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
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
- Top reasons our billing
company gets denial notices from your insurors:
- 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).
- 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).
- "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
- 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.
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
Maximum Benefits Already Paid Out: Your coverage didn't have a high enough benefit amount to cover all of your charges.
Insurance was filed but we received
no response from your insurance Co.:
- we file & if no response we file
- if no response after 45-60 days, we
- A test or procedure you need is denied in
advance, "No, our insurance company is not going
to pay for that." [help]
charge codes (your bill from us, Pathology
Associates of Lexington, P. A.: what we might have done
- 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:
- 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.
- 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):
- "our claims system rejected
- claiming that "code screens" kicked it out
- claiming that provider unbundled codes (see
- 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.
- information doesn't match:
- the "covered's" address doesn't match company records
- the patient's name doesn't match company records; etc., etc.
- 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
If this were an individual health insurance situation (not group policy), most insurance companies will do one of three things:
- postpone the application 6 months until there is evidence that the condition is controlled through diet and exercise.
- 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.
- 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.):
- Staying healthy: eat and exercise healthy, achieve
a healthy weight, and QUIT unhealthy habits.
- Faith: become
a true, practicing Christian [about
faith health benefits]
- 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
- 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.
- Getting Insurance coverage & coverage
programs...a page of info & sources. AND Christian cost sharing programs.
- Lawyer payment-dispute advocates: health-care
attorney firm web sites have info [example]
(and see above)
- Getting some help:
- Reduce prescription drug costs by way of Patient Assistant
Programs...PAPs & other ways:
Medicaid: do you or your children qualify? Check here.
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.
- 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
- 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.
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
- 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
- Partnership for Presciption Assistance: offers assistance
locating PAPs (1-888-477-2669).
- Together Rx Access: offers assistance locating PAPs
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
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.
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.
qualifying info in S. C..
- link listings
for Healthy Children in South Carolina.
- Healthy Connections Kids (HCK): this program in S. C. is administered by the S. C. Dept. of HHS.
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
Senior-citizen (you don't have to be a senior for some benefits)
financial help and discounts:
- Free or very low-cost clinics: in all states, by city.
- 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].
- Columbia, S. C. area since 1984, The Free Medical Clinic.
- dental: In Columbia, S. C. area, some free dental care for children, Smiles, through Welvista.
- Free eye exams, Vision USA by AOA for low income, uninsured.
The problem of the "Uninsured":
- AARP web site for
- 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
- 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
- Pharmaceutical Research & Man. of America (PhRMA) sources.
- Pfizer's "Share
- the Together
Rx program, covering about 150 widely
prescribed medicines, 1-800-865-7211; your
hospital social services department may help
you with this.
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.
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.
Diabetic Supply, Inc.....free home delivery;
eliminate out-of-pocket expenses, 800-230-8322.
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].
- "Cover The Uninsured Week" (March 10-16,
- 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:
- independent living arrangements (almost
like a boarding house):
- Assisted Living Facilities: information.
- institutional living (such as nursing
the main advisory index page]
(posted Aug. 2001; latest addition 26 August 2012)