Archive for the ‘Cost of care’ Category

PostHeaderIcon Responding to petition to defund Obamacare

There are many things wrong with a petition below.  Please read my comments as a proper response to this scare tactic petition created by Mike Lee (Senator UT) and Ted Cruz (Senator TX).   On October 1st, millions of Americans will be required to enroll in Obamacare and could lose access to their doctors and be forced to pay higher premiums and higher taxes. But there’s still time to stop it. Republicans and Democrats in Congress can stop Obamacare if they refuse to fund it.

Obamacare, or its proper name Patient Protection and Affordable Care Act (PPACA), is a law not insurance.  The Exchanges (insurance purchase marketplaces) set to open on the first of October 2013. Depending on the insurance policy people will chose they will have access to doctors. For already insured US citizens it is likely that they can purchase the same insurance they already have on the open marketplace; effectively retaining the same physician and hospital network.  The question about pricing is yet to be known, but for those who cannot afford it there are federal subsidies set in place to help pay for it. Only people who chose NOT to have insurance will have to pay a tax penalty. People with limited means will actually receive a subsidy, not a penalty.

The PPACA have many provisions already in place, so I can’t even image how defunding would affect it.  The petition does not tell you anything about the implication. It simply runs a headline and tries to scare people. Personally, I think this is silly season in politics.

Overall, this law helped children with pre-existing conditions getting insurance, improved the Medicare prescription plans coverage, allowed young adults to stay under their parents policy longer, eliminated lifetime limits under policies, etc. These are just a few benefits already in place that made healthcare a little better for US citizens.  It is not perfect, but an improvement from what we had before.

If republicans in congress want to do anything it should be working on making it better. Defunding would just mean for confusion and more fighting within the two branches of government. As you recall this law was reviewed by the Supreme Court and it was found constitutional.  As you also recall it was signed into law by congress.  We need to move forward, not backward.

PostHeaderIcon New trend in medical billing – Watch your money


We all know the big changes in medical insurance and the effect of the Patient Protection and Affordability Care Act. (I still hesitate to call it Obamacare)
The new trend in the delivery of medical care is hospital based medical practices. Hospitals are buying large medical group practices.  On the surface nothing has changed; seeing the same doctor in the same office.  In actuality, there is a big change. The same practice now belongs to the hospital, where more administration, higher “standard of care”, accreditation and increased staffing levels take place.  The doctor’s equipment now belongs to the hospital.
The financial outcome:  patients treated by the doctor now receiving two bills, one for the doctor and one for the facility.  Why should you care?  The facility based bill can easily be 10 times higher than the doctor bill.  All this for the same service you may have received in the past.
Many people have high deductible medical insurance. Many of the small group and individual policies hide a significant amount of patient responsibilities in a small print.
I think the time have passed for most people to be shy about the cost of their medical care. Everyone has a right to know how much a medical procedure will cost them. Ask the receptionist when you make an appointment.  Don’t be shy.  Your doctor isn’t shy about collecting their payments.
The blueprint to do this:  when you are making an appointment as the receptionist a few questions:

  1. Is the doctor participating in my insurance network?
  2. Is the doctor owns the practice, or is the practice owned by a hospital?
  3. How much my visit will cost?
  4. What is the procedure(s) code for my visit?   (Usually a five digit number, but could be one letter and four numbers)
  5. Do I need prior authorization for this service?
  6. Then call your insurance, with the information you have at hand and find out how much they will pay.

I am not advocating abstaining from medical care. I simply advocate for you to know how much it will cost in advance.

PostHeaderIcon Medicare Supplement – Medigap – policies

Most Medicare enrollees know that Medicare has parts, A, B,C, and D.

It is necessary to detail Medicare part A and B benefits and cost shares to understand Medigap Policies.

Medicare part A is a hospitalization benefit. It covers medical, mental health,  and skilled nursing facility.   For hospital admissions and mental health inpatient admissions portion of the bill is left for the beneficiaries to pay. That is called a deductible.  In 2013 the Medicare part A hospitalization deductible is $1,184. It covers the first 1-60 days. The 60 days counter runs even if the patient is discharged and readmitted within this 60 day window. From days 61-90 the patient enters a per day coinsurance liability period, which will cost them $296 per day. From days 91-150 days, called a “lifetime reserve days” carries a $592 per day coinsurance.

The complication comes in how Medicare provides these benefit periods.  Once discharged from a hospital the counter starts and ends at 60 days. Once a person is “facility free” (not hospitalized) for 60 days the Medicare benefit periods starts from day 1 again.  This is good in a sense that benefits are available again, but bad because they are liable for the deductible yet again.

Skilled Nursing Facility services are covered only if it followed by a minimum of 3 days hospitalization and the patient is in need of rehabilitation.  There is no liability for the first 20 days. From day 21-100 there is a $148 per day coinsurance. Medicare does not cover Skilled Nursing Facility services behind 100 days.

Lifetime reserve days don’t start over; once they are used they are gone. Medicare does not pay medical hospitalizations behind the continuous 150 days. In addition there is a lifetime limit of 190 days for mental health hospitalizations.

Medicare part B covers doctors, laboratory, outpatient hospital, medical equipment, infusions, diagnostic services, etc.  Basically part B is coverage for anything that is not hospitalization. There is an annual deductible and a cost share of 20% in most cases. In 2013 the annual deductible is $147.  Medicare pays most other services at 80% of a locally approved Medicare rates.

Medicare supplemental polies are purchased by beneficiaries to cover the above mentioned additional cost.  These plans are formulated and approved by the Federal government. Policies lettered from A to N. There are slight differences in actual plan offerings from state to state. However, the actual benefit package remains the same. Plan A offers basic benefits, plan B to D gives slightly more with each progression of the letter. The full Plan F offers the most benefit, including part B excess charges.  Plan G covers most, with the exception of part B deductible.  Plan K to N are the mixed plans with partial benefits and higher cost shares.  Plan N offers a unique mix of regular and copayment based benefits.

Prices for these plans are based on the state and often county where the beneficiary lives.  Cost is between under $100 to about $400. Again, it is based on geographic location, plan coverage, and insurance company.

PostHeaderIcon There is No Such Thing as a 10-Minute Office Visit


Article written by Mary Pat Whaley, FACMPE  Medical Practice Expert

I will never forget something a patient told me several years ago when I was covering the front desk in a practice I was managing. If you manage a practice and haven’t worked at your check-in and check-out desks recently, I highly recommend it. An insured patient that I checked out was shocked when I said the charge for her visit was $100. She said, “But he was only in the room for ten minutes!” I was briefly at a loss for words.

I recovered, we agreed on a payment plan for her co-pay, I made a note on her encounter form for the billing office and she left. I’ve been thinking about our conversation, and thinking about what that $100 – actually the payer would probably only pay about $35 and with her co-pay, the grand total would be $55 – and what that $55 is supposed to cover…

1. First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it.

2. When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID. An encounter form was generated at the nurse’s station to notify her of the patient’s arrival.

3. The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief Chief Complaint and History of Present Illness, review the medications she is taking and check to see if she needed any chronic medication refills while she was there.

4. The physician came in to see her, asked about any changes since she’d last been seen, reviewed her History of Present Illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.

5. He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.

6. He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the check-out desk.

7. He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled. The chart was filed, and the encounter form was sent to the billing office.

8. At the billing office the charges and any payment was posted and the claim was filed. If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer.

9. If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted.

10. Since the patient did not pay her co-pay at the check-out desk, the patient balance is billed to the patient.

If the patient pays on the very first statement, it has taken the practice from 45 to 60 days to receive the complete payment of $55. I know that patients often say “But he only spent 10 minutes with me.” Checking back with the provider, I find it was typically longer. Patients tend to underestimate the time as it goes very fast. The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller. It took 8 people, and at least 45 minutes of work to make that appointment happen. Plus, that visit had to help pay the expenses for the rent, the utilities, malpractice insurance, medical supplies, computers, phones and janitorial services. The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable. It’s what we all want. And it isn’t cheap. Even though healthcare and healthcare reimbursement have been sizzling hot topics in the past few years, most patients – already anxious and often sick – do not have a strong grasp of what actually goes into the services they receive. They see very little of the behind-the-scenes efforts. I don’t think the patient visit is necessarily the perfect time to educate patients on what goes into an office visit, but maybe each of us should be prepared to offer a meaningful answer when the patient says “”But he only spent 10 minutes with me.”

You can also view this article at

PostHeaderIcon 5 Tips for Handling Medical Claims — guest post by Erin Palmer


It can be upsetting to undergo medical treatment, but when medical bills start to arrive it’s easy to move from upset to completely overwhelmed. For families and patients, understanding how to handle medical claims can make all the difference in dealing with the financial stress and time-consuming nature of medical bills.  Consider these tips when handling medical claims:

1. Don’t wait!  Many families wait until there is an unbearable amount of medical paperwork to wade through before beginning the process.  A better way to handle medical billing is to deal with them when they arrive.  Take time to carefully read the information that is enclosed and determine if action needs to be taken.  If the letter is unclear, then immediately call the physician’s office, medical billing organization or hospital to get clarity.  Keeping up with the process is the best way to decrease the stress of medical billing.

2. It’s OK to ask.  Many patients feel intimidated and confused by paperwork that arrives in the mail.  Medical paperwork may be complex and leave patients with more questions than answers.  It is critical for patients to know that not completely understanding their billing is not a problem. It only becomes a problem when patients and their families don’t take time to ask pertinent questions. Virtually every billing statement has a customer service phone number.  Taking the time to call customer service and have questions answered is another effective practice in handling medical claims.

3. Analyze the EOB.  The EOB – or Explanation of Benefits – is one of the first pieces of information provided to a patient and their family.  Before calling the insurance company or provider, there are certain items to identify on the paperwork that will assist in determining next steps.  First, look for the name of the doctor or hospital and the date of the services provided.  The next item to identify is the total charges, noting the amount paid by insurance and the amount owed by the patient.  There should also be a section that shows contractual adjustments. This section should indicate the amount the doctors write off.

4. Know about insurance benefits.  Understanding insurance coverage will help to determine what needs to be paid and what is covered by insurance. Taking time to read the insurance booklet before medical services can help to answer questions before bills arrive.  Also, it is critical to understand the amount due for deductibles as well as co-payments or co-insurance.  To decrease the amount of bills that have to be sorted through, consider paying co-payments at the time of service and pay all bills by check or credit card so that there is a clear payment trail in case of questions later.

5. Don’t ignore bills.  No matter the situation, simply ignoring bills will not make them go away.  Whether there are unexpected bills or too much financial strain, there are ways to effectively work through the process.  The best place to start is to speak with the medical office and ask questions.  Many times, issues can be cleared up quickly and physicians are often willing to take a lower payment for services rather than receiving no payment at all.  Simply ask if there is a way to work out the billing to resolve the issues. Calling the insurance company also often yields results, either by explanation or a promise of reprocessing a claim. Taking a proactive approach, rather than ignoring the bills, will help to avoid frustrating collections calls.

Clearly, it’s upsetting to get a stack of bills while trying to heal from a major medical episode.  With these practical tips, understanding the paperwork, dealing with billing and communicating with doctors and hospitals should be much easier.

This guest post was provided by Erin Palmer. Erin writes about medical billing training programs and medical assistant degrees for US News University Directory. For more information about healthcare careers please visit


PostHeaderIcon How to learn about healthcare reform’s impact on you


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 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.

PostHeaderIcon Appeals – what to look for – how to file

Medical claims can be denied for many reasons. In most cases the reason for the denial is listed by codes right next to the service line. At the bottom of each Explanation of Benefits (EOB) there should be a code explanation. If the explanation is not listed or you don’t understand the first thing to do is find out or clarify what is being denied and why.
By calling your insurance customer service you can ask questions about a denial and full explanation should be given. During this phone call you may find out that the insurance made a mistake and your phone call of inquiry can prompt the customer service person to send back the claim for reprocessing. In this case, don’t feel completely relieved just yet. There are many things can go wrong and your denial could stand the same after thins phone call. So, the best thing to do in this situation is to mark your calendar in 30 days, note the date of your phone call, the name of the person you spoke with and if any reference number given. This way in 30 days you can follow up with a second call if the claim has not been paid.
Once the reason for denial is fully understand you can file an appeal. Always be sure to have the correct appeals address for your insurance. Letters and faxes often go to a specific department, so sending a letter to the wrong address can further delay the answer. Some of these companies are big that your letter can be easily misplaced and land in the “black hole”. I have heard insurance company representatives using this term.
The next important part is listing your information before your letter begins. This should include your name, your insurance ID number, the date services were provided, your address and the claim number listed on the denial.
The first sentence should state that this is an appeal and you are disputing the denial.
The body of your letter needs to explain what taken place and why this claim should be paid. Try to be clear and free of emotion. Accusing a person reading this letter will not help your appeal.
The closing sentence is the repeat of your demand for payment.
If you have supporting documentation of any kind you need include that with the letter.
Time: most claims have 180 days appeal limit, from the time a claim was processed. State laws and policies may vary slightly.

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.

PostHeaderIcon Another bump on the road for Obamacare

Pushing through this monstrous legislation called the Patient Protection and Affordability Care Act (PPACA) was just a beginning of slowly escalating problems with implementation of gradually coming to effect provisions.

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.

PostHeaderIcon Donald Berwick – Medicare Chief Resigned

Due to political pressure Donald Berwick resigned from his post as a Center for Medicare and Medicaid (CMS) administrator.

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.

PostHeaderIcon Medicare open enrollment is here and will close in 3 weeks

The time frame to change current Medicare plans has been moved up. This year, open enrollment started on October 15 and ends on December 7.
Actual changes will take effect, as usual, on January 1.
This is the time to review cost, coverage and convenience. It is time to consider a return to traditional Medicare or to check out if there is a Medicare Advantage plan that may offer better benefit options.
It is also time to change prescription plans. It is the perfect time to review all letters arriving from the present drug plan. There may be changes in the formulary for next year, which can adversely effect your bottom line. As always information is available at
Of course people that are satisfied with their current choices don’t have to make any changes.