ABC ... 123 ... Know your ICD9s & CPTs

Part of me wants to break out into song....or cryout Bingo.

Recently I had a Nuclear Bone Scan to determine the level of bone remodeling around the tip of my hip implant in my femur, to see if there is a difference from before "failed implant" status. Today I received a Lovely call from my local hospital saying I had a copayment of $649.00 for the scan that has a base cost of $2456.08(per the negotiated rate between my insurer and my husbands company). My policy is a 10%copay up to $2500 "out of pocket" maximum per year.

Before you have any conversation with an insurance company or a provider, especially if they have differing opinions arm yourself with these basics to sort out what may be the difference of a extraordinarily large out of pocket fee.

Know your ICD9s (diagnosis codes) and CPTs (procedure codes). These numbers are the most critical for determining whether or not the procedure you are having is covered and at what cost to you and the insurer. At a later date I will discuss the fascinating world of codes and how they make the difference between being paid and not. Sometimes there are alternatives.

Check if provider verified your benefits via a phone call as opposed to on-line.

Ask for a contact ID or name of person you speak to and take notes of the converstaion. As the person if there is a contact ID that tracks the call/conversation. Some insurance companies use representatives names

If there is a discrepancy, request a conference call with your insurer and provider. They usually will try, especially your insurance company.

Hard lessons of Cobra, Medicare, and "Qualifying Events" or All I want to do is go on a Honeymoon!

Today, for the first time since my last surgery of 6 weeks ago, I was relaxed, lighthearted, feeling good. I was finally feeling like I could look across the horizon rather than being bogged down in my small recovery world. I was even preparing a blog post on healthcare issues I have been thinking about, especially a recent new experience I have had. A really positive one.

Great...I was starting to expand my life beyond immediate day to day dealings with healthcare, or the bureaucracy of healthcare...And, then ... you probably can tell...a Large Huge Bummer came from the sky....make that two:

#1: We have been living on my husband's COBRA since he was "separated" from his job. That is nearing it's end. He has been doing contract work, which has been good, but no benefits. We understood that we likely are eligible for an extension of Cobra due to my LTD (Long Term Disability), well today after countless calls over the last two months to the HR department from his company (which has been outsourced) we were told the "qualifying event" of my disability and receiving of Social Security had to occur within and only within  2 months of his being terminated, not after his severance ran out, or when we started COBRA etc.. so it is highly likely we will not qualify for a COBRA extension. The COBRA folks need more info from SS to determine whether or not we are eligible for "the qualifying event". Don't you love those words? I don't! (or at least do not find humor in them today)


#2 I call Social Security to get the needed documentation. They let me know when I started receiving benefits...which makes me think maybe we are not eligible for the Cobra extension which ends in 2 months. YIKES! So, I ask about the worst scenario case for me and my ability to get Medicare, since I think I am eligible. Well, apparently:

1. Since I declined Medicare, which I did because we had good medical coverage and I was trying to save money not to pay two premiums for medical insurance, I was told that for each year of not taking medicare I pay a 10% penalty fee. The agent said, "The good thing is that premiums are dropping next year".
2. I am not eligible for Medicare special enrollment (which means that you can sign up for it anytime if you have a "qualifying event"), because that is tied only to the "qualifying event" of my husband losing his job, not to the severance package period, or to Cobra benefit period. (Oh Shit)
3. I am eligible for Medicare "Open Enrollment" in January of 2012. I would have to pay the penalty of 10% per each year of decling coverage....and, only after 6 months would I be covered....so that means there is a likely scenario I will not have medical coverage (Medicare) until next July.

Well, there went my day... too pieces. Unfortunately I am not like "some" who can deal without coverage. My condition is in constant need of attending. Maybe I will have to throw the dice and hope next year slows medically down after each year of surgeries, sometimes a couple or more. 

All I know is that the harsh reality of my life is that there is never a respite from constant medical attending be it bureaucratic or physical. I am pissed with myself for missing the boat on this. I normally am on top of all things disability, insurance, but I screwed the pooch on this. 

And, today, as I hoped to feel the release of the grip of the chains, and stoke the joy I had from yesterday's  Moose spotting on a drive my husband took me on, to have distance  from being a patient and the shit that comes with it. I am back into the fray again to sort out the details and make the best I can out of a bad situation. 

Not up for it today....and not sure how we are going to make this work.  Other people do so I guess I have to figure it out or not. The bottom line is that I am sick and tired this whole thing is my life. 17 surgeries, fighting for benefits, fighting for rights, fighting for care, plan ole fighting. Thank goodness I have great doctors, from whom I have to travel 1900 miles, and pay for the extra rent. But that is good...I would not even be writing this without them.

I close this with....I just want to go on a honeymoon with the man I love (we haven't yet because we keep needing to go to Colorado, for my doctors to keep holding me together). He has stood by me, going through surgery after surgery, rough spot after rough one, and the continuing onslaught. I thank him and his encouragement for that. He is steadfast in times of trial and tribulation. He is a solid compass and always says don't worry, we are going to be ok. We have so far been so. I guess I need to rest my rage in his caring hands, even when he is unsure of his future....that is courage....and I should take a lesson in that.

Tips for Understanding your Medical Insurance

Dealing with and understanding any medical insurance requires some talent, patience, and mostly perseverance. What happens when you have to change policies? That can be a stressful experience. 

Recently, I had to change from my fabulous traditional indemnity policy (straight 80/20 split) with no distinction between in- and out-of-network benefits) to what is considered by modern day standards pretty darn good insurance a PPO - Plus (boo hoo). The "Plus" only means you have additional out of network benefits.

After I whined and moaned for a while about my fate, I decided to bootstrap it and understand the new animal I was dealing with. And, boy, can it be complicated. Pay special attention to the language; it can be very obfuscating.

Here are some basic questions for the insurance company

1. How do copays work? Do they apply to deductible? Most don't.  That is simply what you pay out of pocket. Your deductible is the "co-insurance" part of the deal

2. What is the definition of in-network and out-of-network benefits? It is important to understand what they mean by whatever breakdown figure they use (for this example I am going to use a  70/30 split).

   What you will ultimately pay is not necesssarily based on what the doctor bills you. It is dependent on what the insurance company deems as "allowable". (And, all use different fee schedules there are no federal or state guidelines, although all insurance companies go off certain standard metrics).

   So, let's say you get a bill for $150 for an out-of-network doctor. Your insurance company may say that $100 is allowable by their schedule. They base their reimbursement on the allowable fee of $100. So, that means they pay $70 and you pay $30. The other shoe that will drop for you is the $50 that insurance did not allow. The docts office will "balance bill" you that amount + your coinsurance. So, your total out-of-pocket costs will be $80. (Sometimes, you can get a doctor to write off that $50, but you have to be proactive and ask.). This is not the same as a co-pay.
   

The other part of the equation is to understand how you provider works with the insurance company. Usually, doctors offices know who they contract with and who they don't. Remember it is your job to ask, so you know what your cost could be. 

There are many flavors of the same insurance company. Just saying Anthem won't get you very far. For instance, Anthem in California is only run by Blue Cross (not both Blue Shield and Blue Cross). You need the specific insurance info, which is determined by ID and Group numbers on your ID card. Those numbers do more than simply identify you and will let you know what the score will be. Think of it as your medical credit card with your personal rate information.

1. If you are not sure how your new insurance will treat a provider (this is usually only significant in the out-of-network scenario(s)) You can always ask for the diagnosis code(s) (ICD9) and procedure code(s) (CPT) the docts office will use for your treatment/visit.

   Then go back to the insurance company and ask to run a test claim. That should give you a good guideline on how insurance will pay. When you do this, make sure to ask if the call has been recorded, and always take good notes that summarize the discussion and outcomes (include name of person, date, and summary). Insurance companies always say that no claim quote is valid until it is completely processed. Good data is key. In the event that something goes wrong, you can point to the conversation you had. It is always more difficult to recreate your memory.

2. If you go to a hospital in your area, make sure you find out if both the facility fees and doctors fees are covered. Ask this of the billing department. The receptionist checking you in is often not a reliable source of information. I have come across cases where the facility is covered but not the doctor (i.e. radiologist, pathologist, emergency). It is a serious drag to not know this in advance. You think you are all covered, but then you get a $450 or more doctor's bill.  

   The hospital is generally not proactive in telling you this (unless you get someone who is on the ball, which in my experience is not very often.) Tell me, how many times have you asked the same question from multiple representatives of a facility or insurance company and gotten as many answers? Please note: Most say, that they do a courtesy billing. That does not mean that they are preferred providers of your insurance company. 

These are some simple techniques to help you better manage your costs. Until our medical system changes and patients have better consumer control over their costs, these simple techniques have been the only way I have some measure of understanding and controlling costs.

I highly recommend doing these basic steps before you need to use services. An emergency can happen at any time, as I have found out the hard way. Once you get a handle on what the expenses are (especially your out-of-pocket ones) before you have any treatments, procedures, etc... you will be much better in control of your outcomes.

Never assume, always ask questions, because it is in your best interest to manage the nuances of your healthcare and be a better CEO of your healthcare and body.

How much is my Time Worth in this land of Mediocrity

Yesterday, I spent over 3 hours on the phone for one medical bill worth 270.00, that I am not exactly keen to pay because it doesn't seem fair to be dinged for a bill I recieved over 1 year post the procedure.

Increasingly we seem to becoming a land of abject mediocrity. Nothing is clear, followed through on properly, and then it seems to be spewed back at the consumer. This particular case is for a bill, from a provider of durable medical goods, that I frequently use following my multiple orthopaedic surgeries. Over the years I have seen nearly 5+ bills from this company that has an agreement with my insurance company. I have never needed to pay out of pocket, since usually, by the time I have surgery, I have reached my out of pocket max.

This time, something went really wrong. I received a bill over a year post surgery, stating that I owed $759.00, because I did not have insurance coverage at the time.  When this came to light, I contacted them directly, providing them with the correct ID (you see my company went through a transition and our insurance cards changed numbers). I thought that should make this go away. Well....Not!

I generally take the stance if I do not receive a bill then I should be ok with said provider. After not hearing from them for months, I received a collections letter for the amount due. I immediately called, requested to speak to a manager, who immediately said I was responsible, I signed an agreement with them for the insurance ID I provided and therefore, if something was wrong I was responsible for the amount. This immediately sent my hackles up. First, they make you sign papers as you are coming out of surgery and full of anesthesia, with blurry eyes, and doped to the max.  I typically do not remember what happened post surgery, so, how do I remember a specific number? It is like asking a drunk person to drive you home.  Anyway, I didn't know the insurance ID changed (everything else from that surgery was completely covered). Someone got the correct ID. I told the manager that I had called previously with the corrected info, but apparently the info did not get reprocessed with insurance. He said there was no documentation of the call. (Now this is where a on top of it patient can go back and look at notes of calls and name a person that they spoke to and the date. Unfortunately I could not find any record of this conversation, so shame on me). the discussion spiraled into an I said he said conversation. At the end, I said this can be solved easily by getting it reprocessed with corrected info. He then started squawking about a penalty for late filing, etc.... Patients typically have a longer timeframe to have claims processed (usually 18 months) than providers (I think 6 months). He seemed to agree to let me do that and hold the account. I called insurance, explained the situation, and they reprocessed it on their end. I expected that they would cover the charges in full (as they have typically done for the same charges). In fact, I just received and EOB for same equipment for my 08 surgeries, leaving a zero balance.

Insurance did not pay things in full. Frankly, after looking at the math over the series of multiple reprocessed EOBs I cannot ferret out exactly what insurance paid. The $ don't add up. According to the company insurance left a balance of 271.59. I received a call from the collector last week to pay the amount due. I told them since insurance paid I would like to work something out with the provider (Orhto Rehab).  They gave me a week to sort it out.

Part of me was thinking, shit, just pay it, and get this off your plate of things. I sat on that, but, the niggling feeling of injustice and that this just wasn't right sat with me.  So, I rolled up my sleeves and started calling all the numbers for Ortho Rehab. I was thinking of finding a VP to complain to. I called a different number for Ortho Rehab for my current bill to see if they could help. The original call center, in Arizona, was not helpful. The Denver call center did not know about Arizona, so I was again stuck. My brain and irritation was driving me to distraction.

Then I had a bright idea, why not contact the sales rep who provided me with the "goods" for my latest surgery. She was nice. I did get her number.  I called her, and she provided with a name of a person at the Arizona call center who may be able to help me out, or at least point me in the right direction. I contacted Mr Forrester. He picked up the phone. I explained my situation, he said he would look into it and try to help me figure out how to make this work to an amicable resolution. He was able to pull up my payment history, see how many times I have used their services, and wanted to assure me that they were about customer service. I said, wow, this is the first time anyone within the billing department took a big picture view, and that I was appreciative. We parted on good terms promising to resolve this in the near term.

And, so that is where things stand. I am not sure if the bill will be written off, but most importantly I found someone, who seemed to appreciate my situation, had initiative to look at my history, and was willing to do the right thing and figure out what happened, especially, given my history.

The lessons for me and others here should be:

1. Stay on top of complex billing situations.
2. Write down notes from any conversation you have with anyone about a bill or any complex situation.
3. Trust your instincts. If something doesn't seem right, it probably isn't.
4. Be creative about how you approach a problem. Or, sometimes doing the same thing over and over, you will get a different response.
5. Leverage your payment history (if it is good) or customer history.
6. Leverage insurance payment patterns if something seems different.

Now, I have to deal with several more of these types of bills, the next one is for $17K that insurance keeps telling me they did not receive the records they needed to process it. Although I have a note stating they had them in Dec. No rest for the wicked it seems. 

More about Medical Bills and the Insurance Morass

Following up to my rant/post yesterday I want to share two articles on dealing with the medical bill morass.

The first outlines some of the important techniques that can be successfully employed to help reduce out of pocket costs. It comes from a real life experience of a couple that tackled their spiraling costs. I have used a number of the techniques and it mostly works. Sometimes, like I said yesterday, it is random based on who is on the other end of the line. So, it always good to try and try again. 10 Ways to Cut your Medical Bills

Another article a couple of days ago addressed how a family member stepped up to help advocate for her brother. Negotiate Your Medical Bills And, through Htzpah, persistence, looking over an itemized bill for a hospital visit (that is enough to make anyone sick) -- Crimminy, up to $10 for a Tylenol pill. It is a sad state in this country that we have come to this.

In addition to some of the techniques identified I use the following:

1. Always, Always, keep notes for each conversation. Write, the date, who you spoke to, what about, and followup action item. This is useful when some action agreed to does not happen (no matter who it is) you can leverage that they said that they would do x, y, and/or z. Lack of Followup is great leverage.
2. When you review a bill, there are CPT codes associated with the charges, if the charge has been denied by your insurance company, find out why, then go back to the provider of services and see if they can legitimately change the CPT code (sometimes they can) and re-bill.  That has helped save me money in a number of circumstances. Each insurance company has slightly different policies and coding. I am beginning to see this as a new pattern.

If all this too much to do on one's own, or if, one doesn't have a family member, there are always professional advocates, who charge a fee, however, the reduction of stress of dealing with, let alone understanding, EOBs ( "Explanation of Benefits" for the luckily uninitiated), medical bills, insurance policies, and negotiating down the bills, may be worth the up to $80/hr fee some people pay. Benefit Advocates Help Reduce Fees.

Those are my hot insurance billing tips of the day. Good Luck and give a shout if you have further suggestions or need help.

Random Resolutions: Keep on Calling your Insurance Company

Most people may think that being a chronic patient allows for swathes of time and relaxation opportunities, in between medical appointments and other healthcare activities. Well, I can attest that is entirely not true. I cannot keep up with nearly anything. If I tried to not live any type of meaningful, proactive life, maybe there would be time. I have become passionate about not being complacent in the system -- this includes treatment, billing and insurance, and rehabilitation -- easily packaged as wanting to be an empowered patient, which is a full time job.

After all my broad medical experiences over the years, including treatment and consumer challenges I cannot simply blindly believe what anyone has to say, which can make me a pain in the ass to some, but my own best friend. It is exhausting and sometimes incredibly frustrating, but, if I don't do it, no one will.

There are so many times, I could just walk away from an insurance debacle or medical procedure decision and, just avoid dealing with them. And boy there are times I have, but I find I have to drag my sorry ass back to the table because I wouldn't be able to stand myself for giving up.

Here is a short story about dealing with insurance, which resulted in a success story, but when you consider the method of resolution I think it is immensely frustrating:

I have found nearly 9 times of 10 with insurance/billing problems the more I simply go back, make another call, find another operator to speak to, I can resolve my insurance/billing issue and have them pay, or get the doctor to write off charges.

Recently on one series of bills, it took 5 or 6 times of sending the documents insurance said they needed/didn't have to find out that they never undated the newer documentation in the system. In and amongst those 6 calls one insurance operator for Aetna, said, Mam, you need to appeal, that is all you can do. I threw my hands up, but several weeks later (2 weeks ago) I tried again, and finally got a reasonable rational result. The result I originally expected which is that insurance should have paid the charge. The bummer is that the result was merely achieved by persistence, nothing really savvy, but not giving up. It is frustrating because it is random. There is often no rhyme or reason and that sucks.

The lesson of the day: Keep on Calling!

The insurance quagmire -- enough to make your sick!

Today, was one long day of digging into the insurance nightmare. I am boggled how medical billers (doctors, hospitals, any medical provider etc) charge the amount they do for services, or sometimes they don't charge for services. Sometimes insurance pays far more than I think they should, and other times, they have these bizzare rules that make, what seems like a legitimate charge ineligible. It is completely random. I have over 5" of Explanation of Benefits (EOBs, in industry speak) for this year. That is over 2 reams of 500 sheets of paper. It is insane. What is more insane is that I, as the patient, am stuck in the uncomfortable middle. There is no transparency in the medical billing/insurance system. It is totally fucked up! I as a consumer have almost no rights, which seems completely wrong. All I can go by is my hutzpah. Sometimes that only goes so far. There are times I simply pay because I am too exhausted to fight.

There are so many different types of billing schedules for every variety of insurance plans offered within a single company (i.e. PPO, HMO, traditional indemnity, other flavors of indemnity, etc...) and then add across all companies. It is insane, and a huge time synch to fight for your rights. It is bad enough to deal with a series of cascading health events. Then, add the stress of insurance. No wondering why our country is in the hole with medical care. I really hope with the new administration there will be leverage to improve (what I really mean is overhaul) the healthcare system in our country. I hope that some healthcare 2.0 initiatives take on insurance issues, including patient advocacy.