When being a bad patient is good.

There are some scary statistics out there:

• When you see the doctor, the diagnosis will be wrong as many as one out of four times, according to a report by the Agency for Healthcare Research and Quality.

• One out of 14 times you have an abnormal test result, doctors will fail to let you know, according to Archives of Internal Medicine research out last year.

• In 2006 the Institute of Medicine reported that 1.5 million Americans are sickened, injured, or killed each year by medication errors.

It is because of stats like these that it pays to be a 'bad' patient.  One who speaks up and asks questions.  If your doctor says you need a certain procedure, do not be afraid to ask why. Get involved in your decisions about your medical care including prescriptions being prescribed and diagnostic tests being ordered, all which are increasing the costs of health care.

Be an empowered patient. Share in the decision model when it comes to your health. The reality is that a significant number of medical errors can be prevented or even eliminated by taking a proactive role in your health care. 

San Diego Reader | That's ok, sir, I am authorized to offer a 50% discount

An excellent, article appeared in the San Diego Reader by Chad Deal on Wednesday, July 7, 2010

Key points I feel everyone needs to be aware of:

1. When choosing a hospital, get a quote on your visit from the hospital’s billing department
2. Research fair prices ahead of time. www.healthcarebluebook.com
3. Ask what the room price includes, bring your own tissues, prescription drugs, toothbrush and towels
4. Keep a detailed log of every test, treatment, and medication you are given when in the hospital, or ask a family member or friend to do it.
5. When you get the bill, confirm admission and discharge dates.
6. Be aware of charges for items you did not receive (see #4) and double charges on your hospital bill. If you’re not sure, ask.

How can insurance dictate your medication?

Overview
A common feature of all insurance plans whether it's Medicare, a group or an individual policy is to regulate the prescription drugs prescribed for its members. This is done in four ways: requiring a prior authorization, step therapy, maximum dispensing limits or excluding certain medications from its prescription drug list.

Prior Authorization

Some drugs must undergo a criteria-based approval process by your insurance carrier prior to being covered under your health insurance plan. The approval process varies by insurance provider.

Step Therapy

Step therapy protocols require you to utilize medications commonly considered first-line medications prior to being able to using a medication considered second line or third line. You receive benefits for drugs subject to step therapy only after trying alternative medications first.

Prescription Drug List (PDL)

Your insurance carrier creates a prescription drug list (PDL) each year which dictates which medications are or are not covered by your insurance plan. The list can also change during the year depending on your policy guidelines.

Maximum Dispensing Limits

Maximum dispensing limits are based on the product information approved by the Federal Drug Administration (FDA) and recommendations from the drug's manufacturer. Your carrier limits the quantity of medication you are able to receive from your pharmacy at one time.

Restrictions

According to Humana, a health insurance company, the cost of a drug drops in price between 30 percent to 80 percent once the patent expires and it is available as in a generic form. Step therapy, prior authorization and PDL are ways to help control health care costs with maximum dispensing limits in place as a safety measure.

Considerations

You may not like the measures implemented by your insurance company to restrict dispensing specific medications; you can however get an exception made to each of the restrictions. The procedure for doing this will vary depending on your insurance carrier.

Report Medical Insurance Fraud

Medical insurance fraud is committed in a number of ways. For instance, when a consumer files a claim for services or prescription drug he never received or a provider bills for a service it never actually provided, a crime has been committed. Anytime a consumer or provider knowingly presents to her insurance company false information with the intent of receiving health care benefits, medical insurance fraud has occurred. According to Cornell University Law School, "statistics now show that 10 cents of every dollar spent on health care goes toward paying for fraudulent health care claims." Such unscrupulous acts need to be reported.

Step 1

Find the insurance fraud bureau for your state. This can be located on the Coalition Against Insurance Fraud website using the link in Resources. If your state does not have an insurance fraud bureau, search for your state's department of insurance website.

Step 2

Call the hotline number listed for your state insurance fraud bureau or the consumer helpline found on your state's department of insurance website. You will want to provide the agency with the name or any details and information you have about the medical insurance fraud situation.

Step 3

Contact the insurance company you believe the fraudulent activity occurred against. You can locate a company's phone number by finding its corporate homepage on the Internet.

Step 4

Report Medicare or Medicaid fraud by calling the Department of Health and Human Services' Office of Inspector General Fraud Hotline. You can either call 800-447-8477 or email HHSTips@oig.hhs.gov. You will need to provide information such as who committed the fraud and where and how it happened. Plus, according to Medicare, "your identity will be protected to the maximum extent allowed by the law."

 

Step 5

Voice your concerns to the National Insurance Crime Bureau (NICB). You can submit the information via the link in Resources or call the bureau's national hotline at 800-835-6422. If you are using a cell phone, you can send a text by typing the word "FRAUD" and then the fraudulent information you are reporting in the message section. The text is sent to TIP411 (847411). You are allowed to keep your identity anonymous when reporting fraudulent information.

Do you have a medical proxy appointed?

A medical proxy is also known as a health-care proxy or medical power of attorney. It is a legal agreement where you appoint someone to make decisions on your behalf if you become unable to make a medical decision for yourself.

Why Do I Need One?

There are two situations when a medical proxy is needed: when you are temporarily unable to make a health-care decision or if you are permanently unable to make your own decision. For instance, if you were having surgery and something happened while under anesthesia where a choice had to be made, without a medical proxy in place, the surgery would have to stop. You would have to come out from under the anesthesia and then be asked your preference and go through the surgery preparation procedures all over again.

Who Should I Appoint?

It may be difficult to decide whom you should choose to make medical decisions on your behalf. When making your choice, consider if the person will be able to make tough decisions, based on your wishes, when faced with a situation and whether the person can understand the medical information regarding your treatment.

How Do I Appoint Someone?

A medical proxy is a legal document and the requirements vary by state. You can obtain a proxy form from an attorney or some hospitals. Once the form is completed, you will want to share a copy with your primary physician as well as provide the person whom you appointed a copy. You can also register your medical proxy with an online database, OnlineMedicalRegistries.com, which, according to the site, allows “accredited, registered hospitals and healthcare providers access, if needed.”

Health Insurance Claims Processing Issues

Insurance claims are processed in two ways: electronically or via a universal paper claim form. Regardless of which method is used, claims can be delayed or denied for several reasons. If you are aware of a few common billing errors, you might be able to avoid or resolve some issues with processing insurance claims.

History

A national universal claim form was approved by the American Medical Association in April 1975. This universal form allows for a standard format and quicker claims processing by insurance carriers. Before 1990, all claims were processed manually; however, as technology advanced, equipment was developed to optically scan and auto-adjudicate, or digitally process, universal claim forms.

Process

A paper insurance claim form is filled out and mailed or faxed to your insurance company. The insurance company then scans the document and converts it to an electronic format. Alternately, an electronic claim is submitted directly from your physician’s computer to your insurance carrier’s computer as a digital file. This is received in the necessary electronic format for processing. Regardless of how the form is submitted, the digital data ultimately is run through a software program designed to review the claim for all the required information, and the program either approves it or denies it.

Human Error

Human error can cause the processing software to reject an otherwise appropriate claim. For example, if you hurt your finger playing baseball and go to the emergency room, your claim should have a diagnosis code for a finger injury. However, if the claim is submitted with a diagnosis code for a finger injury and a procedure code for a chest X-ray (instead of the code for a finger X-ray), the system won't process the claim because a chest X-ray is not an appropriate procedure for an injured finger.

Other Issues

Each insurance carrier allows a specific amount of time after your date of service for a provider to submit a claim, and claims submitted outside this time frame are denied. Claims also can be denied when the specific information required is missing, recorded incorrectly or illegible. This information can include the patient's name, member identification number, date of birth, diagnosis code, procedure codes, date of service, place of service, amount charged, physician’s identification numbers and physician’s signature.

Solution

After each claim is processed, an explanation of benefits (EOB) is sent to you from your insurance carrier. The EOB details how your claim was processed, how much you owe your provider and how much the insurer paid your provider. If a portion was not covered, the EOB will list a reason code, giving you an explanation. If you do not understand what the code means or you believe there is an error, call your insurance company and ask for assistance. Your insurance company can tell you the reason the claim was not paid. If it is something your provider needs to correct, your insurance carrier will contact the provider regarding the mistake.

COBRA Insurance Requirements

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) created a Federal Law requiring most employers with more than 20 employees who offer group health care coverage to give their employees, spouse and their dependents the option to continue their health care coverage when a loss in coverage occurs. COBRA coverage is the same coverage the employee had when they were actively working for the employer. However, the employee is responsible for 100 percent of the premiums, plus possibly a two percent administration fee.

Qualified beneficiary

You, the employee, your spouse and any dependents who were covered on your health insurance plan the day before you lost health insurance coverage are considered a qualified beneficiary and eligible for COBRA coverage.

Qualifying event

Quitting your place of employment, being let go from your place of employment or having your hours reduced so you are no longer considered a full-time employee are all considered qualifying events. A qualifying event makes you, your spouse and your dependents eligible for COBRA coverage. Additional qualified events for your spouse and dependents include if you pass away, get divorced or have a child reach the maximum age eligible for coverage on your plan.

General notice

When a qualifying event occurs and you lose your insurance coverage, COBRA law requires your employer to notify you of the COBRA law and your potential eligibility for COBRA. The notice sent to advise you of this information is called the general notice. The general notice must be sent to you, your spouse and your dependents within 90 days of the date your coverage ends.

Qualifying event election notice

The qualifying event election notice informs you of your right to continue your health insurance under COBRA. The notice must be sent out within 44 days of your employer being made aware of the qualifying event.

Time frames

Within 60 days after the qualified event notice is mailed or after your coverage ends, whichever is later, you have 60 days to decide whether you want to elect COBRA coverage. If you elect coverage, you have another 45 days to pay all the retroactive premiums due. Going forward, you will then have a 30 day grace period to pay your monthly COBRA premiums.