ultimately paid to a hospital can vary considerably for treatment of similar medical problems. “It’s kind of like the airline industry,” Dr. Pines said. “It’s rare that two people on a plane will have paid the same amount for their seats.”
THE SURPRISES
Besides being charged for each service you receive, you will be charged an emergency room fee corresponding to the complexity of treatment that your injury required.
Normally there are five levels of care — Level 1 is for minor problems like an earache. Level 5 is for more severe problems like a broken bone. (There are higher levels of care reserved for critically ill patients.) Charlie’s stitches, for instance, were considered Level 2 care, and the emergency room fee was $488.
When an outside doctor is called in, you will receive a bill directly from the doctor or from your insurance company. The fee will be high, but your insurer probably will pay for most of it, depending on your plan and whether you have met your deductible.
In the end, our final out-of-pocket costs for the entire emergency were less than a third of the original charges. That sounds good, but the bill was still $1,579.
Some insurance plans require that you get preauthorization before receiving emergency care, said Gordon Wheeler, associate executive director for public affairs at the American College of Emergency Physicians.
The new health reform law, though, stipulates that a patient may not be penalized for receiving out-of-network care in the case of an emergency, and that a patient does not need to seek preapproval. The final regulations on this issue are to be released at the end of this month.
Whether you have insurance or not, here are some strategies for avoiding high emergency room bills and steps to take when the amount you owe seems unreasonably high.
DON’T GO THERE
If your situation is not dire — you twisted your ankle or have a persistent sore throat, say, or your child receives a small burn — call your doctor first and ask for advice.
While this might sound obvious, many people routinely head to the E.R. for nonurgent problems. The top three reasons for emergency room visits in 2007 were for sprains and strains, superficial injuries and contusions, and upper respiratory infections, according to Ryan Mutter, a senior economist at the federal Agency for Healthcare Research and Quality.
Call your insurer’s nurse triage hot line. A trained nurse can help you determine whether a swollen ankle is broken and should be immediately X-rayed, for instance, or whether a burn requires a doctor’s attention or just judicious at-home treatment.
Another good alternative to the E.R. is an urgent care center. There are now 8,700 of them across the country. They are typically faster and cheaper than E.R.’s. Urgent care centers specialize in treating mild injuries like sprains, broken toes and fingers and mild cuts. To find a nearby urgent care center, call your insurer or go to iTriagehealth.com.
SCRUTINIZE THE BILL
If a charge looks wrong or the amount seems unreasonably high, call the hospital’s billing department. Hospitals and insurers process thousands of claims a day, and mistakes do happen. If you received two stitches in your finger, but were billed $700 for Level 3 care, ask why this is so.
“Never be afraid to ask questions about your bill,” Ms. Leone said.
MAKE AN OFFER
If the final bill is beyond your means, it will pay to bargain — particularly if you do not have insurance.
“The majority of hospitals will discount private paying patients’ bills,” Ms. Leone said. “Most hospitals are generous in their discounts.”
You can negotiate even when you have insurance. Two years ago Lisa Cullen’s father, Thomas Reilly, became very ill and made three trips to the emergency room. Each visit cost about $15,000. Mr. Reilly’s insurer contested some of the charges, and the family ultimately was left owing the hospital $11,000.
The hospital was able to reduce the bill to $5,000. “I was surprised to learn hospitals would rather receive partial payment than no money at all,” Ms. Cullen, a writer in Leonia, N.J., said. Often you can work out a payment plan with the hospital whereby you pay your bill in installments rather than all at once.
Negotiate with doctors, too, over their individual bills.
ACT QUICKLY
Unpaid hospital bills are usually forwarded to collection agencies that report uncollectible accounts to credit agencies. When faced with exorbitant bills, don’t hesitate to contact the hospital’s billing department and start a dialogue.
“By the time your bill lands at the collection agency, your credit score will have taken a serious hit,” Dr. Pines warned, “and it might be hard to borrow money in the future.” If that happens, a trip to the emergency room will feel like the beginning, not the end, of your troubles.
By Lesley Alderman : NY Times : August 6, 2010
During a snowstorm last winter, my 6-year-old son fell and cut his chin — not outside on the ice, but inside on the tile bathroom floor. My husband walked our son, Charlie, through the knee-high snow to the local emergency room.
Charlie’s gash was small, less than half an inch long, but deep. The hospital called in a plastic surgeon, who put 14 tiny stitches into his chin.
Charlie called the incident “the worst day of my life” — mostly because he had to spend hours in a hospital instead of throwing snowballs. Weeks later, when the bills arrived, we had our own bad day.
The total charges for his minor spill came to $5,398. The largest single charge was a shocking $4,950 from the plastic surgeon.
Emergency room bills are notoriously high and perplexing; patients often are left feeling like captives who have few alternatives. It is impossible to know how much the services will cost when you walk in the door. The hospital bill, which arrives weeks later, may include seemingly inflated charges for things like Tylenol or an M.R.I. Doctors who treated you may send their own separate bills, further complicating the payment process.
The first step toward managing this expense is understanding what goes on in the hospital’s billing department.
NOBODY PAYS RETAIL
The majority of hospitals are required by law to treat any person who walks into an emergency room whether that person has insurance or not. To make up for those who cannot or will not pay, a hospital sets its so-called gross charges very high.
At the same time, hospitals negotiate contracts with managed care and commercial insurance carriers that specify prices much lower than the gross charges. Medicare and Medicaid dictate lower rates for medical services to hospitals. In virtually every instance, “we get paid a lot less than we bill,” said Michelle Leone, senior vice president for revenue cycle operations at Continuum Health Partners in New York City.
You may receive a statement that shows your E.R. visit totaled $3,000, for example, but your insurer may agree to pay just $500, which the hospital will accept. Depending on your plan, you owe either a portion of that $500 — say, 20 percent, after a deductible — or a co-payment.
People without insurance end up with bills that are much higher than those for covered patients, because the uninsured are charged the hospital’s gross rates.
“People don’t realize that the prices on the bill are just a starting point,” said Dr. Jesse M. Pines, an associate professor of emergency medicine and health policy at the Center for Health Care Quality at George Washington University. “Prices listed on the bill often don’t represent what the insurer or the patient will ultimately pay.”
The prices ultimately paid to a hospital can vary considerably for treatment of similar medical problems. “It’s kind of like the airline industry,” Dr. Pines said. “It’s rare that two people on a plane will have paid the same amount for their seats.”
THE SURPRISES
Besides being charged for each service you receive, you will be charged an emergency room fee corresponding to the complexity of treatment that your injury required.
Normally there are five levels of care — Level 1 is for minor problems like an earache. Level 5 is for more severe problems like a broken bone. (There are higher levels of care reserved for critically ill patients.) Charlie’s stitches, for instance, were considered Level 2 care, and the emergency room fee was $488.
When an outside doctor is called in, you will receive a bill directly from the doctor or from your insurance company. The fee will be high, but your insurer probably will pay for most of it, depending on your plan and whether you have met your deductible.
In the end, our final out-of-pocket costs for the entire emergency were less than a third of the original charges. That sounds good, but the bill was still $1,579.
Some insurance plans require that you get preauthorization before receiving emergency care, said Gordon Wheeler, associate executive director for public affairs at the American College of Emergency Physicians.
The new health reform law, though, stipulates that a patient may not be penalized for receiving out-of-network care in the case of an emergency, and that a patient does not need to seek preapproval. The final regulations on this issue are to be released at the end of this month.
Whether you have insurance or not, here are some strategies for avoiding high emergency room bills and steps to take when the amount you owe seems unreasonably high.
DON’T GO THERE
If your situation is not dire — you twisted your ankle or have a persistent sore throat, say, or your child receives a small burn — call your doctor first and ask for advice.
While this might sound obvious, many people routinely head to the E.R. for nonurgent problems. The top three reasons for emergency room visits in 2007 were for sprains and strains, superficial injuries and contusions, and upper respiratory infections, according to Ryan Mutter, a senior economist at the federal Agency for Healthcare Research and Quality.
Call your insurer’s nurse triage hot line. A trained nurse can help you determine whether a swollen ankle is broken and should be immediately X-rayed, for instance, or whether a burn requires a doctor’s attention or just judicious at-home treatment.
Another good alternative to the E.R. is an urgent care center. There are now 8,700 of them across the country. They are typically faster and cheaper than E.R.’s. Urgent care centers specialize in treating mild injuries like sprains, broken toes and fingers and mild cuts. To find a nearby urgent care center, call your insurer or go to iTriagehealth.com.
SCRUTINIZE THE BILL
If a charge looks wrong or the amount seems unreasonably high, call the hospital’s billing department. Hospitals and insurers process thousands of claims a day, and mistakes do happen. If you received two stitches in your finger, but were billed $700 for Level 3 care, ask why this is so.
“Never be afraid to ask questions about your bill,” Ms. Leone said.
MAKE AN OFFER
If the final bill is beyond your means, it will pay to bargain — particularly if you do not have insurance.
“The majority of hospitals will discount private paying patients’ bills,” Ms. Leone said. “Most hospitals are generous in their discounts.”
You can negotiate even when you have insurance. Two years ago Lisa Cullen’s father, Thomas Reilly, became very ill and made three trips to the emergency room. Each visit cost about $15,000. Mr. Reilly’s insurer contested some of the charges, and the family ultimately was left owing the hospital $11,000.
The hospital was able to reduce the bill to $5,000. “I was surprised to learn hospitals would rather receive partial payment than no money at all,” Ms. Cullen, a writer in Leonia, N.J., said. Often you can work out a payment plan with the hospital whereby you pay your bill in installments rather than all at once.
Negotiate with doctors, too, over their individual bills.
ACT QUICKLY
Unpaid hospital bills are usually forwarded to collection agencies that report uncollectible accounts to credit agencies. When faced with exorbitant bills, don’t hesitate to contact the hospital’s billing department and start a dialogue.
“By the time your bill lands at the collection agency, your credit score will have taken a serious hit,” Dr. Pines warned, “and it might be hard to borrow money in the future.” If that happens, a trip to the emergency room will feel like the beginning, not the end, of your troubles.
Pushing Back When Your Insurance Company Denies Your Claim
By Anna Mathews : WSJ Article : September 26, 2008
Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to join the growing number of people who are appealing coverage denials, there are several strategies that can bolster your case.
More and more people are appealing insurers' denials of coverage, but that doesn't mean it's gotten any easier. Watch the story of on couple's struggle to get the treatment they wanted. WSJ's Anna Matthews reports. (Sept. 25)
Some health-coverage problems -- such as when your doctor enters a wrong code on a claim form -- can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you. Faced with such a situation, you may need to enlist help from your doctor, and even do some scientific research of your own. As a last resort, most states will consider appeals that have been denied by private insurers.
Insurance companies generally don't disclose how many appeals they receive. But state regulators keep data on the frequency of cases filed with them, and the trend is up -- 12% growth between 2004 and 2006, according to a survey by America's Health Insurance Plans, an industry group, which says such appeals represented less than one out of every 10,000 insured people. That's a small share of the total, though, since most appeals never get to the state bodies.
New York's regulator, the state Insurance Department, is one of the few agencies that also keeps track of how many people in its state file appeals with health insurers. In 2007, the number was 33,355, up 18% since 2004.
Self Protection Having a game plan when fighting a health insurer's denial of coverage can better your odds of a successful appeal.
In any case, appealing an insurer's decision is often complex and tricky, and the deck can seem stacked against you. It is often hard for consumers to know what is covered and what isn't in an insurance plan. Indeed, insurers have been winning a majority of the cases reviewed by state regulators in recent years, with victories for insurers at 59% in 2006.
Here are some ways you may be able to better your odds.
Getting Started First, figure out what led to the denial of coverage and learn your insurer's procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can't be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.
An Appealing Option If you are considering appealing a decision by your health plan, here are some online resources that can help.
Tips and tutorials on how to file an appeal:
There are a growing number of health consumer advocacy operations that will work with people who want to file appeals. Before you hire anyone, ask about fees and success rates.
Nonprofits:
You will need the denial letter. You should also get a copy of your plan's full benefits language, sometimes called the "Evidence of Coverage," as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Inc. and Aetna Inc., post their medical policies online.
Sometimes the appeal is straightforward. Murielle Curcio, 51 years old, of San Jose, Calif., was told by Blue Shield of California last October that it wouldn't pay for a genetic test to gauge her risk of breast cancer. The letter said the test hadn't been preauthorized by the company or performed by her primary-care physician. With more than $3,000 at stake, Ms. Curcio enlisted the help of Health Advocate Inc., a firm that works under contract with her employer.
Ms. Curcio filed an appeal in January. She says she got a letter from the testing lab confirming that her physician had ordered the test and that his office had been told by the insurer that it would be covered. In her appeal, Ms. Curcio also cited the insurer's policies to argue that such tests were covered by her plan, and that she was a medically appropriate candidate. A few weeks later, Blue Shield paid for the test.
A Blue Shield of California official said he couldn't comment specifically on Ms. Curcio's case because the insurer hadn't received a release form from her. But the official said appeals often stem from a lack of complete information, and "the most common reason for overturning a decision is, we get information we didn't get at the outset."
Building a Case After you gather the facts, set a strategy. Your appeal may hinge on proving that your treatment qualifies for coverage under your plan's benefits and rules. Tom Bridenstine, managed-care ombudsman for the state of Virginia, says he once worked with a consumer whose insurer refused to pay for bariatric surgery because such obesity treatments weren't allowed benefits. Mr. Bridenstine says he helped win a reversal by showing that the woman's weight issue was actually a symptom of a rare disease.
Many appeals focus on demonstrating that a treatment is scientifically proven and medically necessary. Your doctor should be able to write a detailed letter on your behalf. You also may be able to bolster your case by researching the scientific evidence online on sites like pubmed.gov, sponsored by the National Library of Medicine.
David Foglesong, a history professor from Montgomery Township, N.J., began searching medical databases soon after Horizon Blue Cross Blue Shield of New Jersey declined to pay for a targeted chemotherapy treatment for his wife, RoseMary. During one library visit, he found a new study that showed the treatment had helped patients with conditions similar to his wife's disease, advanced sarcoma that had spread to her liver.
The couple, advised by Patient Advocate Foundation, a nonprofit group, solicited new letters from Ms. Foglesong's doctors, and her primary oncologist argued on her behalf in a conference call with the insurance company's reviewers in June. The company reversed its earlier decision, and Ms. Foglesong, 49, got the treatment in July.
Horizon officials say the procedure was initially denied because it was deemed experimental and not the standard for Ms. Foglesong's condition. The company said a review committee reversed that decision because of the "whole totality of her case," including the medical literature.
Last Resort Even if your insurer rejects your appeal, you still have other options. If your employer has a self-funded health plan, which might be administered by a private insurer but is backed by the employer, your next step is often to sue in federal court, a tough and expensive proposition.
If your insurer has denied your appeal, here are other resources to try.
Sharon Hines, 52, of Middletown, Conn., appealed to the state after her insurer refused to pay for Avastin, an expensive biotech drug that has drawn debate over what uses are justified. Ms. Hines, an oncology nurse practitioner, says she and her husband, a truck driver, couldn't afford the roughly $100,000 a year cost of the treatment.
Ms. Hines said her insurer, ConnectiCare Inc., a subsidiary of Health Insurance Plan of Greater New York, had raised various objections to Avastin, including that there wasn't evidence the treatment would work for someone, like her, who had previously taken Tarceva, another cancer drug. In August, the state's reviewer ruled that Avastin was medically necessary because Ms. Hines would be getting it with first-line chemotherapy, its approved use. "It was such a sense of relief," she says.
In a statement, a ConnectiCare official said the independent oncologist who reviewed Ms. Hines's appeal for the company "did not agree with the use of Avastin" and the insurer followed his recommendation. When the insurer got the state review's decision "we immediately covered the drug for her....We wish her well with her courageous battle."
Medicare Appeals For Medicare beneficiaries, there is a separate, federal appeals-review process. That is what Ellen and Paul Hoppe used after Health Net of California, the Health Net Inc. unit that provided Mr. Hoppe's Medicare Advantage plan, declined to pay for proton-beam radiation for his prostate cancer. The denial document said there was no evidence that Mr. Hoppe, 67, would get any added advantage from proton-beam therapy, which is significantly more expensive than conventional X-ray radiation.
Need more research to bolster your appeal? For evidence about the medical treatment you want: PubMed is a service of the U.S. National Library of Medicine that includes biomedical articles dating back to the 1950s.
Some health plans, like Aetna , Wellpoint and Cigna, post their medical policies online. Even if you're not covered by them, you may want to compare their policies to those of your plan.
But the Hoppes, phone-company retirees in California, were convinced that proton-beam therapy carried a lower risk of side effects such as incontinence. They got backing from Mr. Hoppe's doctor at Loma Linda University Medical Center, who wrote a six-page letter, including two pages of research citations. In June, Medicare's appeals contractor sided with the Hoppes, saying the proton-beam therapy qualified for the federal standard of "reasonable and necessary" treatment.
Health Net said in a statement that it couldn't comment on Mr. Hoppe's case because it hadn't received a release from him. But it said, "Any single portrayal of a less-than-satisfactory customer service experience does not represent the overall experience of our customers." A Health Net spokesman added that medical coverage decisions aren't affected by the cost of treatment.
How Not to Get Blindsided by Out-of-Network Fees
By Walencia Konrad : NY Times Article : February 14, 2009
How much, if anything, does your health insurance company reimburse you when you receive out-of-network care? The question has never been more scrutinized than now.
An investigation led by the New York attorney general, Andrew M. Cuomo, recently uncovered that the database the nation’s insurers use to calculate out-of-network charges consistently shortchanges patients. And because the database is owned by the giant insurer UnitedHealth Group, Mr. Cuomo’s office found that it was fraught with conflicts of interest.
Typically, patients go outside their insurer’s network of preferred doctors and hospitals for two reasons. A medical emergency may demand immediate treatment from whatever doctor or hospital is nearby. Or the patient may need to see a specialist who is not part of the insurer’s network.
Plaintiffs’ lawyers throughout the country have filed several class action suits on behalf of patients who feel they have been overcharged or unfairly denied reimbursement for getting out-of-network care. And this past Tuesday the American Medical Association, joining several state medical associations, announced it was suing health insurers Aetna and Cigna, saying they used the flawed database to underpay doctors for more than a decade.
This magnifying glass is good for consumers. Seventy percent of insured working Americans are enrolled in plans that let them choose their own doctors — and typically pay a higher premium for that privilege — which means that most insured people would potentially benefit from reforms to the system. If out-of-network reimbursements were more in line with reality, the average payment on the insurer’s part could increase by 10 to 28 percent, Mr. Cuomo’s office estimated.
But change won’t happen overnight. Until a new database can be set up by an independent operator — a process that could take 6 to 18 months — the flawed database will continue to be used to calculate out-of-network charges industrywide. And even with reforms, consumer health care advocates don’t expect an end to out-of-network disputes with insurers.
“There will still be cases where emergency room visits to out-of-network hospitals get denied or an insurer turns down a request for an out-of-network specialist,” predicted Candy Butcher, president of Medical Billing Advocates of America, a clearinghouse for firms that help consumers when they have a dispute over a medical bill.
So, the next time you need out-of-network care, here’s what you need to do. Find out exactly what your plan covers. The recent headlines have sent plenty of employees scurrying to their health plan handbooks to check up on out-of network policies. You should too. Taking the surprise out of the equation can help you decide whether to go out of network, when you have a choice, and can help you plan for your share of the bill.
Most plans offer out-of-network emergency coverage, although the burden may be on you to explain why the situation was an emergency and why you went to an out-of-network facility. H.M.O.’s and other similarly restrictive plans may pay a portion of out-of-network care only in an emergency or when you can prove that the network does not include a specialist you need. So-called preferred provider organizations, known as P.P.O.’s, offer more generous out-of-network coverage, usually 70 to 80 percent of “reasonable and customary” charges.
But there’s the rub. The insurance industry uses that Cuomo-maligned database to calculate what’s reasonable and customary in a local market.
Even if the insurer’s calculations can be trusted, often people forget about or don’t understand the reasonable and customary part, says Tom Billet, a senior executive with the benefits consulting firm Watson Wyatt. “They figure if they have a $100 doctor’s bill, they’ll get a check for $80,” Mr. Billet said.
But the insurer will reimburse you only 80 percent of what are considered reasonable and customary charges in your area. If that number turns out to be $80, your insurer will only reimburse you $64 (80 percent of $80). Your share of the bill now goes from $20 to $36.
The new database should help increase the amount your insurer considers reasonable and customary, but in the meantime you’re on the hook for the extra payment. And even under the new system, 80 percent won’t necessarily mean 80 percent of the doctor’s actual bill.
Find out what your insurer’s reasonable and customary fee is for specific treatments.
Then, call your insurance company asking for prices. If the rep balks at giving you this information, don’t be afraid to remind him or her of a little-followed but important advisory by the Department of Labor that says usual and customary charges should be disclosed to patients, said Cheryl Fish-Parcham, the deputy director of health policy at Families USA, a consumer advocacy group. For more information on the Labor Department advisory click here.
Negotiate with your doctor. If you find out your reimbursement for a specific treatment will be lower than you expected, tell your doctor exactly what the insurance company is going to pay and ask if he or she can lower the fee to that amount. “When they join a network, doctors routinely discount their bills by 35 percent or so, “Ms. Butcher explained. “You should ask for the same, lower rate.”
Prepare carefully for a hospital visit. If you receive care at an in-network hospital you might assume that all the doctors you see will also be in your network. Warning: That isn’t necessarily true.
Your surgeon may be on your network, but the hospital’s anesthesiologist or other practitioner that treats you may not be. Some hospitals have contract practitioners that are not staffers and thus not part of your network either. Be sure to ask your doctor and someone in the hospital admissions office what doctors you’ll be seeing and whether or not they are part of your network. If they are not, find out if an in-network doctor is available.
Even with careful planning you may still end up being seen — and billed — by an out-of-network provider. In that case, Ms. Butcher said, you need to tell the hospital and the doctor that because you were not made aware of the specific extra charges, the out-of-network provider should accept the fee your insurer is willing to cover. There are no rules or regulations on this, but Ms. Butcher said that in her experience most practitioners agree to the reduced rate when patients complain.
If you think you were overcharged — fight back. You have the right to appeal any denial of payment by your insurance company. First step, follow the appeal procedures on your explanation of benefits. Also, contact your doctor’s billing manager and your employee benefits manager for help in filing the appeal. Your state’s attorney general and department of insurance may be able to help you.
Finally, a health care advocate can negotiate with the insurer on your behalf, for a fee. To find one near you click here.
Pleading your case on medical bills is a sound policy
By Bina Venkataraman : Boston Globe | February 18, 2009
When Nicole Stamas of Hudson, N.H., got slapped with a $1,720 bill in November for an ambulance trip between two hospitals that was not covered by her insurance policy, she could not afford it. She's 22, works full time as an optician at Sam's Club, and hopes to start saving money to go back to school to study interior design.
Rather than panic, Stamas remembered reading a newspaper article about a couple who had negotiated a discount on their medical expenses. She wondered if she could do the same. She sought help from a health advocacy group that helped her draft a letter to the ambulance company explaining her financial situation and she included a $50 check from her flex spending account to show the company she had good intentions.
Two weeks later, she received a call from the financial services department of the ambulance company. The company was willing to knock off nearly half her bill and offered her a payment plan of $50 per month, interest free.
If, like Stamas, you are struggling to pay your medical bills, you are not alone. But you might be missing an opportunity to haggle with your doctor, dentist, or even the hospital billing department to get a better deal.
"Not enough people know that medical bills are negotiable," said Andrew Cohen, Medical Debt Program Manager for The Access Project, a Boston-based group that trains healthcare service organizations around the country to help people deal with medical debt. (Cohen helped Stamas with her letter, but says the group is shifting away from giving direct advice to patients.) "Hospitals and other medical providers are often willing to work with people to give a discount or a payment plan."
The best way to keep out-of-pocket medical expenses low, of course, is to have insurance and to choose treatments and doctors in your insurance company's network. But if your insurance does not cover an exam or procedure, you should appeal to the company to have it covered, says Cohen. And whether or not you have insurance, you may qualify to have uninsured medical expenses, including copayments and prescription costs, covered by a public program such as the Health Safety Net.
When all else fails, you can, and you should, negotiate directly with the billing department of a hospital or clinic to have your bill discounted or to get charity services. But Cohen says if you seek public assistance or insur ance coverage first, you will improve your chances of successfully haggling for lower medical bills.
What are the secrets to negotiating a lower medical bill? The Access Project recommends the following: Think and act ahead. Request a cost estimate in advance and be upfront with the provider if you think you will have trouble paying. Although many doctors and hospitals will not know the precise cost until the examinations and procedures are complete, you will be in a better position to negotiate before you receive the care rather than after. Check www.nahdo.org to research the going rate for medical services. As soon as you receive a bill that you cannot afford, contact the billing department of the hospital or clinic to let them know you are having trouble. Don't delay.
Pay in cash. This will both increase your likelihood of getting a discount and protect you from credit card and other forms of high-interest debt.
Make a personal connection. When you call a hospital billing department to negotiate a bill, ask to speak to a manager. Tell your story, don't be shy, be sincere. Explain briefly why you are having trouble paying. If you lost your job, had your work hours cut, or had some unexpected big expense, those can all serve as explanations. But the reason can also be simpler, such as that you have lots of bills piling up.
Write a letter to follow up on your request. Chronicle your reasons for requesting a discount or charity care. This allows you to outline the cost-saving measures you have already taken, such as asking for your insurance company or public programs to cover the expense, and makes your request official.
Be persistent. If you don't succeed at first, keep calling and writing, and ask to speak to people further up the management ladder. Keep careful records of who you speak to and when you speak to them.
There is also another way to save money on healthcare, that doesn't involve haggling over price. Just seek out lower cost medical services at the start.
If you don't mind being a test subject, the Forsyth School of Dental Hygiene at Massachusetts College of Pharmacy and Health Sciences charges $20 for adults and $10 for seniors and children for a dental check-up, cleaning, and fluoride treatment.
Dental hygiene students under supervision by dentists do the work. You can also see if you qualify for free medical care at one of the state's community health centers. For details go to www.massresources.org, click on Health Care Programs, and then Health Safety Net. The safety net is available to residents of Massachusetts who are underinsured or who do not have insurance, regardless of citizenship status.
Advice to the Jobless on Getting Health Coverage
By Lesley Alderman : NY Times Article : February 28, 2009
It's the dreaded one-two punch. You lose your job. Then you have to pay thousands of dollars out-of-pocket for the health insurance an employer no longer provides.
Besides the financial pain, even finding affordable insurance can be agonizing. Which is why today’s “Patient Money” column is here to help.
We’ll talk about steps to take if you have recently lost your job and need health coverage. Next week, in a companion column, my colleague Walecia Konrad will provide health benefits guidance if you still have a job but worry that you, too, could soon find yourself out of work. And who among us doesn’t harbor such fears these days?
Because the soaring unemployment rate has thrust so many people into the ranks of the suddenly uninsured, the government is scrambling to help. The economic stimulus package that President Obama just signed into law provides at least some temporary relief. For one thing, it will be easier and relatively less expensive for the newly unemployed to obtain health coverage under the 1986 law known by its acronym, Cobra.
And earlier this month, Congress passed legislation adding millions of children to those eligible for the Children’s Health Insurance Program — known as CHIP — which covers children in families that earn too much to qualify for Medicaid, but too little to afford private health insurance.
Read on, to see if Cobra and CHIP might be options for you and your family. If not, you’ll probably have to line up private insurance — a process you could start by comparison shopping at a Web site like eHealthInsurance.com.
As you weigh all your insurance options, while considering your or your family’s specific health needs, here are some things to keep in mind. And for further information see the list of resources that accompanies this column.
If you have access to Cobra... Take advantage of it.
Under Cobra, most workers laid off from a company that has more than 20 employees and provides health benefits are allowed to keep those benefits for up to 18 months. But until recently, doing so was forbiddingly expensive. The out-of-work employee had to pay 102 percent of the premiums — or more than $12,900 a year on average for families and nearly $4,800 for individuals, according to the Kaiser Family Foundation, a health research organization.
The new stimulus package at least temporarily changes the rules. If you lost your job after last Sept. 1 and your family income is less than $250,000 a year ($125,000 for individuals), you will have to pay only 35 percent of the premium for the first nine months. The government picks up the rest.
That is a boon for people like Jennifer C. Graham, a single mother who was laid off in December with just five weeks of severance pay. Ms. Graham, who was a senior associate at a Manhattan interior design firm, immediately signed up for Cobra to make sure that she and her twin girls were covered. But the $966 monthly payments ate up more than half of her $1,600-a-month unemployment benefit.
“It’s completely ridiculous,” she said. “How can people get back on their feet?”
With the stimulus relief, her payments will soon fall to a more affordable level: $338 a month. Ms. Graham, who has an M.B.A., says she hopes to have a new job before the nine-month subsidy ends.
Another change under the stimulus package is that if you qualify for the subsidized Cobra benefit, you can also switch into a lower-cost health plan, like an health maintenance organization, if your former employer offers one, even if you were signed up for a more expensive plan while you were working.
If you, or someone in your family, has a pre-existing condition ...You can use Cobra to your advantage, even if you don’t qualify for the new subsidy.
Let’s say you have diabetes, but the rest of your family is healthy. Insurers will charge your family more than the average rate, because you are considered a high risk. In this case, you could stay on Cobra at an individual rate, and buy private insurance for the rest of the family. Look for policies at a large insurance broker site like eHealthInsurance.com, which offers more than 10,000 plans. Put in your sex, ZIP code and date of birth and the site will tell you which plans are available in your area. Many of them have been reviewed by customers, and you can apply online.
If you have children ... Explorekeeping yourself and your spouse on Cobra, or buying private insurance, and enrolling your children in the federally financed CHIP program, suggests Ron Pollack, executive director of Families USA, a nonprofit consumer advocacy organization.
Government plans typically have higher income allowances for children than for adults. For instance, if you live in New York State and your yearly household income is $88,200 or less (for a family of four), your children would qualify for the Child Health Plus plan, which costs no more than $40 a month for each child, depending on your income. For you and your spouse to qualify for low-cost coverage, too, your household income could be no more than $33,075.
Worried about the quality of care your children will receive? According to a recent Kaiser Family Foundation survey, families with children in Medicaid or CHIP programs found the care comparable to what they received under private insurance.
Rules and income limits vary by state. A Web site operated by the nonprofit Foundation for Health Coverage Education has information about the rules in your area
If Cobra is not an option, and you’re young and healthy ...Consider getting a high-deductible health plan that can be linked to a health savings account.
This is a viable option if you expect to have few medical expenses or you hope to have a job within the year — or both. Such plans have low premiums but high annual deductibles — the amount of care you have to pay for before the insurance kicks in. For instance, a family of four in Chicago could find a plan that costs just $398 a month — $4,776 a year — but comes with a $5,000 deductible.
To pay for the out-of-pocket costs, you are allowed, by law, to set aside up to $5,950 ($3,000 if you are single) in a health savings account. This account is not taxed and — unlike a flexible spending account — the money can be rolled over from year to year. But make sure you have the money to cover the deductible, Mr. Pollack of Families USA cautions.
“If you have an unexpected event, say you break your leg, you may be unpleasantly surprised,” he said. “You will have to spend every dollar of your care until you meet your deductible.”
If your income is low ...You may qualify for government-sponsored health insurance, or services, if your total household income is coming from unemployment insurance, if you are a single parent, or if you lost your job because your company moved out of the country.
“A lot of people don’t know these programs exist,” said Phil Lebherz, executive director of the Foundation for Health Coverage Education. Go to the foundation’s site, www.coverageforall.org, and answer the five-question quiz displayed on the home page to find out what services you may be eligible for. Or call the help line (1-800-234-1317), which is staffed 24 hours a day.
No matter what, make sure you have insurance. It is no surprise that studies show that people without insurance end up with less medical care — the harried emergency room staff doesn’t count — and poor recovery rates from serious illnesses. And if you are sick, you will be less able to land a new job with excellent health benefits.
Hanging On to Health Coverage, if the Job Goes Away
By Walecia Konrad : NY Times Article : March 7, 2009
If you’re fortunate to still have your job, but aren’t sure how much longer that will be the case, lost income may not be your only worry. Your medical insurance is at risk, too.
“When you’re still on the job, even if it’s just for a little while longer, you’re in a slightly better position to make the most of the benefits you have now and to figure out your options,” said the Oklahoma insurance commissioner, Kim Holland, a longtime promoter of affordable health insurance.
She and other experts offer the following advice about girding for the worst case.
Use it before you lose it. “My clients wouldn’t want to hear me say this,” said Tom Billet, a senior executive with the corporate benefits consulting firm Watson Wyatt. “But if you feel a layoff is pending, now is the time for you and your family to get physicals, dental check-ups, eye exams and prescriptions filled.”
That’s what Denise Young Farrell is doing. Ms. Farrell, the mother of two children in Park Slope, Brooklyn, lost her job early this year when her department at the Lifetime Networks cable channel moved to California. Her husband lost his job at Bear Stearns last year. Ms. Farrell’s severance package included two months of paid health care.
Check your benefits handbook to see how long your health care coverage will last if you do lose your job. Often, employers will continue coverage until the last day of the month in which the employee worked. So if your last day at work was March 5, for example, you may have coverage until March 31, giving you a few extra days for those doctor visits.
Sign onto your spouse’s plan. If your spouse has employer-sponsored family health insurance benefits, he or she can add you and your dependents anytime during the year. But do be aware of the deadlines. Most companies require any changes to be filed within 30 or 60 days of the “qualifying event.” Depending on your spouse’s company, that could mean the day you were laid off or your last day of coverage.
In addition, some companies require written proof from your former employer that you were laid off. To avoid snags, try to arrange this before your last day of work. And be sure to check when the new coverage takes effect. If your spouse’s plan has a three-month waiting period, for example, you’ll need to find temporary coverage elsewhere.
Get to know Cobra. If you have health benefits in your current job, odds are you’ll be eligible to continue purchasing that coverage temporarily under the 1986 law known by its acronym, Cobra.
Cobra requires employers with 20 or more workers to make health insurance available to a former employee for up to 18 months after leaving the job — regardless of whether you quit or were laid off. But because the former worker must pay the full cost of that insurance, the premiums can easily exceed $1,000 a month for family coverage.
The new federal stimulus plan that President Obama recently signed into law does provide some temporary relief for laid-off workers. But even if you qualify for the subsidy, you’ll still pay 35 percent of the total health premium, compared to the 10 or 15 percent you paid as an employee. So you might be paying $300 to $400 or more a month. And that is for only the first 9 months of the 18-month Cobra coverage. For the second nine months you’ll be paying full fare.
For fuller details on the new Cobra provisions, see the Web site tinyurl.com/akh5mz.
If you do choose Cobra, pace yourself. Time it right, and you can essentially get two months of free Cobra coverage.
After your last day of coverage under your employer’s plan, you have 60 days to sign up to extend that coverage under Cobra. If you think you’re on the verge of getting a new job, or if you’re trying to find a more affordable insurance option, you can put off paying two months of Cobra premiums until you approach the deadline. If the new job or alternate insurance works out, you will have avoided those hundreds of dollars in Cobra premiums. But if you do fall ill or get in an accident in the interim, you will be covered — as long as you pay those back premiums.
Do be vigilant, though, about that 60-day deadline. Miss it, and you lose your Cobra eligibility.
Try to negotiate health care as part of your severance. If you are eligible for any type of severance, consider asking for an extension of health insurance in exchange for a smaller cash payout. That will give you more time to research your health insurance options and help you avoid a gap in coverage.
There is one caveat, said Kathryn Bakich, national health care compliance director for the Segal Company, a benefits consulting firm: Avoid having your company pay part or all of your Cobra premiums as part of a severance agreement. Employers are still waiting for guidance on this point from the Labor Department and other government agencies, but if your former employer pays your Cobra premiums directly, you may be ineligible for the new Cobra subsidy, according to Ms. Bakich and other benefits experts. You’d be better off trying get a lump sum payment that you could use to pay Cobra premiums, if extending your current coverage isn’t an option.
When Cobra is not an option ... If you work for a small company (fewer than 20 employees) that doesn’t offer Cobra, 40 states offer what’s called mini-Cobra continuation coverage that allows you to stay in your group plan. Some states may offer the new Cobra subsidy in these plans. (Check with your state’s insurance department.) If you do not have access to Cobra or a state continuation plan, or if those benefits are close to running out, it’s important to find insurance of some kind, whether it is group or individual.
Federal law mandates that at least one nongroup insurer in your state must provide coverage to everyone, regardless of health issues. In many cases this is your state’s high-risk insurance pool, but there are no limits on how much insurers can charge for this coverage, so premiums can be extremely expensive. For more information on what your state offers, go to the National Association of Insurance Commissioners’ Web site, naic.org, to link to your state’s insurance department.
If you have a flexible spending account — use it. Here’s a little known bonus in the employee’s favor:
Let’s say you signed up to contribute $1,000 this year through payroll deductions to your health care flexible spending account. So far you’ve only put in about $200. No matter. “Companies must still reimburse you for the full amount you’ve elected even if you haven’t contributed the total to the account yet,” Mr. Billet said.
In this example, if you file claims for $1,000 of eligible health care expenses before your last day on the job, you will get the full reimbursement — not just the $200 you’ve paid in.
Correction: March 7, 2009
An earlier version of this article posted online misstated the deadline for signing up to extend health care coverage under the law known as Cobra. It is 60 days, not 63 days, after the last day of coverage under a former employer's plan.
Why Patients May Be Billed for Free Exams Coding-System Confusion Can Cause Insurers to Deny Coverage of Preventive Care
By Anna Wilde Mathews : WSJ Article : May 21, 2009
Imagine going in for a free medical screening and then being hit with a big bill. It's happening a lot these days.
Company health plans increasingly are offering to pay the full cost of preventive services such as physicals, colonoscopies and mammograms to help employees stay healthy. But some patients then find they owe money for such screenings, sometimes hundreds or thousands of dollars, because their insurers didn't consider certain procedures preventive.
When the mix-ups stem from simple billing errors, consumers may be able to get them corrected quickly. But sometimes patients are stuck with unexpected bills, or have to wage a protracted battle to get them reversed.
Donald Carpenter thought he'd have to pay nothing for the screening colonoscopy he scheduled after his 50th birthday. Instead, the Nashville, Tenn., accountant was billed more than $1,000. Besides the screening, Mr. Carpenter's doctor had removed some polyps, and the insurer hadn't classified the doctor's work as preventive. So Mr. Carpenter was charged what he would owe for a typical surgery.
Paying Up Patients are sometimes billed for preventive screening exams that their plans cover at 100%. Here's how this can happen:
Unfortunately this isn’t something you can do with one phone call. First ask your doctor, or better yet, the person in your doctor’s office who handles billing, for the “C.P.T. code” — the current procedural terminology — for the test, treatment or consultation you’ll be receiving out-of-network. Get it in writing to avoid errors.
This type of billing problem is tied to the system of codes that doctors use in the claims they send to insurers. Every service performed by a physician is translated into a code. So is the patient's diagnosis. Based on those codes, insurers automatically send out payments and generate explanations of benefits for consumers.
Health-care providers must choose from among thousands of separate codes, which are developed by medical groups and government agencies. Patients get socked with unforeseen bills when their doctors' offices don't use the specific codes that their insurers classify as preventive.
The diagnosis code for any screening exam should begin with the letter V to indicate the care is preventive. In a claim from a doctor's office, this is separate from the procedure codes that explain the services the physician is billing for. A screening mammogram, for instance, could be billed as 77052, for a digital screening mammogram, or 77057, for a traditional screening mammogram.
Sometimes, the doctor's office makes an error or doesn't know the insurer's procedures, which vary by company. For instance, an annual preventive-care exam, which a health plan might pay for in full, can mistakenly be described in a claim as a typical doctor visit to deal with a patient's existing symptoms. That could result in the patient being billed for various charges, including a co-payment or a deductible.
Other times, surprise bills arise when a patient unknowingly received some care the health plan didn't consider preventive. Margo Opsasnick, chief executive of Delta Medix, a physician practice in Scranton, Pa., says doctors sometimes order more views of suspicious masses they spot as they are doing a screening mammogram. This then gets billed as a diagnostic mammogram, which deals with existing symptoms, rather than a screening, which is for people without any specific signs of risk. For patients, that shift could mean new fees.
"What's the doctor going to do -- say we saw something but we don't want you to be charged for it?" says Ms. Opsasnick. "It's a catch-22."
John Duffy, a sales associate at Hammond Lumber Co. in Farmington, Maine, says he was charged about $200 for lab tests his wife got as part of her physical two years ago. He says the insurer told him the problem was the coding on the claim, which signaled that the tests were for health problems she already had, not for screening. But the doctor's office wouldn't change the codes.
By Anna Mathews : WSJ Article : September 26, 2008
Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to join the growing number of people who are appealing coverage denials, there are several strategies that can bolster your case.
More and more people are appealing insurers' denials of coverage, but that doesn't mean it's gotten any easier. Watch the story of on couple's struggle to get the treatment they wanted. WSJ's Anna Matthews reports. (Sept. 25)
Some health-coverage problems -- such as when your doctor enters a wrong code on a claim form -- can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you. Faced with such a situation, you may need to enlist help from your doctor, and even do some scientific research of your own. As a last resort, most states will consider appeals that have been denied by private insurers.
Insurance companies generally don't disclose how many appeals they receive. But state regulators keep data on the frequency of cases filed with them, and the trend is up -- 12% growth between 2004 and 2006, according to a survey by America's Health Insurance Plans, an industry group, which says such appeals represented less than one out of every 10,000 insured people. That's a small share of the total, though, since most appeals never get to the state bodies.
New York's regulator, the state Insurance Department, is one of the few agencies that also keeps track of how many people in its state file appeals with health insurers. In 2007, the number was 33,355, up 18% since 2004.
Self Protection Having a game plan when fighting a health insurer's denial of coverage can better your odds of a successful appeal.
- First, find out what led to the insurer's decision, and keep a careful paper trail.
- Be prepared to prove that your treatment qualifies for coverage under your plan.
- Even if your insurer rejects your appeal, most states will consider appeals as a last resort.
In any case, appealing an insurer's decision is often complex and tricky, and the deck can seem stacked against you. It is often hard for consumers to know what is covered and what isn't in an insurance plan. Indeed, insurers have been winning a majority of the cases reviewed by state regulators in recent years, with victories for insurers at 59% in 2006.
Here are some ways you may be able to better your odds.
Getting Started First, figure out what led to the denial of coverage and learn your insurer's procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can't be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.
An Appealing Option If you are considering appealing a decision by your health plan, here are some online resources that can help.
Tips and tutorials on how to file an appeal:
- In-depth explanation from the Kaiser Family Foundation and Consumers Union
- Step-by-step guide from the Patient Advocate Foundation
- Tips from the Connecticut Healthcare Advocate's office, including how to write an appeal letter
There are a growing number of health consumer advocacy operations that will work with people who want to file appeals. Before you hire anyone, ask about fees and success rates.
Nonprofits:
- The Patient Advocate Foundation is a nonprofit that works on appeals
- Families USA offers links to state-based advocacy organizations and state-government health advocates. Not all of these groups work on appeals.
You will need the denial letter. You should also get a copy of your plan's full benefits language, sometimes called the "Evidence of Coverage," as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Inc. and Aetna Inc., post their medical policies online.
Sometimes the appeal is straightforward. Murielle Curcio, 51 years old, of San Jose, Calif., was told by Blue Shield of California last October that it wouldn't pay for a genetic test to gauge her risk of breast cancer. The letter said the test hadn't been preauthorized by the company or performed by her primary-care physician. With more than $3,000 at stake, Ms. Curcio enlisted the help of Health Advocate Inc., a firm that works under contract with her employer.
Ms. Curcio filed an appeal in January. She says she got a letter from the testing lab confirming that her physician had ordered the test and that his office had been told by the insurer that it would be covered. In her appeal, Ms. Curcio also cited the insurer's policies to argue that such tests were covered by her plan, and that she was a medically appropriate candidate. A few weeks later, Blue Shield paid for the test.
A Blue Shield of California official said he couldn't comment specifically on Ms. Curcio's case because the insurer hadn't received a release form from her. But the official said appeals often stem from a lack of complete information, and "the most common reason for overturning a decision is, we get information we didn't get at the outset."
Building a Case After you gather the facts, set a strategy. Your appeal may hinge on proving that your treatment qualifies for coverage under your plan's benefits and rules. Tom Bridenstine, managed-care ombudsman for the state of Virginia, says he once worked with a consumer whose insurer refused to pay for bariatric surgery because such obesity treatments weren't allowed benefits. Mr. Bridenstine says he helped win a reversal by showing that the woman's weight issue was actually a symptom of a rare disease.
Many appeals focus on demonstrating that a treatment is scientifically proven and medically necessary. Your doctor should be able to write a detailed letter on your behalf. You also may be able to bolster your case by researching the scientific evidence online on sites like pubmed.gov, sponsored by the National Library of Medicine.
David Foglesong, a history professor from Montgomery Township, N.J., began searching medical databases soon after Horizon Blue Cross Blue Shield of New Jersey declined to pay for a targeted chemotherapy treatment for his wife, RoseMary. During one library visit, he found a new study that showed the treatment had helped patients with conditions similar to his wife's disease, advanced sarcoma that had spread to her liver.
The couple, advised by Patient Advocate Foundation, a nonprofit group, solicited new letters from Ms. Foglesong's doctors, and her primary oncologist argued on her behalf in a conference call with the insurance company's reviewers in June. The company reversed its earlier decision, and Ms. Foglesong, 49, got the treatment in July.
Horizon officials say the procedure was initially denied because it was deemed experimental and not the standard for Ms. Foglesong's condition. The company said a review committee reversed that decision because of the "whole totality of her case," including the medical literature.
Last Resort Even if your insurer rejects your appeal, you still have other options. If your employer has a self-funded health plan, which might be administered by a private insurer but is backed by the employer, your next step is often to sue in federal court, a tough and expensive proposition.
If your insurer has denied your appeal, here are other resources to try.
- If you have an individual policy, or your employer is fully insured, you can probably appeal to your state's outside review process. The industry trade group America's Health Insurance Plans includes shortcuts to many state agencies.
- If you have Medicare, you can't use the state appeals process, but the federal program has its own review procedure: see guide for instructions.
- If you are in an employer plan that is self-insured (meaning the company backs the plan itself), you also generally can't use the state review processes. The Department of Labor's website has information on the appeals process for such plans.
Sharon Hines, 52, of Middletown, Conn., appealed to the state after her insurer refused to pay for Avastin, an expensive biotech drug that has drawn debate over what uses are justified. Ms. Hines, an oncology nurse practitioner, says she and her husband, a truck driver, couldn't afford the roughly $100,000 a year cost of the treatment.
Ms. Hines said her insurer, ConnectiCare Inc., a subsidiary of Health Insurance Plan of Greater New York, had raised various objections to Avastin, including that there wasn't evidence the treatment would work for someone, like her, who had previously taken Tarceva, another cancer drug. In August, the state's reviewer ruled that Avastin was medically necessary because Ms. Hines would be getting it with first-line chemotherapy, its approved use. "It was such a sense of relief," she says.
In a statement, a ConnectiCare official said the independent oncologist who reviewed Ms. Hines's appeal for the company "did not agree with the use of Avastin" and the insurer followed his recommendation. When the insurer got the state review's decision "we immediately covered the drug for her....We wish her well with her courageous battle."
Medicare Appeals For Medicare beneficiaries, there is a separate, federal appeals-review process. That is what Ellen and Paul Hoppe used after Health Net of California, the Health Net Inc. unit that provided Mr. Hoppe's Medicare Advantage plan, declined to pay for proton-beam radiation for his prostate cancer. The denial document said there was no evidence that Mr. Hoppe, 67, would get any added advantage from proton-beam therapy, which is significantly more expensive than conventional X-ray radiation.
Need more research to bolster your appeal? For evidence about the medical treatment you want: PubMed is a service of the U.S. National Library of Medicine that includes biomedical articles dating back to the 1950s.
Some health plans, like Aetna , Wellpoint and Cigna, post their medical policies online. Even if you're not covered by them, you may want to compare their policies to those of your plan.
But the Hoppes, phone-company retirees in California, were convinced that proton-beam therapy carried a lower risk of side effects such as incontinence. They got backing from Mr. Hoppe's doctor at Loma Linda University Medical Center, who wrote a six-page letter, including two pages of research citations. In June, Medicare's appeals contractor sided with the Hoppes, saying the proton-beam therapy qualified for the federal standard of "reasonable and necessary" treatment.
Health Net said in a statement that it couldn't comment on Mr. Hoppe's case because it hadn't received a release from him. But it said, "Any single portrayal of a less-than-satisfactory customer service experience does not represent the overall experience of our customers." A Health Net spokesman added that medical coverage decisions aren't affected by the cost of treatment.
How Not to Get Blindsided by Out-of-Network Fees
By Walencia Konrad : NY Times Article : February 14, 2009
How much, if anything, does your health insurance company reimburse you when you receive out-of-network care? The question has never been more scrutinized than now.
An investigation led by the New York attorney general, Andrew M. Cuomo, recently uncovered that the database the nation’s insurers use to calculate out-of-network charges consistently shortchanges patients. And because the database is owned by the giant insurer UnitedHealth Group, Mr. Cuomo’s office found that it was fraught with conflicts of interest.
Typically, patients go outside their insurer’s network of preferred doctors and hospitals for two reasons. A medical emergency may demand immediate treatment from whatever doctor or hospital is nearby. Or the patient may need to see a specialist who is not part of the insurer’s network.
Plaintiffs’ lawyers throughout the country have filed several class action suits on behalf of patients who feel they have been overcharged or unfairly denied reimbursement for getting out-of-network care. And this past Tuesday the American Medical Association, joining several state medical associations, announced it was suing health insurers Aetna and Cigna, saying they used the flawed database to underpay doctors for more than a decade.
This magnifying glass is good for consumers. Seventy percent of insured working Americans are enrolled in plans that let them choose their own doctors — and typically pay a higher premium for that privilege — which means that most insured people would potentially benefit from reforms to the system. If out-of-network reimbursements were more in line with reality, the average payment on the insurer’s part could increase by 10 to 28 percent, Mr. Cuomo’s office estimated.
But change won’t happen overnight. Until a new database can be set up by an independent operator — a process that could take 6 to 18 months — the flawed database will continue to be used to calculate out-of-network charges industrywide. And even with reforms, consumer health care advocates don’t expect an end to out-of-network disputes with insurers.
“There will still be cases where emergency room visits to out-of-network hospitals get denied or an insurer turns down a request for an out-of-network specialist,” predicted Candy Butcher, president of Medical Billing Advocates of America, a clearinghouse for firms that help consumers when they have a dispute over a medical bill.
So, the next time you need out-of-network care, here’s what you need to do. Find out exactly what your plan covers. The recent headlines have sent plenty of employees scurrying to their health plan handbooks to check up on out-of network policies. You should too. Taking the surprise out of the equation can help you decide whether to go out of network, when you have a choice, and can help you plan for your share of the bill.
Most plans offer out-of-network emergency coverage, although the burden may be on you to explain why the situation was an emergency and why you went to an out-of-network facility. H.M.O.’s and other similarly restrictive plans may pay a portion of out-of-network care only in an emergency or when you can prove that the network does not include a specialist you need. So-called preferred provider organizations, known as P.P.O.’s, offer more generous out-of-network coverage, usually 70 to 80 percent of “reasonable and customary” charges.
But there’s the rub. The insurance industry uses that Cuomo-maligned database to calculate what’s reasonable and customary in a local market.
Even if the insurer’s calculations can be trusted, often people forget about or don’t understand the reasonable and customary part, says Tom Billet, a senior executive with the benefits consulting firm Watson Wyatt. “They figure if they have a $100 doctor’s bill, they’ll get a check for $80,” Mr. Billet said.
But the insurer will reimburse you only 80 percent of what are considered reasonable and customary charges in your area. If that number turns out to be $80, your insurer will only reimburse you $64 (80 percent of $80). Your share of the bill now goes from $20 to $36.
The new database should help increase the amount your insurer considers reasonable and customary, but in the meantime you’re on the hook for the extra payment. And even under the new system, 80 percent won’t necessarily mean 80 percent of the doctor’s actual bill.
Find out what your insurer’s reasonable and customary fee is for specific treatments.
Then, call your insurance company asking for prices. If the rep balks at giving you this information, don’t be afraid to remind him or her of a little-followed but important advisory by the Department of Labor that says usual and customary charges should be disclosed to patients, said Cheryl Fish-Parcham, the deputy director of health policy at Families USA, a consumer advocacy group. For more information on the Labor Department advisory click here.
Negotiate with your doctor. If you find out your reimbursement for a specific treatment will be lower than you expected, tell your doctor exactly what the insurance company is going to pay and ask if he or she can lower the fee to that amount. “When they join a network, doctors routinely discount their bills by 35 percent or so, “Ms. Butcher explained. “You should ask for the same, lower rate.”
Prepare carefully for a hospital visit. If you receive care at an in-network hospital you might assume that all the doctors you see will also be in your network. Warning: That isn’t necessarily true.
Your surgeon may be on your network, but the hospital’s anesthesiologist or other practitioner that treats you may not be. Some hospitals have contract practitioners that are not staffers and thus not part of your network either. Be sure to ask your doctor and someone in the hospital admissions office what doctors you’ll be seeing and whether or not they are part of your network. If they are not, find out if an in-network doctor is available.
Even with careful planning you may still end up being seen — and billed — by an out-of-network provider. In that case, Ms. Butcher said, you need to tell the hospital and the doctor that because you were not made aware of the specific extra charges, the out-of-network provider should accept the fee your insurer is willing to cover. There are no rules or regulations on this, but Ms. Butcher said that in her experience most practitioners agree to the reduced rate when patients complain.
If you think you were overcharged — fight back. You have the right to appeal any denial of payment by your insurance company. First step, follow the appeal procedures on your explanation of benefits. Also, contact your doctor’s billing manager and your employee benefits manager for help in filing the appeal. Your state’s attorney general and department of insurance may be able to help you.
Finally, a health care advocate can negotiate with the insurer on your behalf, for a fee. To find one near you click here.
Pleading your case on medical bills is a sound policy
By Bina Venkataraman : Boston Globe | February 18, 2009
When Nicole Stamas of Hudson, N.H., got slapped with a $1,720 bill in November for an ambulance trip between two hospitals that was not covered by her insurance policy, she could not afford it. She's 22, works full time as an optician at Sam's Club, and hopes to start saving money to go back to school to study interior design.
Rather than panic, Stamas remembered reading a newspaper article about a couple who had negotiated a discount on their medical expenses. She wondered if she could do the same. She sought help from a health advocacy group that helped her draft a letter to the ambulance company explaining her financial situation and she included a $50 check from her flex spending account to show the company she had good intentions.
Two weeks later, she received a call from the financial services department of the ambulance company. The company was willing to knock off nearly half her bill and offered her a payment plan of $50 per month, interest free.
If, like Stamas, you are struggling to pay your medical bills, you are not alone. But you might be missing an opportunity to haggle with your doctor, dentist, or even the hospital billing department to get a better deal.
"Not enough people know that medical bills are negotiable," said Andrew Cohen, Medical Debt Program Manager for The Access Project, a Boston-based group that trains healthcare service organizations around the country to help people deal with medical debt. (Cohen helped Stamas with her letter, but says the group is shifting away from giving direct advice to patients.) "Hospitals and other medical providers are often willing to work with people to give a discount or a payment plan."
The best way to keep out-of-pocket medical expenses low, of course, is to have insurance and to choose treatments and doctors in your insurance company's network. But if your insurance does not cover an exam or procedure, you should appeal to the company to have it covered, says Cohen. And whether or not you have insurance, you may qualify to have uninsured medical expenses, including copayments and prescription costs, covered by a public program such as the Health Safety Net.
When all else fails, you can, and you should, negotiate directly with the billing department of a hospital or clinic to have your bill discounted or to get charity services. But Cohen says if you seek public assistance or insur ance coverage first, you will improve your chances of successfully haggling for lower medical bills.
What are the secrets to negotiating a lower medical bill? The Access Project recommends the following: Think and act ahead. Request a cost estimate in advance and be upfront with the provider if you think you will have trouble paying. Although many doctors and hospitals will not know the precise cost until the examinations and procedures are complete, you will be in a better position to negotiate before you receive the care rather than after. Check www.nahdo.org to research the going rate for medical services. As soon as you receive a bill that you cannot afford, contact the billing department of the hospital or clinic to let them know you are having trouble. Don't delay.
Pay in cash. This will both increase your likelihood of getting a discount and protect you from credit card and other forms of high-interest debt.
Make a personal connection. When you call a hospital billing department to negotiate a bill, ask to speak to a manager. Tell your story, don't be shy, be sincere. Explain briefly why you are having trouble paying. If you lost your job, had your work hours cut, or had some unexpected big expense, those can all serve as explanations. But the reason can also be simpler, such as that you have lots of bills piling up.
Write a letter to follow up on your request. Chronicle your reasons for requesting a discount or charity care. This allows you to outline the cost-saving measures you have already taken, such as asking for your insurance company or public programs to cover the expense, and makes your request official.
Be persistent. If you don't succeed at first, keep calling and writing, and ask to speak to people further up the management ladder. Keep careful records of who you speak to and when you speak to them.
There is also another way to save money on healthcare, that doesn't involve haggling over price. Just seek out lower cost medical services at the start.
If you don't mind being a test subject, the Forsyth School of Dental Hygiene at Massachusetts College of Pharmacy and Health Sciences charges $20 for adults and $10 for seniors and children for a dental check-up, cleaning, and fluoride treatment.
Dental hygiene students under supervision by dentists do the work. You can also see if you qualify for free medical care at one of the state's community health centers. For details go to www.massresources.org, click on Health Care Programs, and then Health Safety Net. The safety net is available to residents of Massachusetts who are underinsured or who do not have insurance, regardless of citizenship status.
Advice to the Jobless on Getting Health Coverage
By Lesley Alderman : NY Times Article : February 28, 2009
It's the dreaded one-two punch. You lose your job. Then you have to pay thousands of dollars out-of-pocket for the health insurance an employer no longer provides.
Besides the financial pain, even finding affordable insurance can be agonizing. Which is why today’s “Patient Money” column is here to help.
We’ll talk about steps to take if you have recently lost your job and need health coverage. Next week, in a companion column, my colleague Walecia Konrad will provide health benefits guidance if you still have a job but worry that you, too, could soon find yourself out of work. And who among us doesn’t harbor such fears these days?
Because the soaring unemployment rate has thrust so many people into the ranks of the suddenly uninsured, the government is scrambling to help. The economic stimulus package that President Obama just signed into law provides at least some temporary relief. For one thing, it will be easier and relatively less expensive for the newly unemployed to obtain health coverage under the 1986 law known by its acronym, Cobra.
And earlier this month, Congress passed legislation adding millions of children to those eligible for the Children’s Health Insurance Program — known as CHIP — which covers children in families that earn too much to qualify for Medicaid, but too little to afford private health insurance.
Read on, to see if Cobra and CHIP might be options for you and your family. If not, you’ll probably have to line up private insurance — a process you could start by comparison shopping at a Web site like eHealthInsurance.com.
As you weigh all your insurance options, while considering your or your family’s specific health needs, here are some things to keep in mind. And for further information see the list of resources that accompanies this column.
If you have access to Cobra... Take advantage of it.
Under Cobra, most workers laid off from a company that has more than 20 employees and provides health benefits are allowed to keep those benefits for up to 18 months. But until recently, doing so was forbiddingly expensive. The out-of-work employee had to pay 102 percent of the premiums — or more than $12,900 a year on average for families and nearly $4,800 for individuals, according to the Kaiser Family Foundation, a health research organization.
The new stimulus package at least temporarily changes the rules. If you lost your job after last Sept. 1 and your family income is less than $250,000 a year ($125,000 for individuals), you will have to pay only 35 percent of the premium for the first nine months. The government picks up the rest.
That is a boon for people like Jennifer C. Graham, a single mother who was laid off in December with just five weeks of severance pay. Ms. Graham, who was a senior associate at a Manhattan interior design firm, immediately signed up for Cobra to make sure that she and her twin girls were covered. But the $966 monthly payments ate up more than half of her $1,600-a-month unemployment benefit.
“It’s completely ridiculous,” she said. “How can people get back on their feet?”
With the stimulus relief, her payments will soon fall to a more affordable level: $338 a month. Ms. Graham, who has an M.B.A., says she hopes to have a new job before the nine-month subsidy ends.
Another change under the stimulus package is that if you qualify for the subsidized Cobra benefit, you can also switch into a lower-cost health plan, like an health maintenance organization, if your former employer offers one, even if you were signed up for a more expensive plan while you were working.
If you, or someone in your family, has a pre-existing condition ...You can use Cobra to your advantage, even if you don’t qualify for the new subsidy.
Let’s say you have diabetes, but the rest of your family is healthy. Insurers will charge your family more than the average rate, because you are considered a high risk. In this case, you could stay on Cobra at an individual rate, and buy private insurance for the rest of the family. Look for policies at a large insurance broker site like eHealthInsurance.com, which offers more than 10,000 plans. Put in your sex, ZIP code and date of birth and the site will tell you which plans are available in your area. Many of them have been reviewed by customers, and you can apply online.
If you have children ... Explorekeeping yourself and your spouse on Cobra, or buying private insurance, and enrolling your children in the federally financed CHIP program, suggests Ron Pollack, executive director of Families USA, a nonprofit consumer advocacy organization.
Government plans typically have higher income allowances for children than for adults. For instance, if you live in New York State and your yearly household income is $88,200 or less (for a family of four), your children would qualify for the Child Health Plus plan, which costs no more than $40 a month for each child, depending on your income. For you and your spouse to qualify for low-cost coverage, too, your household income could be no more than $33,075.
Worried about the quality of care your children will receive? According to a recent Kaiser Family Foundation survey, families with children in Medicaid or CHIP programs found the care comparable to what they received under private insurance.
Rules and income limits vary by state. A Web site operated by the nonprofit Foundation for Health Coverage Education has information about the rules in your area
If Cobra is not an option, and you’re young and healthy ...Consider getting a high-deductible health plan that can be linked to a health savings account.
This is a viable option if you expect to have few medical expenses or you hope to have a job within the year — or both. Such plans have low premiums but high annual deductibles — the amount of care you have to pay for before the insurance kicks in. For instance, a family of four in Chicago could find a plan that costs just $398 a month — $4,776 a year — but comes with a $5,000 deductible.
To pay for the out-of-pocket costs, you are allowed, by law, to set aside up to $5,950 ($3,000 if you are single) in a health savings account. This account is not taxed and — unlike a flexible spending account — the money can be rolled over from year to year. But make sure you have the money to cover the deductible, Mr. Pollack of Families USA cautions.
“If you have an unexpected event, say you break your leg, you may be unpleasantly surprised,” he said. “You will have to spend every dollar of your care until you meet your deductible.”
If your income is low ...You may qualify for government-sponsored health insurance, or services, if your total household income is coming from unemployment insurance, if you are a single parent, or if you lost your job because your company moved out of the country.
“A lot of people don’t know these programs exist,” said Phil Lebherz, executive director of the Foundation for Health Coverage Education. Go to the foundation’s site, www.coverageforall.org, and answer the five-question quiz displayed on the home page to find out what services you may be eligible for. Or call the help line (1-800-234-1317), which is staffed 24 hours a day.
No matter what, make sure you have insurance. It is no surprise that studies show that people without insurance end up with less medical care — the harried emergency room staff doesn’t count — and poor recovery rates from serious illnesses. And if you are sick, you will be less able to land a new job with excellent health benefits.
Hanging On to Health Coverage, if the Job Goes Away
By Walecia Konrad : NY Times Article : March 7, 2009
If you’re fortunate to still have your job, but aren’t sure how much longer that will be the case, lost income may not be your only worry. Your medical insurance is at risk, too.
“When you’re still on the job, even if it’s just for a little while longer, you’re in a slightly better position to make the most of the benefits you have now and to figure out your options,” said the Oklahoma insurance commissioner, Kim Holland, a longtime promoter of affordable health insurance.
She and other experts offer the following advice about girding for the worst case.
Use it before you lose it. “My clients wouldn’t want to hear me say this,” said Tom Billet, a senior executive with the corporate benefits consulting firm Watson Wyatt. “But if you feel a layoff is pending, now is the time for you and your family to get physicals, dental check-ups, eye exams and prescriptions filled.”
That’s what Denise Young Farrell is doing. Ms. Farrell, the mother of two children in Park Slope, Brooklyn, lost her job early this year when her department at the Lifetime Networks cable channel moved to California. Her husband lost his job at Bear Stearns last year. Ms. Farrell’s severance package included two months of paid health care.
Check your benefits handbook to see how long your health care coverage will last if you do lose your job. Often, employers will continue coverage until the last day of the month in which the employee worked. So if your last day at work was March 5, for example, you may have coverage until March 31, giving you a few extra days for those doctor visits.
Sign onto your spouse’s plan. If your spouse has employer-sponsored family health insurance benefits, he or she can add you and your dependents anytime during the year. But do be aware of the deadlines. Most companies require any changes to be filed within 30 or 60 days of the “qualifying event.” Depending on your spouse’s company, that could mean the day you were laid off or your last day of coverage.
In addition, some companies require written proof from your former employer that you were laid off. To avoid snags, try to arrange this before your last day of work. And be sure to check when the new coverage takes effect. If your spouse’s plan has a three-month waiting period, for example, you’ll need to find temporary coverage elsewhere.
Get to know Cobra. If you have health benefits in your current job, odds are you’ll be eligible to continue purchasing that coverage temporarily under the 1986 law known by its acronym, Cobra.
Cobra requires employers with 20 or more workers to make health insurance available to a former employee for up to 18 months after leaving the job — regardless of whether you quit or were laid off. But because the former worker must pay the full cost of that insurance, the premiums can easily exceed $1,000 a month for family coverage.
The new federal stimulus plan that President Obama recently signed into law does provide some temporary relief for laid-off workers. But even if you qualify for the subsidy, you’ll still pay 35 percent of the total health premium, compared to the 10 or 15 percent you paid as an employee. So you might be paying $300 to $400 or more a month. And that is for only the first 9 months of the 18-month Cobra coverage. For the second nine months you’ll be paying full fare.
For fuller details on the new Cobra provisions, see the Web site tinyurl.com/akh5mz.
If you do choose Cobra, pace yourself. Time it right, and you can essentially get two months of free Cobra coverage.
After your last day of coverage under your employer’s plan, you have 60 days to sign up to extend that coverage under Cobra. If you think you’re on the verge of getting a new job, or if you’re trying to find a more affordable insurance option, you can put off paying two months of Cobra premiums until you approach the deadline. If the new job or alternate insurance works out, you will have avoided those hundreds of dollars in Cobra premiums. But if you do fall ill or get in an accident in the interim, you will be covered — as long as you pay those back premiums.
Do be vigilant, though, about that 60-day deadline. Miss it, and you lose your Cobra eligibility.
Try to negotiate health care as part of your severance. If you are eligible for any type of severance, consider asking for an extension of health insurance in exchange for a smaller cash payout. That will give you more time to research your health insurance options and help you avoid a gap in coverage.
There is one caveat, said Kathryn Bakich, national health care compliance director for the Segal Company, a benefits consulting firm: Avoid having your company pay part or all of your Cobra premiums as part of a severance agreement. Employers are still waiting for guidance on this point from the Labor Department and other government agencies, but if your former employer pays your Cobra premiums directly, you may be ineligible for the new Cobra subsidy, according to Ms. Bakich and other benefits experts. You’d be better off trying get a lump sum payment that you could use to pay Cobra premiums, if extending your current coverage isn’t an option.
When Cobra is not an option ... If you work for a small company (fewer than 20 employees) that doesn’t offer Cobra, 40 states offer what’s called mini-Cobra continuation coverage that allows you to stay in your group plan. Some states may offer the new Cobra subsidy in these plans. (Check with your state’s insurance department.) If you do not have access to Cobra or a state continuation plan, or if those benefits are close to running out, it’s important to find insurance of some kind, whether it is group or individual.
Federal law mandates that at least one nongroup insurer in your state must provide coverage to everyone, regardless of health issues. In many cases this is your state’s high-risk insurance pool, but there are no limits on how much insurers can charge for this coverage, so premiums can be extremely expensive. For more information on what your state offers, go to the National Association of Insurance Commissioners’ Web site, naic.org, to link to your state’s insurance department.
If you have a flexible spending account — use it. Here’s a little known bonus in the employee’s favor:
Let’s say you signed up to contribute $1,000 this year through payroll deductions to your health care flexible spending account. So far you’ve only put in about $200. No matter. “Companies must still reimburse you for the full amount you’ve elected even if you haven’t contributed the total to the account yet,” Mr. Billet said.
In this example, if you file claims for $1,000 of eligible health care expenses before your last day on the job, you will get the full reimbursement — not just the $200 you’ve paid in.
Correction: March 7, 2009
An earlier version of this article posted online misstated the deadline for signing up to extend health care coverage under the law known as Cobra. It is 60 days, not 63 days, after the last day of coverage under a former employer's plan.
Why Patients May Be Billed for Free Exams Coding-System Confusion Can Cause Insurers to Deny Coverage of Preventive Care
By Anna Wilde Mathews : WSJ Article : May 21, 2009
Imagine going in for a free medical screening and then being hit with a big bill. It's happening a lot these days.
Company health plans increasingly are offering to pay the full cost of preventive services such as physicals, colonoscopies and mammograms to help employees stay healthy. But some patients then find they owe money for such screenings, sometimes hundreds or thousands of dollars, because their insurers didn't consider certain procedures preventive.
When the mix-ups stem from simple billing errors, consumers may be able to get them corrected quickly. But sometimes patients are stuck with unexpected bills, or have to wage a protracted battle to get them reversed.
Donald Carpenter thought he'd have to pay nothing for the screening colonoscopy he scheduled after his 50th birthday. Instead, the Nashville, Tenn., accountant was billed more than $1,000. Besides the screening, Mr. Carpenter's doctor had removed some polyps, and the insurer hadn't classified the doctor's work as preventive. So Mr. Carpenter was charged what he would owe for a typical surgery.
Paying Up Patients are sometimes billed for preventive screening exams that their plans cover at 100%. Here's how this can happen:
Unfortunately this isn’t something you can do with one phone call. First ask your doctor, or better yet, the person in your doctor’s office who handles billing, for the “C.P.T. code” — the current procedural terminology — for the test, treatment or consultation you’ll be receiving out-of-network. Get it in writing to avoid errors.
- A problem can occur when a doctor's office doesn't use the specific billing code that insurers classify as preventive.
- Patients unknowingly may have received care, such as additional testing, that their health plans don't consider preventive.
This type of billing problem is tied to the system of codes that doctors use in the claims they send to insurers. Every service performed by a physician is translated into a code. So is the patient's diagnosis. Based on those codes, insurers automatically send out payments and generate explanations of benefits for consumers.
Health-care providers must choose from among thousands of separate codes, which are developed by medical groups and government agencies. Patients get socked with unforeseen bills when their doctors' offices don't use the specific codes that their insurers classify as preventive.
The diagnosis code for any screening exam should begin with the letter V to indicate the care is preventive. In a claim from a doctor's office, this is separate from the procedure codes that explain the services the physician is billing for. A screening mammogram, for instance, could be billed as 77052, for a digital screening mammogram, or 77057, for a traditional screening mammogram.
Sometimes, the doctor's office makes an error or doesn't know the insurer's procedures, which vary by company. For instance, an annual preventive-care exam, which a health plan might pay for in full, can mistakenly be described in a claim as a typical doctor visit to deal with a patient's existing symptoms. That could result in the patient being billed for various charges, including a co-payment or a deductible.
Other times, surprise bills arise when a patient unknowingly received some care the health plan didn't consider preventive. Margo Opsasnick, chief executive of Delta Medix, a physician practice in Scranton, Pa., says doctors sometimes order more views of suspicious masses they spot as they are doing a screening mammogram. This then gets billed as a diagnostic mammogram, which deals with existing symptoms, rather than a screening, which is for people without any specific signs of risk. For patients, that shift could mean new fees.
"What's the doctor going to do -- say we saw something but we don't want you to be charged for it?" says Ms. Opsasnick. "It's a catch-22."
John Duffy, a sales associate at Hammond Lumber Co. in Farmington, Maine, says he was charged about $200 for lab tests his wife got as part of her physical two years ago. He says the insurer told him the problem was the coding on the claim, which signaled that the tests were for health problems she already had, not for screening. But the doctor's office wouldn't change the codes.
Some sound advice about your bills and how to avoid problems
- Understand as much as possible about your insurance benefits.
- Keep the benefits booklet and take with you to the billing department.
- Do not ignore a medical bill and just put it off until another time.
- Doctors offices and hospital will work with you. They also want to be paid, so it is in their best interest to help you. Discuss this with them in a quiet and respectful way. Do not approach this in an entitled, rude and angry way. You will find people more willing to help you if you are reasonable and pleasant.
- Everyone "thinks" they have the "best insurance plan" and that it will pay for everything...........unfortunately it rarely lives up to expectations.
- Remember to pay your co-payment at the time of your visit. It is YOUR responsibility and is mandated by your insurance company.
- If a referral to a specialist is required or a prior authorization for a particular medication or study is needed, make sure that this has been taken care of BEFORE the procedure, visit or study. Your insurance company can refuse to pay and then the bill will be YOUR responsibility. It is almost impossible to have this back dated especially as they are transmitted electronically. This is a common mistake that patients make. Unfortunately this is the reality of the times we live in and most insurance companies have some form of prior authorization rules in place especially when it comes to expensive procedures or studies.
- Before seeing specialist make certain that they not only are on your health plan, but that they accept the health plan reimbursement in full. If a referral to see them is required, see that this is in place, otherwise your insurance company can refuse to cover the visit and it is YOUR responsibility.
Fighting Denied Claims Requires Perseverance
By Walecia Konrad : NY Times Article : February 6, 2010
Maria Carr, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.
Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.
“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.
Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.
Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.
But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.
“I decided I would fight,” she said. “After all, what did I have to lose?”
Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.
The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.
The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.
UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.
“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”
Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.
Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.
Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.
Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.
But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.
“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”
Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.
READ YOUR POLICY
Always check your policy carefully before you undergo treatment.
Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.
TAKE YOUR TIME
When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.
Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.
Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.
Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk.
Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.
DO RESEARCH
Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.
Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.
Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.
You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.
Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.
You also must prove the medical necessity of a treatment, especially if it is considered experimental.
Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.
For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.
Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.
GO THE DISTANCE
Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.
If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.
In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.
Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.
GET HELP
Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.
Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.
You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.
By Walecia Konrad : NY Times Article : February 6, 2010
Maria Carr, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.
Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.
“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.
Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.
Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.
But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.
“I decided I would fight,” she said. “After all, what did I have to lose?”
Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.
The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.
The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.
UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.
“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”
Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.
Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.
Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.
Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.
But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.
“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”
Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.
READ YOUR POLICY
Always check your policy carefully before you undergo treatment.
Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.
TAKE YOUR TIME
When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.
Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.
Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.
Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk.
Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.
DO RESEARCH
Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.
Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.
Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.
You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.
Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.
You also must prove the medical necessity of a treatment, especially if it is considered experimental.
Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.
For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.
Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.
GO THE DISTANCE
Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.
If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.
In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.
Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.
GET HELP
Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.
Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.
You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.
