Archive for the ‘Pre-exisitng condition’ Category

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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.

Insurance language defines pre existing condition as a symptom, illness or health condition that was known and existed prior to the writing and signing an insurance contract. Health or life insurance policies will typically not cover pre-existing conditions until a specified period of time has elapsed. Depending on federal and state laws pre-existing conditions may not be covered at all.

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.

Below are some highlights in phase two of the Health Care Reform Bill.

This is the year when our tax codes are going through significant changes driven by the health care law.  Overall, health care is getting more regulated, therefore it is forcing businesses, health care providers and insurance companies to spend more money on administration.  There are a lot of plans that are studying and “advising” on how to make health care better.  Sadly, those groups and advisory bodies should have been created prior to the enactment of this law.

• Minimum Medical Loss Ratio

Health plans, including grandfathered plans, must report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

• Consumer Protection

Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage as well as rescinding coverage except in cases of fraud.  Annual limits are still in effect until 2014.  The provision also prohibits plans from denying children coverage based on pre-existing medical conditions.

• Standardizing the Definition of Qualified Medical Expense

Match the definition of qualified medical expenses for HSAs, FSAs and HRAs to the definition used by the IRS itemized deduction.  Over-the-counter medicine will now only be considered as medical expense of accompanied by a doctor’s prescription.

• Reporting Health Coverage Costs on Form W-2

Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2.

• Creating Simple Cafeteria Plans

Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax‐free benefits to their employees.

• Appealing Health Plan Decisions

Appoints the right to appeal medical claim and/or policy decisions made by any health plan and the right to appeal decisions made by the health plan to an outside, independent decision-maker, no matter what state a person lives in or what type of health coverage a person may have. This includes, for the first time, new self-funded plans.

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Many health care reform provisions went into effect on September 23, but as with any new law some will start right away, and others will slowly be implemented over time.

Small business tax credits for companies with fewer than 25 employees are now in effect. Provisions to rescind policies are banned. People now are afforded federally protected appeals rights.
Some provisions are not welcome by the insurance industry and are being challenged in their own way. For example, insurers are now prohibited from denying coverage for children with pre-existing medical conditions. Insurance companies have responded by eliminating children’s policies in several states.
The ugly duckling, known as the medical loss ratio, is being legislated at 80% for small groups and 85% for large groups with a mandated rebate if the insurer fails to meet these ratios. Insurance companies have responded by reclassifying certain expenses as medical services.
Although other provisions are already in effect, such as dependent coverage for adult children up to age 26 for all policies, and requiring qualified health plans to provide minimum coverage for certain preventive services without cost sharing, these will only start when policies are renewed. In many instances, this will be in January 2011.
Interstate insurance exchange programs should already be in place, but they are running far behind schedule. The federal government does not know how to run them and state programs are so different from each other that most states have decided not to run their own.

Most states estimate serious financial shortfalls in this program; therefore they are hesitant to get it started.

Medicare changes are taking effect as well, such as cuts in all hospital payment rates, payment reduction to Medicare Advantage plans and a significant start in eliminating the prescription coverage gap.

Nobody wants to get a $4,000 medical bill; especially if they haven’t been in a hospital for years.  But it can happen to anyone and according to a recent survey by the Ponemon Institute it already happened to 5.8% adults in America. They have been a victim of medical identity theft, costing an average of $20,160.  The human cost is even higher.
Patients whose medical identities are stolen face serious drawn out effects. Fraudulent health care events can leave erroneous data in medical records. This erroneous information, such as information about tests, diagnoses and procedures, can greatly affect future health care and insurance coverage along with costs. Patients are often unaware of medical identity theft until a medical bill or a collection notice exposes the problem. Then, the burden of proof is with the patient and it is difficult to get the patient’s legitimate medical records cleaned up. The consequences can be life threatening and can lead to serious medical treatment errors and fatalities.
We all are at risk. Our personal information is sprinkled all over in the globe.  US companies hire subcontractors in other nations to provide customer service; data processing and many other functions. Your and my medical claims data can be accessed in the Philippines, because labor is cheaper there.  But even if we consider staying within the border of our nation we can all remember stories about stolen government laptops, lost backup tapes.
Last year CVS, the pharmacy giant, was fined $2.25 million for failing to protect sensitive financial and medical information of its customers and employees.
Just recently 12,000 Medicare enrollees had their protected health information compromised by a simple filing cabinet donation gone wrong.  Blue Cross & Blue Shield of Rhode Island donated a filing cabinet to a nonprofit organization without first removing surveys that contained Medicare PHI (Protected Health Information). 
While all these stories are awful I believe the real danger is still lies with individuals who work for doctors, clinics and hospitals.  They steal patient records in minutes by downloading information on a flash drive and sell it on a black market.  This could be an unhappy employee or someone recently hired to take a position simply to purloin information.
The only real protection is keeping a close eye on your medial identity.  Check your insurance Explanation of Benefits, look online and make sure that services billed are actually received, ask your insurance company to send you an annual statement for all your medical services.

The pre-existing condition is a health condition or illness that you have had before your first day of coverage on a new plan. The actual health coverage for those with pre-existing conditions depends on a number of factors such as the type of health insurance plan, the level of care that required for your pre-existing condition, and your health insurance history. A person with a pre-existing condition can cost an insurance company big bucks and naturally, it is in their best interest to exclude those who have them.

On the ligth side, here’s The Wizzard of ID cartoon that does describe the meaning of pre-existing condition on a morbid way: