Healthcare  reform has been in the news lately, especially so because of the Supreme Court’s consideration of the Affordable Care Act. If you’ve been trying to keep up with the law and its effects, then you know how difficult it can be. Take a look at some of the resources available to everyone from consumers to healthcare professionals:

1. U.S. Department of Health & Human Services

The federal government has a vast and informative collection of information available at the www.healthcare.gov website. Here you can find everything from a copy of the full text of the Affordable Care Act to easy-to-understand timelines and explanations of the current state of affairs in healthcare. This site is a good starting point for anyone looking for an overview.

2. Talk to your doctor

It’s easy to forget, but your doctor’s office can give you answers to many of the questions you might have. This might not be the best source for future reforms and changes, but for the current situation there aren’t many places that are going to have better information. They have to comply with regulations and changes, so it makes sense that they would have the required information to do so. In addition to asking your doctor questions, you can talk with staff before or after your appointment to get the answers you need.

3. Specialized information sources

The basics are a good start, but you may find that there will be specialized information you need. The kinds of questions small business owners are going to have are going to be different than those of consumers, doctors, or nurses. The Small Business Administration site has good information for small business owners.

If you’re a nurse or doctor (or you’re going to school to become one) you can often find information at your place of work or school. Healthcare reform is going to affect every subset of people in the field differently, so you might have to search out alternative resources if you can’t find what you need.

Healthcare reform doesn’t have to be confusing. Check out these resources to find the answers to your questions.

Author’s bio: Carolyn Knight is a guest writer on the topics of healthcare reform, registered nursing schools, and medical technology. She lives in Austin, TX and attended the University of Texas at Austin.

Types of denials:
• Coverage based
• Technical
• Medical

Coverage based: these are denial when the insurance company states that your policy does not cover this service.
Example: a client had an oral device made by a dentist to treat his sleep apnea. The claim was denied based on the dental component. I successfully argued that his oral appliance was to treat a medical condition.

Technical: these are claims denials mostly for timely filing or coding problems.
Most claims have to be filed within a 180 days from the time services were provided. Missing this deadline will produce a timely filing denial.
Example: the patient was hospitalized for an extended time period, therefore could not file a timely appeal.
Coding problems: each medical claim have to contain a several numbered codes, such as provider tax ID, place of service, CPT or HCPCS, diagnosis, NPI or license numbers. Missing or using a wrong one will produce a denial. In this case there is no need for an appeal. Simply you need to decipher which code needs a correction and simply can resubmit a claim with correct codes.
I am fully expecting these denials to multiply starting on October 2013. That is when the ICD-10 coding change will be implemented and codes will multiply by nearly 55,000.

Medical: these are services denying by the insurance saying that the service was not medically necessary for your specific condition. The appeal should explain why it was necessary and be paid.
In case the first level of appeal is denied I always file a second level of appeal. The review of this appeal takes place with a different department and there is a chance to overturn the first level of denial.

If a second level of appeal is denied there is always an option to file the next level to the Commissioner of Insurance or the Benefit Administrator. The deciding factor is based on the type of policy the person have. Fully funded insurance policies are appealed at the Commissioner of Insurance level, and self-funded insurance policies are appealed at the Benefit Administrator.

We did really well eliminating pre-existing condition limits for children, and everyone liked the young adult coverage extension to age 26, under the parents large group policies.

We are hitting a bump on the road with implementation of the medical loss ratio, which is now in the books and forcing the insurance companies to pay out about 80% of collected premiums on claim expenses. Just like any other business, insurance companies have regular business expenses they have to account for. So the battle was brewing for a while to decide which expenses can be allocated under the general umbrella of claims expense.

The new major outcry is now originating from religious groups. The law added a significant change which makes women health and reproduction along with planned birth control part of a category of preventive care.

In the past religion based institutions were exempted from covering birth control and coverage for reproductive services, other than child birth. The PPACA now requires faith based large organizations, such as hospitals and universities to cover birth control as part of the basic preventive care. (Small churches with only faith based employees are still exempt.)

There is nothing in this law that force women to use birth control, it is only an option to do so. My insurance covers surgery for broken leg, yet I don’t go and break my leg, just because it is covered. This law simply gives women the option to use family planning, fertilization treatments and birth control if they so desire.

Why should this option denied for women who do not agree with the church dogma, or not even catholic, just because their employer has a religious objection to it?

These same religious organizations receive significant federal funding; yet want to be excluded from public healthcare policy. It would seem fair to me to obey federal policy in return for federal funding.

Dr. Berwick was appointed by president Obama in 2010 during a congressional recess, effectively forcing his position to be reconfirmed by congress this year. Prior to this pending confirmation 42 Republican senators signed a letter pledging to block his confirmation, effectively ending any chance of him serving beyond 2011.

What is so wrong with Dr. Berwick? What did he do to make many republicans angry?

He praised the UK National Health Services when he was visiting the UK. He also made some comments that can be interpreted as rationing. Honestly I don’t know too much about the UK National Health Services. All I know that everyone gets basic medical care free of charge, and they have problems with waiting for advanced imaging and surgeries. I would say the first part is admirable, the second part no so much.

I am still puzzled the anger of congress regarding rationing. If you think about it healthcare rationing is a way of life in the US. We just call it Utilization Management in the case of insurance, Local Policy Determination in the case of Medicare. When we are considering Medicaid we simply have no doctors whom are willing to treat patients for the assigned cost. Our last group is the uninsureds, whom can’t afford insurance, therefore can’t afford healthcare. Presently in the US we are rationing by ability to pay.

I am a believer that Dr. Berwick would have made a difference in our health care system if congress gave him a chance to continiue on the path he already started.

Dr. Berwick came to CMS following enactment of the controversial Patient Protection and Affordable Care Act (PPACA). In his 18-month tenure, Dr. Berwick supervised the rollout of essential health reform regulations that promised to reshape both the private insurance market and the Medicare program. CMS drafted rules for the new health insurance marketplaces, called exchanges, where Americans will be able to compare and buy health insurance plans in 2014. He is responsible for putting in place a pilot program to move Medicare away from paying doctors based on volume of services to quality of care.

Dr Berwick advocates patient centered care; hospital care that works with the needs of the patient; not the medical staff. He doesn’t want a patient or himself “to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep.”

I am personally sad to see him go. His medical values and believes would significantly improved our overall health care.

Neurologist says that if he can get to a stroke victim within 3 hours he can reverse the effects of a certain types of strokes. They say the trick is getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours.

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke.

RECOGNIZING A STROKE

Doctors say a bystander can recognize a stroke by asking three simple questions:

Ask the individual to SMILE.
Ask the person to TALK and SPEAK A SIMPLE SENTENCE (Coherently)
Ask him or her to RAISE BOTH ARMS.
Ask him or her to STICK OUT YOUR TOUNGE

WHAT YOU ARE LOOKING FOR IS : being crooked. A smile where the lip is droopy in one side, a sentence where the words are slurred, arms that don’t go up the same height, tongue that ends up one side or the other. You are looking for pronounced weakness in either side of the body.

If he or she has trouble with ANY ONE of these tasks, call emergency number immediately and describe the symptoms to the dispatcher.

But I will let Karen explain what she does:
Late payment notices, overdraft fees, missed paperwork deadlines, confusing invoices–not keeping up with paperwork can be costly and stressful for people of all ages and especially overwhelming for people facing medical challenges and seniors. A trusted family member or friend can help, but people often do not want to be a burden or might not have a support system in place. Letting things “slip through the cracks” can be disastrous and costly.
Here is where a daily money manager comes to the rescue. Ours is a relatively new profession but a needed one. We’re not accountants, attorneys, or financial planners but we often provide the “boots on the ground” for these professionals working with individuals who want or need in-home help with paperwork and accumulated clutter.
My current clients range in age from 18 to 94 and access my services on a weekly, monthly or “as needed” basis. Some of my clients are simply outsourcing that aspect of their lives—relying on me to open mail, pay bills, track their spending, organize paperwork for taxes and bring to their attention important correspondence. Others simply can’t keep up with these essential tasks any more because of age or medical condition. My assistance helps them keep their independence. Each client is different and I tailor my services to their needs.

Karen Rosenberg Caccavo, MBA is owner of Personal Money Manager, a daily money management firm. She can be reached through her website, PersonalMoneyManager.net or Karen@Personalmoneymanager.net or LinkedIn.

The FDA issued “black box” warnings against prescribing atypical antipsychotic drugs for patients with dementia, cautioning that the drugs increased dementia patients’ mortality. At the same time CMS reports that, nationwide, 39.4% of nursing home residents who had cognitive impairments and behavior problems but no diagnosis of psychosis or related conditions received antipsychotic drugs.

Use of chemical restraints is a major cause of nursing home falls, including hip fractures, which are estimated to cost $746.5 million.

Lack of toileting leads to urinary incontinence, in turn it leads to skin irritation, decubitus ulcers, urinary tract infections, and additional nursing home admission and hospitalization. Estimated cost $3.26 billion annually.

Poor hydration, along with poor nutrition, decreased mobility and cleanliness leads to pressure ulcers. Treatment costs are estimated to range between $1.2 and $12 billion.

Hospitalization of a dehydrated nursing home resident costs, on average, more than $18,000. Dehydration is often avoidable if residents are given more fluids. Insufficient staffing leads to less fluid intake by residents.

Three-quarters of all nursing home residents have at least one fall each year, and a quarter of the falls require medical attention. Twenty to thirty percent of the falls are preventable. Falls cost, on average, $19,440 and hip fractures, more than $35,000.

Poor care leads to excess hospitalizations, costing nearly $1 million.

Present plans by our government to fix nursing home expenses for Medicare and Medicaid patients:

Medicare-Medicaid Coordinating Office (MMCO) was established under the authority of the PPACA to address cost of care and improve access.

There are three initiatives in the works.

1. Capitated model – basically contracting with insurance companies to create a blended Medicare-Medicaid rate

2. Fee-for-service model- this model supposed to share savings from Medicare hospitalization reduction due to better quality care in dual eligible nursing home residents within each state.

3. Improved Care Quality for Nursing Facility Residents – this project plans to contract with independent entities to implement better practices to prevent conditions that leads to hospitalizations. The project aims to target 150 Skilled Nursing Facilities with high rate of hospitalizations. (Will observation be counted into these admissions?)

The real fix is simply having more nurses and nurse aides to provide better care.

by Karen Rosenberg Caccavo, MBA, Personal Money Manager

One of the things I do for clients as a daily money manager is uncover and banish “hidden” fees that clients inevitably pay–but shouldn’t have to. Some are large, others are small, but they all add up and annoy the heck out of my clients–and probably yours (and you) too!

I was recently reviewing a client’s bank statement and noticed that the insurance premiums for his home and auto were being automatically deducted in two separate payments each month and a $1 service fee was being added to each payment. I called his insurance broker to ask why the premiums weren’t deducted as one payment (with a single $1 fee) and was told, “The client has to ask us to do this.” I pointed out that the client is on a fixed income and meets with his broker every year to review his account but did not know that this simple fee saving option was available. The broker’s reply to me: “We don’t look at every client’s bill in detail.”

Because I DO look at my client’s bills in detail, I asked for the change to be made to his billing immediately, reducing his monthly “convenience” fee from $2 to $1. But I was told that there would be a one month delay as the next deductions were “only” 8 days away.

When I got off the phone and conveyed the information to my client, he was angry. “I’ve been insured with this agency for 30 years,” he said, “But now I want to switch.” He insisted we submit a “broker of record” letter so he can change insurance brokers.

I can’t help but wonder about the broker who lost this client after so many years–not to a charming lizard who also sells insurance, but by subjecting his client to $1 in unnecessary fees!

Karen Rosenberg Caccavo, MBA is owner of Personal Money Manager, a daily money management firm. She can be reached through her website, PersonalMoneyManager.net or Karen@Personalmoneymanager.net or LinkedIn.

The Health Insurance Portability and Accountability Act (HIPAA) provide some protection for people in transition, although it doesn’t go far enough.  The HIPAA law allows a 63 day gap between health insurance coverage.  Once the person is without medical insurance over 63 days, they are vulnerable to insurance company searches in to their medical records.

Unfortunately there are a lot of people affected by this unreasonable rule created by the insurance companies.
 
In a recent case a young woman was hospitalized and one of her old diagnosis was listed on her medical bill.  This code was put on to represent her historical medical condition and had nothing to do with her recent hospitalization.  Unfortunately, this simple coding oversight prompted her insurance company to deny her hospital and all other relevant medical bills.  The denial brought on disbelief, then frustration and anxiety.  Finally a well drafted letter from the treating physician clarified this new medical care need and all her claims got paid.

Another case involves a man who has been out of work for about two years.  His COBRA had run out and he couldn’t afford medical insurance, therefore his coverage gap went over the 63 day threshold.  One month later he finally got a job with medical insurance. Three month later he found himself in emergency surgery.  Unfortunately the surgery was similar in many ways to his previous condition and anatomical location.  Fortunately, the sudden illness was a newly manifested condition; therefore his insurance cannot deny his medical claim.  With that said it does not mean they don’t try.  Several request letters were sent to the patient.  These letters are originating from a third party company and asking for his signature to give authorization to request all his medical records.  Fortunately he was referred to us at MedBillsAssist, before he had signed any authorizations.  Our first action with the client was to acknowledge the request letters, but did not authorized access to his medical record.  It is always a bad idea to permit third party company to start looking through medical documentations.  The reason is simple:  records aren’t always correct. Hospital and physician records are handled by many and the process is error prone.  It is a very good idea for patient to request medical records and review them for accuracy.   According to HIPPA regulations, a patient can request their own medical records simply by signing and dating a request to release.       Once a person satisfied that the documentation is what he/she understands to be true, then it can be forwarded to the third party for review.  If there is an error the patient has a legal right to request correction of that error.  A simple letter to the hospital or physician to modify the medical record should be sufficient.

The Patient Protection and Affordability Care Act prohibited insurers to deny claims for children, except in grandfathered individual health insurance plans, based on pre-existing condition starting last fall.  The same law will apply to adults in 2014; provided the law will not be modified.