New Requirements for Health Insurers

Did you know that by March 2012 the Department of Health and Human Services will require that all health insurers provide easy-to-understand information that clearly states the plan's annual premium, dedictible, exclusions and other costs?  This is to help consumers wade through all the confusing definitions, rules and exclusions so they can make effective decisions when choosing health insurance.   When in doubt, always verify any information that is confusing or you may not understand with your Human Resouces Manager and/or your insurance broker.

Health Vault

I came across an article the other day about a way you can keep your medical records and reports online and easily accessible.  I haven't really delved into it yet, but from what I see, it looks like it would be worth a look-see.  It's call Health Vault....      www.healthvault.com

You need to sign up for it and create a user name and password.  Once you've gone through the free registration you will be able to:

Get your medical records in one place:

You can track and manage prescriptions and chronic conditions, organize your medical records in one place so that it's available to you when and where you need it.

Prepare for an emergency:

Whether you travel, have kids, or are a caregiver, getting timely information to the right person can be vital.

 

Tools to care for your family:

With all of your family's info in one easily accessible place, you're always prepared, for everyday doctor visits or emergencies.

 

There is also a Get Healthy section where it gives you tips on firing up your fitness program.

 

Thee is also a Newsletter you can sign up for that will keep you up with the latest health tools and tips.

 

I know I'll be looking into this soon, and will share any further ideas I have about it with you. 

 

http://www.microsoft.com/en-us/healthvault/get-healthy/fitness.aspx 

Challenge Questions 6 - 10

Now you've had a chance to test your knowledge on a few insurance basics.   Of course, like any good teacher would tell you, there's always room for more.....which brings me to questions 6 - 10.  They're still basic concepts, but hopefully you'll learn something new from these questions.

True or False

1.      Your doctor can make you pay the contracted adjustments that are not allowed by your PPO insurance that he participates with.

2.      You can only have one insurance policy for billing purposes.

3.      If you go to a contracted provider that takes your insurance, the provider must write off all of the contracted adjustments.

4.      Your doctor can share information about you to other sources without your permission.

5.      Your doctor can bill you for your deductible if your insurance applies it towards his claim.

I'm Back - (Pre-test Questions #1-5)

As you may have noticed, I haven't been posting for the last two months.  Summer has arrived along with my very first grandson Carter.  It’s been a crazy couple of months.  My daughter developed a severe form of pre-eclampsia called HELLP.  It's basically where your liver gets out-of-whack and the enzymes start destroying your red blood cells, as well as your blood pressure goes sky-high.  Needless to say she had to have an emergency C-section under general anesthetic and blood transfusions.  Baby Carter was in the NICU for a week (as he was 3.5 weeks early), but all is well with both mother and baby now. 

Back to the Blog:

For the next couple of weeks I'll be giving you some challenge questions.  These questions all come from my ebook in the form of a pre-test.  Hopefully after you've read my book, you will know the answers to these questions. I'll post five questions at a time and you can see if you know the answers.  If you do, you can email them to me or respond on my blog.  If you would like the answers, email me as well.  I haven't decided if I'll openly post the answers yet or not. 

True or False

1.      Your doctor can charge your insurance company any price that they want.

2.      If you have a HMO, you can go anywhere you want for services and your insurance company will pay the charges.  

3.      A deductible and co-pay mean the exact same thing.

4.      All insurance companies pay the same.

5.      COBRA law allows you to purchase health insurance if you get laid off.

Good Luck

Happy 4th of July

Make it a Happy and Safe One and Remember to Honor Those who Fought for our Freedom!

Insurance Webites

Did you know that with most insurance’s you can review your claims on their website?  I for instance have Anthem Blue Cross Select.  I found their website (the information is usually on the back of your insurance card) and signed up.  In order to sign up, you will need to have your insurance card handy and a valid email address.  Most websites will ask you questions and have you click the “I accept” disclaimer in order to join.  Once you’ve gone through the steps of setting up your account and password you would just log onto the website.  I recommend you save the website to your “favorites” so that it’s easy to find.  You will now be able to look at and print your claims.  There may be claims that say “processed, pending or rejected”.  You would just click on the one that you need and it will show the charges, what was allowed, what went towards the deductibles or co-pay, what the provider was paid, or what wasn’t paid and why.  Every member in your household will need their own sign in name, password and email to access claims.  

You can also find providers that are contracted with your insurance company.  But beware….just because they may be listed, doesn’t mean that they’re current.  If you find a provider that you want to see, call their office and double-check that they take your insurance.  Not all insurance companies keep their providers lists up to date, and providers may drop out of the plan, yet still show up on the website.

The website may also have information on wellness, health assessment, treatment- cost- advisor, compare facility cost and quality, your health record, a place to compare plan coverage options and a glossary/definition area as well.  These are very handy tools to have at your disposal.  There’s may even be a place where keep track of what money went towards your annual deductible and out-of-pocket expenses.  Not all insurance companies have the same information on their websites, but they’re great to utilize if they’re available and I would recommend that you start using it right away.

HMO's

HMO:  (Health Maintenance Organization) Health HMO’s are a form of Managed Care Organizations. The HMO agrees to provide health insurance coverage through hospitals, clinics, doctors and other providers with whom they have a contract, thus you are limited to providers that are contracted with your HMO plan. You must select a Primary Care Provider (PCP) who acts as the “gatekeeper” of your health needs.  He will be the first line of contact when you need to be seen or referred to a specialist or ancillary provider.  There are also “direct” referrals, which mean that he can give you an order for a service that does not need authorization or permission from your HMO.  This might be a lab test or simple x-ray.  Then there are the types of specialists or procedures that need “authorization” from your HMO.   When deciding to choose an HMO vs a PPO, make sure that the providers that you generally see are contracted with the HMO, otherwise you may have to establish relationships with a whole new set of medical providers.

COBRA Insurance Coverage

COBRA

Did you know that you may be able to continue your health insurance coverage in the event of a layoff?  If you meet the criteria, you and your currently covered family members may be eligible to purchase your insurance through COBRA coverage.  If you work for an insured employer group of 20 or more employees, Congress passed the landmark Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986 that lets you continue to purchase health insurance for generally up to 18 months if you lose your job or your coverage is otherwise terminated, and in some instances may permit a beneficiary to receive a maximum of 36 months of coverage.  Group health coverage for COBRA participants is usually more expensive than health coverage for active employees, since usually the employer pays a part of the premium for active employees while COBRA participants generally pay the entire premium themselves. It is usually less expensive than individual health coverage though. 

ABN's (Non-covered service form)

ABN

Advance Beneficiary Notice of Non-coverage

There may be an instance when you want or need to have an exam or procedure that insurance will not cover.  In this case, the provider may have you sign an ABN (Advance Beneficiary Notice of Non-coverage), which states that you may be responsible for the charges in the event your insurance company does not pay the charges.  An example of a non-covered service would be fertility testing.  Most insurance companies will not pay for any fertility testing and your provider may have you sign an ABN before any fertility examinations or procedures are performed.  You can ask your provider if they will discount your bill to “insurance rates”, (what your insurance would pay them if it were a covered benefit), but chances are they will ask you for the full payment up front when you come in to have the service.  You can also ask them to bill your insurance company, but chances are your insurance company will deny payment.

EOB’s (Explanation of Benefits)

EOB’s are the reports you get from your insurance company.

Not all EOB’s are identical, but they may have all or some of the following information ~

                       

Patient Name:                              This is the patient that is receiving the services.

Insured’s Name:                          This is the person who carries the insurance policy under them. 

I.D. Number:                                 This is usually on the front of the insurance card and identifies the patient.

Group Number:                           This identifies which group health insurance the patient belongs to.

Patient Account Number:       This is an identifying number the provider-of-services assigns to the patient.  (Each provider has their own patient account number.)

Claim Number:                            This is a number that the insurance company assigns to each claim to identify it.

Dates-of-Service:                        The dates you were seen and had services.

Units-of-Service:                         Denotes the amount of something provided, such as charged hours or medication amounts.

Billed Amount:                             What your provider billed the insurance company.

Allowed amount:                        The amount your provider is contracted to bill the insurance company.

Contractual Adjustment Amount:  The contracted amount that has to be written off the charges.

Notes:                                              Denotes information pertinent to the claim/charges.

Deductible:                                    The dollar amount applied to your annual deductible on the claim.

Co-Pay Amount:                          The dollar amount applied to your annual coinsurance on the claim.

Amount Paid:                                The dollar amount the insurance company paid to your provider.

When calling your insurance company about a claim, always have the EOB available as you will likely be asked information directly from it.

QUESTIONS - QUESTIONS - QUESTIONS

My daughter suggested I open my blog up to a question and answer page.  I’ll look into trying to create a separate section just for this, but in the meantime, if you have any questions, what-so-ever, I’ll try to answer them to the best of my ability, or direct you to the proper resources that can help. You can add a comment to any question or comment to any posting or email me directly.  Did you know there is an entity that you can report suspected insurance fraud?  A group that helps with Medicare related problems?  Did you realize there are even laws that regulate and govern health insurance and those who are responsible for administering it?   There are no “wrong” questions to ask.  Now here’s my question…. who will be the first one to ask me a question?

REFUNDS, REFUNDS, REFUNDS

My youngest daughter recently went through some rather expensive claims, where we saw #1) Nurse Practitioner , then a few days later #2) Went to the emergency room, had ER charges (facility) and separate ER Physician charges (professional)  and lastly was referred to #3) ENT/Plastic Surgeon.  Our deductible is $500.00, than they pay 80% up to $1500.00, then100% thereafter.  Needless to say, she’s met her deductible and were well on our way to meeting her out-of-pocket.  Here’s where the refund comes in.  When we finally made it to round #3, the physician charged us a consultation and then did an office surgery on my daughter.  Our insurance has a $20.00 co-pays for office visits/consultations.  We paid that, as we realized it was due.  The next part of the bill was for her office surgery.  This was charged separately from the consultation and billed accordingly.  The charge for this part of the service was $345.00; insurance allowed $189.96, and the write off was $155.04 (patient savings for going to a preferred provider).  The $189.96 went towards our deductible, which we paid up front.  Nine days later we had to go back to the physician for a follow-up on her surgery.  Again we were charged a $20.00 co-pay which we paid up front.  Around two weeks later I received an explanation-of-benefits (EOB) from our insurance company stating that the follow up visit was included in the surgical fee.  Benefits are not payable for this as a separate expense.  Okay, so I figure I’ll be getting a check back for the $20.00 we paid up front.  First week goes by, nothing.  Second week goes by, nothing.  At this point I call the physician’s office and ask for the phone number to his billing office.  I’m tell them who I am and am told back that they do their own billing, the biller is on another line and will call me back.  This is usually code for, “take a message so I can see what’s going on with the claim.”  About thirty minutes later “Karen” called me back.  She said that “yes, we are due a refund, she will send the information to the bookkeeper and we will either get it this week or the following week.” Having worked in a billing office, I frequently used the line, “Your refund request has been sent to our bookkeeper and it will take about ten business days to get back to you.”  Truth-be-told, our “bookkeeper” was ten feet away from me in another room.  When you use the term “bookkeeper” it sounds like an accountant’s office in a whole other building. Do you think I would have automatically received our refund if I had not called the doctor’s office?  My guess is probably not.

Today’s lesson:  It’s important to scrutinize your EOB’s and make sure you follow-up on refunds that you feel are due to you.  If you don’t do this, who will?

Billing and Coding Confusion

Insurance billing/coding can be as confusing to understand as it is to actually do.  Every year new coding (CPT and ICD-9) books come out with changes and updates.  New codes may be added and some codes may be deleted altogether.  There are also numerous bulletins that providers get from insurance companies letting them know their changes to their own policies and procedures. Mistakes can easily happen when you’re dealing with hundreds or thousands of insurance companies with different guidelines and policies, therefore it is extremely important to keep on top of matters if your claims get denied.  Denied claims could be something as easy as your provider using an obsolete code to a making a typographical error.

Discrimination

Did you know that if you meet the eligibility requirements to be covered by a group health insurance, it is unlawful for the insurance company to establish separate rules for eligibility for enrollment under the terms of the plan based on any of the factors for yourself or family members that you want to enroll?  These would include but may not be limited to:

            Health Status

            Medical condition (physical and/or mental)

            Past claims

            Receipt of health care

            Medical history

            Genetic information                     

            Evidence of insurability

            Disability

If you work the minimum hours required to qualify for your employer’s group health insurance, you or your eligible family members cannot be excluded or charged a higher premium than the rest of the participants.

http://www.understandingyourmedicalclaims.com/

EBook Release

I’ve almost finished my EBook.  It should be completed by April 1, 2011.    As soon as it's finished, I'll post updates on how to order it.  Hooray for me!!!

HIPAA LAWS

A couple days ago I blogged about a denied insurance claim on my husband.  As stated earlier, I called our insurance company to get to the bottom of this.  First and foremost, I wanted to verify that my husband’s physician was a preferred provider.  “Tina” asked for all the appropriate information; patient name, date-of-birth, ID #, etc.  But when she realized that I was not the patient, THE BRAKES WENT ON.  Due to HIPAA laws, she could go no further with our call.  I had to get my husband on the phone, and he had to verbally give her permission to speak with me (which he did).  I know this can sometimes be a pain in the you-know-what, but HIPAA is ultimately for our own protection.  “Tina” went on and discussed the claim with me, but also indicated if I needed to call again about him, she would again have to get verbal permission.  To side step this for future calls, she is going to mail him a permission form to fill out and mail back.

HIPAA

HIPPA stands for The Health Insurance Portability and Accountability Act, a Federal law that passed in 1996, that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. It also ensures patients have access to their own medical records while adding new responsibilities to those charged with protecting this information.  Many refer to HIPPA as a privacy protection law.

Choosing Your Health Plan

Choosing between health plans can be a very confusing and daunting endeavor.  There are many plans to select from and it’s best to weigh your options to see which one will fit your individual or families needs.  Plans can differ greatly.  While one plans premiums may be low, the services may cost you quite of bit of money once you utilize the providers.  Other plans may have a high monthly premium, yet you may owe little or nothing to your providers after you see them. Although insurance companies seldom cover 100% of all the medical costs, some will cover more than others.  Some factors that you will need to consider are ~

*Do you need insurance for just yourself or your family?

* Do you need to make adjustments to your current plan?

*Do you want to be able to have access to a large number of providers that you can see without getting permission from your insurance company?

*How much will it cost me?

* How affordable are the different plans?

*Do you want to have a high deductible so that you’re monthly premiums will be lower?

*How do I pick a health plan?

*Do I need to pick a primary care physician?

*Am I able to see my current doctor on the plan?

*What do the plans cover?

*Are there any limits on how much I will have to pay in case of a major illness?

*Does it cover hospitalizations for elective services?

*Does is cover pre-existing conditions, chronic illnesses and preventative care?

*Do I need referrals to see specialists?

*What will my insurance company cover if I need attention for an emergency of when I’m out of town?

*Are there any wellness incentives?

*Will it coordinate benefits with my spouses insurance?

Make sure you discuss any questions or concerns about your insurance with your insurance broker.  If you’re not sure who to contact, talk to the Human Resources Manager where you are employed.

I Need to Change My Mind-set

We’ve had an HMO (through a Health Maintenance Organization) insurance plan for several years.  With a HMO, you choose your Primary Care Provider (doctor) who acts like a “gatekeeper” for all your healthcare needs.  This means that you must get permission from your PCP before you can see any specialists.  (Of course there are always a few exceptions to the rules.)  For example, if you feel you need a dermatologist, you either have to see your PCP, or you may be able to call his or her office and he or she will agree to set up a referral without seeing you first.  Either way, you just can’t just make an appointment with the dermatologist before following the correct steps.  The first of this year we changed from an HMO to a PPO (Preferred Plan Organization). We don’t need our PCP to refer us anymore.  If something urgent comes up that we feel we need to see a specialist about, we can call the specialist ourselves and make our own appointment.  No longer do we need to get “permission” from our PCP.  Now here’s where I need to change my mind-set.  My husband noticed a lump where it didn’t belong.  We automatically resorted to our “old way of thinking” and called his PCP to be seen.  Originally he didn’t have anything for a couple weeks out, but he did eventually get him in within a day.  Had he not been able to see him for a couple of weeks, we could have just bypassed his PCP altogether and called a specialist for an appointment.  Now granted with our PPO, we can refer ourselves and make our own appointments, but there are still specialists that won’t see you without a referral or recommendation from your PCP.  This has nothing to do with the way your PPO insurance works; it just has to do with the specialist’s policies and procedures.  We’re still working on my husband’s condition, and now if we feel if we aren’t satisfied with his PCP’s treatment, we can self-refer him elsewhere.  Important Note: When self-referring, make sure the specialist is a PPO Plan Provider with your insurance.

Denied Insurance Claim

I received an EOB (explanation-of-benefits) in the mail today for my husband.  We had just changed our insurance on the first of the year from a HMO to a PPO.  We decided we needed a little more flexibility with our choices.  The HMO would have been less money out-of-pocket for us, but the monthly premiums were higher.  We hoped that we wouldn't have any "major" issues that we would have to pay out towards our deductibles and co-pays this year.  WRONG ANSWER (that’s a whole other blog).   I’m looking over the EOB (see attached) and it states:  Total Charges: $160.00 (for an office visit only).  Amount Not Allowed:  $81.51; Deductible Amount:  $78.49; Amount Paid: $00.00 BUT THE BIG CLINCHER was on the messages:  *** It is your responsibility to pay:  $160.00*** There is a section on the EOB that says Physician Member:  NO.  Hmmm, before my husband chose his physician, he did his homework.  He went to the insurance website and made sure that he was a participating provider; which he was.  He presented his insurance card at his office visit to the receptionist.  There was nothing said to him that the doctor was NOT a participating provider.  So far, everything that he did was correct.  Now some people would just go, “oh well, I messed up, I need to pay the $160.00”.  Not me.  I could have called the doctor’s billing office, but I decided to get to the heart of the matter.  I went directly to our insurance company.  There’s a phone number at the bottom of the claim for customer service.  I had all my ammo ready.  I had the insurance card available, and had the insurance website up showing where the doctor was a participating provider.  After waiting on the line for about 30 minutes, I was able to speak with Tina.  She could not figure out why the claim wasn’t paid either.  She checked her information and saw that the physician was a participating provider.  She said she would send the claim back through for an adjustment (a fancy term indicating they would reprocess it) and it would take 2-3 weeks.  I documented the date and time I called, who I spoke with (Tina), the outcome (sent back for an adjustment) and asked for a “tracking number” for this call.  What went from possibly owing $160.00 went down to a $20.00 co-pay.  There could have been one other possible explanation for the insurance error.  Some physicians have two entities; i.e. John Johnson, MD and a group name, i.e. Johnson Family Medical Group.  Sometimes, not both are associated with the contracted insurance companies.  John Johnson MD may have a contract, but if the claim was billed under Johnson Family Medical Group, (who isn’t contracted) the claim would be denied.  If this ever happens to you, ask the insurance to reprocess it correctly.  If they won’t do this per your request, call the doctor’s billing company and ask them to resubmit a “corrected claim”.  I know I could use and extra $140.00, couldn’t you?

Do you automatically pay your medical bills when they come in the mail?

 Do you assume that your provider’s billers are posting the payments and adjustments correctly?  Have you ever wondered if you are getting billed for services that were not provided?  Do you wonder if you’ve overpaid on services and are due a refund, but not sure how figure it out?  Do the EOB’s (explanation-of-benefits) that come from your insurance company confuse you? I have worked in the medical field since 1978 and in the billing aspect since 1994.  I am not a certified billing coder, (who may be trying to optimize the highest reimbursement possible from insurance companies for their clients), but I am a consumer who is concerned about the rising cost of healthcare.  Every single day patients pay on their statements when no money is due.  They just assume because they get a bill that they need to pay it…..no questions asked.  Why would you pay for balances that are not your responsibility?  As a medical biller, I have made my fair share of mistakes.  When I was “learning” to post payments, I didn’t always take the appropriate adjustments when patients had one or more insurances.  After both insurances paid, if there was a balance, I just billed the patient.  No one double-checked my work.  Mr. X called me one day and asked why he still owed money on his deceased wife’s bill.  “After all” he stated, “you are contracted with both of her insurance companies.  Aren’t you supposed to take the highest adjustments regardless of who was primary and who was secondary?”  Sadly, I did not know this answer.  I went to my supervisor, who concurred with Mr. X and was told, “yes, take the additional adjustments”. What went from Mr. X initially owing over $300.00 (from the erroneous statement I sent him), changed to owing absolutely nothing.  Had Mr. X not questioned his statement, he would have paid money that was not due from him and no one would have known the better.  I know I could use an extra $300.00 on something other than medical bills, can you?  I’ve also learned to question my own families’ medical bills from early on.  When my daughter had a tonsillectomy, I could not believe the exorbitant fees the hospital charged.  Not knowing what to look for, I asked for an itemized copy of all the charges.  I then took this copy to the doctor that did the surgery.  He scrutinized the charges and saw that a surgical pack was billed twice.  The charge for each pack was over $400.00!  (That was back in the 80’s, now days it would be much higher.)  I immediately went over to the hospital billing department and asked them to correct this, plus I insisted that they send a “corrected claim” billing to my insurance company, so they wouldn’t inadvertently pay the duplicate charge in error.  Even more recently, my youngest daughter went to the emergency room for an infected ear.  I received separate EOB’s from both the facility and the treating physician.  Had I not understood what “split billing” was, I would have ran down to the hospital like a raving maniac and asked why they “double-billed” me. I'm in the process of writing an ebook/manuel to help the consumer understand their insurance billing and claims.  It's not designed to teach you a crash course in medical coding and billing, but to help you understand the process of what takes place in the insurance billing field, and the tools you can utilize if you feel you are wrongly billed.  In the meantime I've decided to post a weekly blog to help people with their billing questions. If you have questions or concerns, feel free to post them on the blog  (without giving away your personal information) or email me.  I'll try my best to answer your questions as quickly as possible, or direct you to resources that can help as well.