Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Insurance Fighting Tips Outline
      

First of all, if you have any notion at all that things are not going right, keep all paper (bills, notices, etc.) until you are absolutely sure that no fighting for your rights is needed. You can always throw records away after the dust settles; but it is way hard to get to the point of, say, making an appeal & have to go back and ask for information copies from "the other side". Keep records and make note of ALL conversations: date & time, who talked to, and what they said.

  • The Kaiser Family Foundation and Consumers Union have started a health insurance information site
  • The Ultimate Insurance site contains a list of health insurers of all types with links to their web sites. If, after all of the below, you feel that there is an insurance company problem/abuse, here's what you could do:
    •  urge your doctor (or the organization that he works for) to officially file one of its new (as of Nov. 2001) "The Health Plan Complaint Form"  with the national physicians' group, American Medical Association's Private Sector Advocacy [website]...in an attempt to help correct abuses nationwide (if abuses aren't "tabulated", then they "didn't happen")...they can file, while a patient cannot. I think that it is abusive, for example, for an insurance company to deny payment on your claim because it was "filed too late". Who ever heard of a company being punitive because they were unexpectedly able to delay payment on a legitimate purchase. This is a tactic to transfer the cost to you! Your state medical association may collect similar data that your doctor could contribute to...offer to help your doctor file such a notice.
    • In South Carolina, the SCMA keeps a paper "Hassle Factor Log" process going for similar reporting by doctors [It is located in/under the section titled "Medical Economics Dept.," located to the left of the SCMA home page], and you could offer to also help with this.
    • In S. C., as a patient, you could file a consumer complaint with the state Dept. of Insurance (DOI) consumer advocacy people [the form].
  • Top reasons our billing company gets denial notices from your insurors:
    1. deductible has not been met (& our charge was applied to your deductible) (we cannot confirm/refute this...you must have your records complete and help us if they are wrong).
    2. service was provided after insurance cancelled (you may have messed up & not made sure that you were still covered; if they are wrong, you must provide us with the proof to help us help you).
    3. "Insurance Cannot ID Patient":
      • We ask the offices to send us a copy of your insurance card with your specimen (and they do a great job of meeting this request 98% of the time); BUT,
      • Many offices are on a "CompuSystems" computer which automatically fills out the requisition for services that accompanies your specimen. A new insurance card may differ from the one in the computer. So, it is possible that the billing company clerk failed to update insurance into their Billing Company computer.
      • Your insurance company may have added more digits to your ID number making your ID number longer than our billing computer had been set for your company.
      • Our billing company's computer is set to automatically fill out your insurance company's claim form with all except the new services. The billing clerk must notice a change to new insurance and over-ride what is already in their computer & they do this most of the time...they could miss it & get a denial.
    4. Routine Services are NOT Covered: Many companies fail to cover "routine check-up services" (you don't have a complaint or disease...yet) or "preventive services". If they do, they may have special rules as to only which provider can do & get paid for those services by them; and they may require that claims contain special codes.
    5. Maximum Benefits Already Paid Out: Your coverage didn't have a high enough benefit amount to cover all of your charges.
    6. Insurance was filed but we received no response from your insurance Co.:
      • we file & if no response we file second time...then,
      • if no response after 45-60 days, we bill you.
  • A test or procedure you need is denied in advance, "No, our insurance company is not going to pay for that." [help]
  • Pathology charge codes (your bill from us, Pathology Associates of Lexington, P. A.: what we might have done and charged).
  • You are contesting charges: if you are provided a service by a provider and you contest their charge (you think that it is much higher than it was supposed to be), you are obligated to make at least a monthly payment of 10% of the balance due during the period of the contested charges (this is what credit cards generally require). I believe that you are NOT under any obligation to make any payment on a charge for a service when you believe that such service has not actually been performed and that the bill is erroneous.
  • When the Insurance statement to you is not yet paid or is denied and non-committal as to any reason, it may be due to: 
    1. Pre-existing illness: the claim is presumed by them to relate to a pre-existing illness & your insurer does not have a copy in their files of your "Certificate of Health Coverage" ("HIPPA certificate") from your previous insurer: the notice "remark code" might say "requested patient medical history from employee". YOU will have to see that this certificate copy gets to your newer insurance company whenever you change insurance coverage (and it will have to be done for each family member covered by your policy...don't assume that your employer will automatically do this for you). Since 1967, the law for this attempted to help protect you from exclusion of coverage for "prior conditions"; and it has sometimes back-fired & given your new insuror an excuse to deny payment.
    2. Still gathering info: insurer may be in process of requesting medical history from hospital, doctor, or other health provider.
  • Fighting 3rd-party payment denials of your claims...a page of info & sources.
  • Provider's (doctor, hospital, other) office or billing company, having submitted the claim for you, is getting delay-tactic denials from your insurer (the law allows insuror to demand a "clean claim"), claiming (and the provider is powerless to contest it):
    1. "our claims system rejected it": 
      • claiming that "code screens" kicked it out
      • claiming that provider unbundled codes (see 88141)
      • claiming that provider unreasonably did more than one procedure in a day 
      • claiming that the listed date of service was not during the policy coverage period; etc., etc.
    2. information doesn't match:
      • the "covered's" address doesn't match company records
      • the patient's name doesn't match company records; etc., etc.
    3. denial of a preauthorization: they said OK...doctor does the work...now they "take it back"
  • Going bare: What if you just don't bother to get health insurance coverage? Firstly, you will be faced with full, "retail', list prices on everything. And, health care/services providers are not obligated to serve you unless it is an emergency. Many will try to help if you will be honest about your situation. There are indigent programs (check with your local county...public...hospital's social services department), "free clinics", etc. If you incur a debt, you should make an honest effort to work out a mutually reasonable and satisfactory resolution. Basically, they can't get blood out of a turnip. But they can turn you over to collection agencies, report your failure to credit bureaus, and possibly file a lawsuit if they think that you have assets that would cover the debt.
  • Correcting or modifying insurer's rating status on you :
  • Example: your doctor found that you had high blood pressure a month before you got health insurance, the info is in doctor's record and you note it on the insurance application, but with a little regular exercise and mild weight loss, your blood pressure is quickly perfectly normal. You don't have a "disease" that requires health-provider treatment. What can you do to "clear your record"?

    If this were an individual health insurance situation (not group policy), most insurance companies will do one of three things:

    1. postpone the application 6 months until there is evidence that the condition is controlled through diet and exercise.
    2. cover you with an exclusion of payments for costs of treating high blood pressure (any treatment or medication relating to this diagnosis). This exclusion or rider may be listed as permanent or for a limited time period (say 2 years) after which they could review your records and, if shown that no treatment has been needed, they might be willing to drop the rider.
    3. cover you with an additional rating (charge) to cover the risk.

    However, if you disclosed this excluded condition on your application and they covered you with no specific action on the condition, then they must cover claims related to the condition as specified in the contract.

    Many companies will allow you to request a review of an exclusion "rider" or rate increase "rider" related to such a condition. Usually this is on your renewal date (one year) from when you purchased the insurance. This typically involves them reviewing your doctor's records. This is from an individual insurance perspective.

  • Access to the provider YOU want is denied because of your coverage...dealing with it: Your doctor does a screening test for prostate cancer & the test is positive. He refers you to a urologist for biopsy, but your insurer won't allow use of the expert pathology group (to interpret the biopsy) and requires that your specimen go to some other lab. You want your mammogram done at the best local hospital, but your insurance won't pay there. You want referral to a particular doctor or hospital and insurance company blocks the request. Options (before the fact vs. after the fact)?
  • Appealing an adverse decision "externally":  Many states operate external appeals boards who may have strict appeals filing deadlines. Check for these at your state's Dept. of Insurance (phone or web site) [more info and state links at California site]. Insurers often have appeals rules specific to their company...contact the company for information and tips. However, if you call the insurance company and tell them, "I am appealing my denied coverage", you may trigger a rule for "timely review" by the insurance company. Our if you have been trying to get them to precertify to cover a treatment, and they are still balking, tell them, "I am appealing my denied care", you may trigger a rule for "timely review" by the insurance company. Dr. Theo's (Jason Theodosakis, M.D.) website has an example of an appeal letter.
  • Some connections to reduce health expenses, especially if you can't afford much (your doctor's office may have someone who can help you connect with the following...and other...programs; or your local hospital's social services department may be able to help; or the hospital's financial counselors may be able to help & advise you at no charge. But you need to be ready & willing to invest your time helping to fill out forms, etc.):
    1. Staying healthy: eat and exercise healthy, achieve a healthy weight, and QUIT unhealthy habits.
    2. Faith: become a true, practicing Christian [about faith health benefits]
    3. Advance planning: You can get an idea of likely costs in your area by way of the on-line Health Care Blue Book. You will save yourself personal, "out of pocket" money if you plan in advance, do more things AFTER your deductible is "used up" & before the insurance year ends, get plans for treatment precertified, and try to, if need be, get the provider of your choice approved ahead of time (that provider may have ways to help you succeed), you may be able to save a whopping amount of money out of YOUR pocket! 
    4. Prompt payment discounts: since fees & charges for services are often set with the knowledge that third party payers are then going to hammer out discounts and then take months to complete the decisions on payment, the cash-paying patient's situation has to be ignored on the front end. Many providers declare privately that they will, therefore, "work with" the cash paying patient. Because of the fact that many insurance and government contracts with providers have "most favored nation" and other types of clauses to insure that no competitor gets a better deal, it can be nearly impossible for a provider to offer a written or standing policy of 30% or so prompt payment discount to cash payors. So, you have to inquire/request a special case-specific deal for your particular situation.
    5. Getting Insurance coverage & coverage programs...a page of info & sources. AND Christian cost sharing programs.
    6. Lawyer payment-dispute advocates: health-care attorney firm web sites have info [example] (and see above)
    7. Getting some help:
    8. Reduce prescription drug costs by way of Patient Assistant Programs...PAPs & other ways: 
        • Universal Medication Form: you can make your copies from on-line examples; you save by keeping all your medications, vitamins, suppliments, and herbals listed on such a form. When you change a dose or how often you take it, make a new entry and keep all the old pages together so a doctor in the ER could have a chance to figure out what might have gone wrong.
        • OTC (over the counter) substitutes (cheaper): as your doctor starts to prescribe medication for you, ask if there is any reasonable OTC substitute. If not, ask if generic will do as well as name brand.
        • Wal-Mart: remember that they started (in 2006) the generic drug (alternative to the "brand name" drugs) program for prescriptions that has very big savings (costs you only $4 per prescription...HERE). To get the $4 deal, you MAY NOT order a supply larger than the amount listed online at the website, above.
        • Publix: certain oral antibiotics taken by mouth are available FREE for a 14-day prescription [HERE].
        • Kroger: started in early 2008, they have a $4 deal [HERE] similar to Walmart's, above.
        • Costco: though this is a membership discount organization, they must let you walk in free to use the pharmacy...if you ask. Check HERE for an idea of the incredible savings on generics. See Costco on-line pharmacy...you may need to be a member for this.
        • Walgreen's & CVS: check their websites...I think they have similar low cost medication deals as of early 2008.
        • Fill only part (a "test sample") of the prescription: Take a smart "test drive" of the medication! Once the medication package is opened, the drugstore can't take any back (you can't return unused medications). Especially if expensive for you, you may be allowed to only fill, say, 1-5 days worth. That way if you have a reaction (can't tolerate the drug), you aren't stuck with unused drugs. Your doctor then switches to another possibility...and you "test drive" that one.
        • long term medication cost reduction: Especially if being treated for months to years with a long-term problem, check Consumers Reports medication cost comparison website (there is an annual fee) & save yourself $1500 or more per year.
        • your doctor's office may be able to arrange what the next help-source item does for low-income persons, particularly seniors [we have used this]...
        • on-line help with cost of prescription medicines for low-incomers from [The Medicine Program]. For about $5 per prescription, they contact each producer of your medications to check for any "manufacturer-sponsored patient assistance drug program". This will be coordinated through the patient and/or care-help person AND the doctor/doctor's office AND possibly a social worker. You need to remember that it takes time for these local people to help you and that they are paid nothing for this. Therefore, be thankful and be ready to do legwork or be whatever help you can be! [we have used this].
        • Partnership for Presciption Assistance: offers assistance locating PAPs (1-888-477-2669).
        • Together Rx Access: offers assistance locating PAPs (1-800-444-4106)."
        • NeedyMeds, Inc. was started in 1997 by Richard J. Sagall, M. D. and Libby Overly, MEd, MSW...their goal is to become the best source of information on patient assistance programs (Melissa Osborne brought this to our attention with a 6 Sept. 2004 letter to the newspaper editor).
        • Foreign purchase of medications...by internet ordering or other means...may save a lot (but how can one be sure of quality or that what they send is even a medication?). I'd avoid this method.
        • Rx-card consolidation: In March 2002, NACDS began an effort to create a prescription drug card-consolidation program for the above called PharmacyCareOneCard. Now (5/03) it may be a program called the Pharmacy Care Alliance. Check status with your local pharmacy.
        • The Together Rx Access Card: unveiled 11 Jan. 2005, a number of large companies provide 25-40% or higher discounts on some 275 brand name drugs to those younger than 65 who have no other drug coverage and meet certain requirements.
        • Rx Outreach operated by Volunteers in Health Care works with generic meds...their website lets you search by brand name.  
        • Welvista free medications (and care?) for yhe uninsured in S. C..
        • NORD help with costs of rare disorders.
        • Drug companies: many have their own PAPs & start with a 3-month supply.
        • see Seniors stuff, below.
    9. Medicaid: do you or your children qualify? Check here.
    10. State Children's Health Insurance Program (SCHIP or CHIP): for children (age 18-19 or younger) of those families who can't qualify for Medicaid but who can't afford private health insurance (8/2003 you may qualify with family income up to $36,000 per year). See this website as to some overall info HERE.
      1. some qualifying info in S. C..
      2. link listings by state.
      3. Partner's for Healthy Children in South Carolina.
      4. Healthy Connections Kids (HCK): this program in S. C. is administered by the S. C. Dept. of HHS.
    11. Free clinics:
      1. Free or very low-cost clinics: in all states, by city.
      2. medical: check with local county health departments about their programs and ask about the additional availability of local "free clinics" [see "community services" on SCMA web site for a S. C. listing].
      3. Columbia, S. C. area since 1984, The Free Medical Clinic.
      4. dental: In Columbia, S. C. area, some free dental care for children, Smiles, through Welvista.
      5. Free eye exams, Vision USA by AOA for low income, uninsured.
    12. Military Veterans: our nation has built a Veterans Administration Hospital (VAH) system to provide care for those who want it in that system. There are a number of benefit programs for diseases (asbestosis)  and/or exposures (Agent Orange). If you join your local VFW chapter, you will often have access to people who know how to "navigate the system".
    13. Senior-citizen (you don't have to be a senior for some benefits) financial help and discounts: 
      • AARP web site for beginning information.
      • National Council on the Aging on-line search program to see if older, low incomers qualify for any government benefits (medications, in-home care, etc.). Fill out a confidential questionnaire.
      • Pharmaceutical company programs (Patient Assistant Programs...PAPs...the Pharmaceutical Research and Manufactures of America notes that 48 of its members offer 400 discounted or free medications) for low-income Medicare or other patients, such as:
        1. Pharmaceutical Research & Man. of America (PhRMA) sources.
        2.  Pfizer's "Share Card".
        3. the Together Rx program, covering about 150 widely prescribed medicines, 1-800-865-7211; your hospital social services department may help you with this.
        4. BenefitsCheckUpRx, run by the National Council on the Aging, enables Americans age 55 and over to quickly determine their eligibility for help from community, state or federal programs or from drug companies that offer free products or discount cards.
        5. Partnership for Prescription Assistance (PPA) is a means by which to link patients in need to the drug company that can help.
      • Medicare Savings Programs (to help with premiums, copays, etc.); call 800-633-4227 to find a local office. If you have Medicare Part A coverage and your income and personal value are low enough, you may qualify for a Medicare Part B (pays the doctor) premium payment supplement.
      • State initiatives to help seniors with medication costs, etc.
      • Carolina Diabetic Supply, Inc.....free home delivery; eliminate out-of-pocket expenses, 800-230-8322.
    14. The problem of the "Uninsured":
      • "Cover The Uninsured Week" (March 10-16, 2003) website.
    15. Health Coverage Coalition for the Uninsured (HCCU): In late 2006 or early 2007, the American Medical association and 16 interested organizations arrived at a plan for congressional action [here].
    16. Caregiver helps:
      • Family Caregiver Support Program (FCSP) [ S. C.] is a program passed by Congress in 2000 as part of the reauthorization of the Older American's Act. It is a source of maybe $2000 per year in cases where the family is rendering eldercare at home rather than through the more expensive "rest home". [we have used this].
      • National Association of Professional Geriatric Care Managers (GCM) web site offers resource web links and location services if you realize this is more than you can handle or if you are the family member in charge but live at too great a distance.
      • Geriatric or elder care:
        1. independent living arrangements (almost like a boarding house):
        2. Assisted Living Facilities: information.
        3. institutional living (such as nursing home):

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(posted Aug. 2001; latest addition 26 August 2012)

 
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