What to Expect if a Relative Goes Into a Nursing Home

My eighty-eight year old father-in-law recently fell at home, (he was by himself), and broke his hip.  

Unfortunately, his Life Alert alarm was in his nightstand drawer, and his fall took place in his living room. It took him two hours to make it to a phone. He called his daughter and son (who lived about twenty minutes away), to come over and help him BUT, unfortunately once they got there, neither of them had a key to his house. When they both arrived, they both came prepared with screwdrivers in hand, hoping to find a window that they could budge.

To make a long story short, they were able to crawl in through an unlocked window and call an ambulance. At the hospital, it was determined that his right hip was broken. He ended up having surgery that night, where he had a rod and three screws placed. After surgery, he was transferred to the ICU, (Intensive Care Unit), then shortly moved to a regular room. He ended up staying four days in the hospital, then he was transferred to a SNF, (Skilled Nursing Facility), for rehabilitation. At this point, his insurance covered his first twenty days in rehab.

Situation	Is my SNF stay covered?
You came to the Emergency Department (ED) and were formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. You were discharged on the 4th day.	Yes. You met the 3-day inpatient hospital stay requirement for a covered SNF stay.
You came to the ED and spent one day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days.	No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Now, this is where it gets tricky.  His orthopedic surgeon told him that due to the severity of his break, he would have to remain completely non-weight bearing on his broken hip, for up to four months. According to Medicare guidelines, they will only pay the first twenty days of rehab. After that, if you don't have a supplemental that picks up the balances, (he has Vetrans insurance), you are reponsible for $161.00/day for days 21-100.  This is exactly where he fell; paying $161.00/day.

Your costs in Original Medicare

You pay:

• Days 1–20: $0 for each benefit period.

• Days 21–100: $161 coinsurance per day of each benefit period.

• Days 101 and beyond: all costs.

Medicare Guidelines

Thankfully, he was able to go home after about two weeks of paying $161.00/day. His daughter was able to make arrangements for caregivers to be with him basically 24 hours/day. It's actually costing more than the SNF for now, but he is at home and mentally doing much better. 

If you are of Medicare age, or have parents or relatives that have Medicare, PLEASE take the time to review your supplemental insuance policies. It was quite shocking to find out how much money a serious injury can cost you, and not all people are prepared for this expense. You may even need to talk to your insurance agent to see if there are any supplemental policies that cover instances like this.

Is Your Provider Billing You Correctly?

One of my relatives have recently had three disputes regarding her insurance bills/claims with her medical providers. One was at a specialists office and the other two with her primary care provider.

First off, she had a MRI at a radiology clinic. She was told up front what her portion of the fee would be. She paid that at her time of visit. Now, we know that most times this is only an "estimate". The amount owed can go up or down a little. When I worked in a radiology office, we always called the patients insuance company to find out what their deductible was, their out-of-pocket and how much had been met so far. This would give us a guildeline for what the patient owed. We usually nailed it exactly, but if there were outstanding claims that the insurance company got before ours, sometimes the patients portions were met, but just didn't show up on paper yet.

Anyway, my relative went to a preferred provider, so that she got the best possible benefit from her insuance.  She was quite surprised when she received a bill for a substanial amount of money. After reviewing her EOB (Explanation Of Benefits) with what was paid, adjusted and what she paid, she figured that she owed nothing. She called the radiology office and gave them her payment information with them, and went over her EOB. In the end, it sounds like they didn't take the correct adjustment and billed her for this, after she made her original payment. Had she not known to look into this and just paid it, she would most likely have been out hundreds of dollars.

The same thing happened with her doctors office. Same scenario. She paid her portion due at the time of service and was billed again for a substantial amount of money. Not only did they do this once, but twice!

How many unsuspecting people do you think overpay their bills and think nothing of it? I know from experience, that unless you advocate for yourself and keep track of your claims, no one else will do it for you.

Have you had any similiar experiences? Have you ever had to question any bills? Do you have any outstanding bills that you feel you don't owe on? If so, maybe I can help. Just email me your questions, (you don't need to give me any personal information, numbers or anything like that). I can tell you what to look for, and how to go about getting it corrected. 



I hope this never happens to any of you, but if you think you have been billed in error, don't be embarrased to call and ask questions. After all, you probably pay a lot of money for your insurance in the first place, and having to pay extra, just doesn't make sense!

YOU are the best Advocate for your Medical Care

I have come to theconclusion that You are the best advocate for your Medical Care. This comes after all the trials and tribulations that my own mother has gone through after recently being diagnosed with breast cancer. Let me give you the scenario - 

My mother had a mammogram, which came back stating that she needed additional testing. Her physician called her and ordered an ultrasound to further diagnose any suspicious areas. Seems pretty by-the-book so far, doesn't it? Well, now is not the time to get too confident on physician follow up or referals. As a side note, she has Medicare as her primary insurance and Blue Cross secondary. Not a HMO or Medi-Caid type of insurance that would need to go through a lengthy referral/authorization process to order tests. 

My mother had the ultrasound, then nothing.  No call from her doctor or the radiology clinic where she had the ultrasound. Makes you say hummmm, what's going on? 

After close to after two weeks have lapsed, my sister and I convinced her that to call her doctor's office to find out what's going on. She finally called and was told that she had a suspicious area and needed a breast biopsy. 

Now chapter two of the waiting game begins. Her doctor was going to send in a referral to a place to have this done. Another week passes and my mother hasn't heard anything. She calls to the office where she had her ultrasound and they don't have any orders. She calls back to the doctors office and the doctor "blames" this on the the new computer system that she's using. Personally, I don't see how that factored into anything, but the doctor says she'll send the order to a town thirty miles north of where she lives for the biopsy.

Chapter three: A couple weeks have passed again and there is no word from the biopsy office. My mother is eighty-three years old, and is under the impression that the radiologist needs to review her previous films first, and just figured that everything must by "okay", since no one called her. My mother finally called them and, my sister called them and they both get the run-around.  I finally get frustrated, (I live 600 miles south of my mother), and call her primary care doctors office. I tell them that someone has dropped-the-ball and nothing has happened. This message miracuously gets to her doctor and gets the ball rolling. Next thing we know, the place where she is supposed to have the biopsy have the order and have her scheduled.

To make a long story short, the biopsy comes back positive for breast cancer and she gets referred to a breast specialist who does a lumpectomy. After the lumpectomy she has eight weeks of radition, and now is on an oral cancer medication. And most importantly, she seems to be doing pretty well.

I'll reiterate the moral of this story. Like I said in the beginning of this blog;

You are the best advocate 

for your Medical Care!

I hope that you or your loved ones never have to go through something like this, but if you do, assume nothing. If you don't hear back from your physicians office, make the call. Don't assume that they will call you. You need to speak up and be proactive.

Emergency Rooms.....Emergency or Not?

I've recently been volunteering at our local emergency room. I sit behind the window and help visitors when they come to visit patients in the Emergency Room. Whoa, why is this? You mean people actually need visitors when they're at the ER to get immediate help? Yes they do, and I'll explain why.

Where I volunteer, there can be up to more than 100 patients in the ER at a time. This includes the waiting room, patients that are in rooms, and patients that are having other services (x-rays, labs, etc), while waiting to be seen. I have seen patients that have been in the ER in excess of 6 hours from the moment they came through the front door, to when they left.

It seems to me that the Emergency Room is one of the most abused services that I've ever seen.  When I think of an emergency, I think of something that needs urgent attention and doesn't happen during regular doctors office hours. Well, apparently this is where my thinking is misguided. People come to the emergency room when they have had a sprained ankle for two weeks to needing pain pills refilled! Ughh. Of course, there are the patients that do need emergent care, but the number of abusers far outweigh the ones that truely need it. Patients also think that if they come in via an ambulance that they will get moved to the front of the line and treated first. This is not so either. Once the patient has been triaged, and off-loaded off the stretcher, they can end up in the waiting room just like everyone else.

Also, a lot of people think that the ER is a full-service hotel. I've had family members of patients ask me to get them a sandwich because they're hungry. They are not even the patient! There is a fully-stocked cafteteria down the hallway, but people feel entitled to a free meal while they're waiting. Of course we feed the patients if necessary, but can't cater to the whole family and their friends. 

Another reason why they may choose the ER over urgent care over their doctor.....money!  The ER can ask to collect co-pays and money due up front, BUT they can not force anyone to pay. The ER can NOT turn anyone away for non-payment up front, where as your doctor's office may turn you away if you don't have the correct funds to give them as the time-of-service.  

Thank goodness there is a system in place that protects the patients that are truely in need of emergent care vs the ones that do not.  This is called TRIAGE.  

tri·age

  (trē-äzh′, trē′äzh′)

n.

1. A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage isused in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated.

2. A process in which things are ranked in terms of importance or priority: 

tr.v. tri·aged, tri·ag·ing, tri·ag·es

To sort or allocate by triage: triaged the patients according to their symptoms.

Triage nurses carefully determine the severity of the illness and are able to "rank" the patient in order of urgency, not first come, first served.

I personally would not want to go to the ER if it were not a true emergency. You have no idea what you are being exposed to in the waiting room. Though there are masks available for people that are coughing, or people to protect themselves, not everyone that should have one uses one. 

Lastly a great article to read is this... To the Woman who doesn't understand why I was seen before her at the ER.  /http://themighty.com/2015/11/to-the-woman-who-doesnt-understand-why-i-was-seen-before-her-at-the-er/

It helps explain from a patient's point-of-view what goes on in the Emergency Room.

HIPAA, HIPAA, HIPAA.....Oh My!!!!

By now, everyone has probably heard about HIPAA, and have an understanding of what it stands for. If not, it's an acronym for Health Insurance Portability and Accountability Act, which is the federal law that protects the privacy of personal health information. 

Did you know, that if you were to work in a medical office and violated the HIPAA law, that both you and your employer could be fined up to $250,00.00 each if you were proven guilty of violating this law? Which brings me to three personal stories of violation of HIPAA that happened within my own family. 

     A close relative had a suspicious mammogram and ultrasound and needed a breast biopsy.  There was a lot of mis-communication with the doctor's office ordering the test, and the radiology office where this test was to be preformed. Another relative has written permission to speak with medical providers on the patient's behalf. A good week has gone by and no one has heard from the radiology office. The patient calls and is told that they will call her after certain parties have reviewed the referral and prior films to determine what needs to be done. They will call her back the next day. Nothing happens. Another few days go by. The relative calls the radiology office and when she gives the patient's information; not only does she give the wrong birthdate, but the receptionist corrects her!  UGHHHH  As soon as incorrect information was given, the correct information SHOULD NOT have been volunteered by the radiology staff. I don't even believe that they verified that "the relative" had permission to speak with them either. 

     Violation #2.  This one personally happened to myself recently.  I needed to get copies of my shot records for MMR and Chickenpox, as I am going to be doing some volunteer work at a hospital. I called the medical office where I had the vaccinations, but didn't expect much as I hadn't been there in over twenty years. I knew it was a long shot that they might have records on me still, but I thought I'd give it a shot.  I called the medical records department and gave them my name. They couldn't find any records on me, (no surprise there), but did volunteer the names of my mother-in-law, sister-in-law, brother-in-law and two neices that are still patients there. I knew that all of these people went to this clinic, but the medical records clerk didn't know that I knew this. She should have never given me their names. She should have merely said, "We don't have you in our system anymore", and left it at that.

Lastly, another realative saw a physician and he ordered a blood test. He sent the order to the printer, and handed it to her. She took it to the lab, and looked to see what he ordered. Ummm, he forgot to check the name on the order before he grabbed it off the copier, and just handed her the first one he grabbed; which belonged to someone else! She handed the paper to the lab tech, and told her it wasn't her. The lab tech was able to get her order and do the correct lab work, BUT she folded the wrong order in half and asked my relative to take it back to the doctor.  OOPS   She should have just taken care of it herself!

I realize that HIPAA is still fairly new, but by now health care workers should have had it drilled in long enough to be uber-careful about it! Let's hope things happen in three's, and this won't happen again to any of my family members or you and your family.




You can read more of my posts about insurance on my blog at http://healthclaimshelp.blogspot.com/

Helping my Daughter with her EOB's/Bills

I recently went to visit my daughter in North Carolina, where proceeded to hand me a stack of medical bills.  She couldn't make heads or tails out of them. One of the "bill's" was actually a statement from her insurance company showing total charges (for 2015), adjustments, payments and her balance. All she saw was the first number, $1632.00 and freaked out!  She thought she owed this. I took everything back to California with me and told her I would sort it out.

First, I went to her insurance website, logged in and matched the bills with the charges.
Next, I made sure there were no "missing" bills.
Then I verified that the billed amounts due from her, were correct with the EOB's online.

Doing this, I found that one item on one of her bills had been denied by her insurance company.  It looked like it was rebilled, yet, I didn't have a bill for it.  The balance according to the webite should have been $25.45.  I called the billing office to pay this. Since I wasn't the patient, (HIPPA privacy law), I had to have my daughter call and give the medical billing office permission to speak with me. The balance that I saw that was due was for an office visit copy ($25.00) and co-insurance $.045. This was for a February visit, but had just been paid by the insurance company in May. When I spoke with "Tianna", she stated the balance was $41.25,  She indicated that the balance was past-due and sent to collections, so had fees added to it. This infuriated me! Just because they billed incorrectly and didn't get payment for 90 + days, they figured my daughter was in arrears. I asked to speak with a supervisor, as it wasn't my daughter's fault that they billed incorrectly. In a nutshell, I got this bill taken out of collections (it was just submitted the end of May), and only owed the original co-pay. 

In conclusion, always look over your bills from your providers and match them up with the EOB's you get from your insurance company. If something doesn't seem right, call right away.  Don't wait until it's too late and your providers place you in collections. Hopefully my daughter has learned a lesson from this!


 

When a Spouse Passes away and the insurance was under his/her name (Obama Care)

One of my good friends (I'll call him Mike) passed away in September from cancer. It was quick-coming, and unfortunately, my friend didn't didn't share with his wife how their health insurance was set up. His spouse (I'll call her Joan) has had nothing but problems with her health insurance (not to mention other things), since his passing.

Mike and Joan were self-employed, live in California and have "Covered California" (Obama care) health coverage. Mike was the subscriber, so any changes to the plan had to be done under him.  Now here's where it gets ugly. When Mike passed away, Joan tried contacting her insurance company to cancel the plan and get on her own plan. Since her social security number was tied up to Mike's plan, this was impossible to do. She even tried going on the Covered California webite to do this, but unfortunately Mike hadn't shared his user name or password with her.

Joan went phyically and talked with insurance agents. All they did, was give her misinformation. I even tried to help. I did an online chat with Covered California and they gave me some steps to try. First off, Joan was to fax (and she also mailed) them a copy of Mike's death certificate. This supposidly would flag their account and give Joan a special circumstance to start up new coverage. She did this in November, and is still getting bills/premiums for Mike. Hopefully, she'll start calling them and bugging them everyday until this gets resolved.

The purpose of this is to let you know that spouses need to share account information and passwords. Had Joan had this, she would have not gone through the extra stress that it's taken on her to get this sorted out.  This doesn't pertain to just health insurance, but bank log-in information, credit cards, On-Star (another one she's having problems with), life insurance documents, etc. Absolutely anything that you can possibly think of that a surviving spouse may need to know about in the event of an umtimely death. 

Had Mike done this before it was too late, Joan would have been able to have one less thing to have to worry about and deal with.