Insurance Coverage of Mental Illness

With a nation still mourning the Newtown mass shooting and on going concerns of what appears to be an epidemic currently taking place in our country, now more than ever before, mental illness is being discussed and addressed as a serious issue.  While the conversation may start with the causes and factors that may lead to such insipid crimes and mental instability, we'll never be able to prevent all mental illness. It's a complex, long term problem that will take years and years of study and reform in how we think and operate as a society.  For the immediate future, the quickest and easiest fix for those with mental struggles is to consider improving treatment through proper care and insurance coverage.

For too long, the health insurance industry has virtually ignored the pressing need for increased coverage and access to mental health care.  One of my Claims Security of America client's who's self employed, and maintains a traditional individual policy through Blue Cross Blue Shield of Florida, has mental health coverage that only allows for 8 visits to a Psychiatrist or Psychologist a year. 8 times in 365 days! That's hardly enough time for any sort of real treatment or help should he need it. What makes even less sense if that he was under a group's insurance plan with more than 50 employees which covers mental illness and treatments, then he'd have no coverage limits as required under the Mental Health Parity and Addiction Equity Act.  Naturally, insurers profit more from indemnifying a group verse an individual; but you could argue a self-employed person is under far more stress and more susceptible to mental health care than someone who's in a full-time position with full-time benefits, and thereby needs the extended coverage even more.

In 2008 Congress passed the Mental Health Parity and Addiction Equity Act, which went into effect Jan. 1 of 2010, but this set of laws still only affected group health plans with more than 50 employees.  Under this law, insurance companies can no longer arbitrarily limit the number of hospital days or outpatient treatment sessions, or assign higher co-payments or deductibles for those in need of psychological services. However, the single self-insured is one again left out. http://www.apa.org/helpcenter/parity-law.aspx# 

Unfortunately, when the recession hit a few years ago, many states and communities made significant mental health care cuts.  ABC NEWS reports:

"Since the recession forced budget cuts in 2009, state general funding for mental health care has decreased by an estimated $4.35 billion nationwide, according to the National Association of State Mental Health Program Directors . . . "

According to The National Institute of Mental Health more than 54 million Americans suffer from sort of mental disorder in any given year. That's roughly 1 in 4 of us. One in 17 people suffer from a "serious debilitating mental illness." An authoritative 2005 study suggested more than half of all Americans, will at some point, experience a major psychiatric disorder or substance abuse in their lifetime. In short, mental instability is the most common struggle we face.  Here's some warning signs to look out for and how to cope with them.

http://www.nmha.org/go/information/get-info/mi-and-the-family/recognizing-warning-signs-and-how-to-cope

Beginning in 2014 the Affordable Care Act (Obamacare) will require that all health insurance plans for small employers (less than 50 employees) and individuals include coverage for mental health and addiction.  Also, states that agree to expand Medicaid under the ACA will make the federal health insurance program's mental health coverage available to more low-income people. In addition, the ACA allocates money to increase the number of mental healthcare professionals across the country. The New York Times offers more detail on Obama's expansion of mental health care.

http://www.nytimes.com/2012/07/10/health/policy/health-care-law-offers-wider-benefits-for-treating-mental-illness.html

Help is on the way, but much more is still needed.  The World Health Organization ranks depression as the world's leading cause of disability. And if you've ever been even slightly depressed, you're well aware of how paralyzing it can be. Until we, as a society, accept mental illness as a disease every bit as life threatening as cancer, real progress will never be made

We know Congress has a full plate already, but nothing is ever solved overnight. Mental health is finally getting the attention it warrants and let's hope we begin to see benefits that work for all of us, not just some of us.  Parity means equal coverage for both mental health and physical health conditions.  Discriminating between group coverage greater than 50 employees, other small groups under 50, as well as individuals, does not conform to the definition of parity. But as long we continue to engage in these kind of discussions,  hope for a better future for all of us seems brighter.

Stay Positive, Stay Informed, Stay Healthy
- The Patient's Advocate

Rising Health Care Costs and Insurance Premiums

Now that the Affordable Care Act (ObamaCare) is here to stay a lot of us continue to wonder how our current care and costs will be affected. The health care industry is a $2.8 trillion business.  Health Care  in the U.S. accounts for almost 20% of the Gross Domestic Product and nearly 25% of the Federal budget. 

As for your personal care, the vast majority of us will not see any significant changes in how we're treated, which providers we can see, or what these services will cost out of pocket. If anything, there will be even more choices available in coverage and care. However, with these additional opportunities there may be a slight initial increase in our premiums.

Anthem Blue Cross of California recently stated it will seek to raise individual policy holder's premiums by an average of 18%.  http://www.latimes.com/business/la-fi-insurance-rate-hikes-20121128,0,1885711.story

That's a pretty hefty increase, but before you get too concerned about it you should now any rate changes are subject to an intense government study and approval; which is one of the more important mandates under the Affordable Care Act.  http://www.healthcare.gov/law/resources/reports/rate-review09112012a.html 

In November of 2014 California will have a chance to vote on whether or not the State's Insurance Commissioner can overturn any premium increases deemed "too excessive" and will be able to order Insurance Companies to refund this money to its subscribers. Plan on other states to follow suit as the government continues to regulate the Health Insurance industry and favor the patient. 

You can also contact your State's Insurance Office now if you feel your premiums are being raised without cause or merit. Do not let private-for-profit corporations just roll over you. As a subscriber, you have more rights and choices than you think. Increased regulation is here to stay.   Controlling the cost of health care is a challenging endeavor. Providers, insurance companies and subscribers each have an interest in a more cost effective and efficient health care delivery system. 

Subscribers should take the time to become more educated about all the options soon to be available. An estimated 30 million more Americans will finally be able to purchase health insurance through the Affordable Health Care Exchanges. That's a lot of new participants in a system that's already plenty complicated and diverse.  See our previous blog entry on Health Care Exchanges for more information:
http://thepatientsadvocate.blogspot.com/2012/11/health-care-exchanges-and-affordable.html

One step in simplifying the maze of insurance land would be for insurance companies to develop and publish a standardized ratings criteria on the various providers they cover so patients can make objective choices based on their specific needs and requirements. Many customer service based industries like hotels, already implement ratings systems for their properties. One of the goals of the Affordable Care Act is to make the Health Insurance industry more transparent and publicly challenged.

Provider reimbursement is yet another area where reform is necessary.  Insurance companies can start by changing the current "fee for service" system which only encourages more services instead of efficiency and  improved care. In other words, no incentive is given to treat a patient effectively and timely because providers automatically earn more, the more services they perform.

Cost of care is generally a combination of price and use of services.  Insurers and Providers can easily control price. Providers have a mind set of "the more I do, the more I get paid."  One idea suggested by Blue Cross and Blue Shield of Massachusetts is a "global payment" approach, an alternative to the traditional fee for service system. Providers, including hospitals and physician groups, are placed on a fixed budget for reimbursement.  Their end financial payout is performance based upon whether or not they meet the initial target budget. HMO's tried a similar payout method years ago with capitation reimbursement.

Under the target budget approach providers are free to perform any services they deem "medically necessary."  The insurer will not interfere with the medical decisions made by the provider.  If the provider group comes in under budget, they are then rewarded with a share of the savings.  If they come in over budget, they agree to absorb part of the losses. To prevent providers from providing too little service and coming in under budget at the expense of providing need care, the insurer has put in place bonuses tied to achieving quality of care measures.  Such measures would include a certain percentage of patients who have high blood pressure under control or who have maintained appropriate cholesterol levels.

Another feature of the Affordable Care Act meant to reduce health care costs is the 80/20 rule.  Under this rule insurers must spend at least 80% of premium dollars on health care benefits. If they fail to maintain this percentage they must provide refunds to subscribers.  The rule provides an incentive for insurance companies to manage their administrative expenses and maximize premium dollars toward benefits, yet another protection for subscribers.

Insurance companies can complain all they want now about their rising costs or percentage of dwindling billion dollar profits, but by the time ObamaCare is in full effect in 2014, there will still be plenty of money to be made on their behalf.  However, the single biggest beneficiary of the new nationwide system is clearly you and me.  Don't let the insurance companies and special interest groups manipulate the truth with claims of "Socialized Medicine" and "Death Squads." In the long term, patients will clearly be better off with more affordable and quality health care because of the reform set by the Affordable Care Act. When it comes to health care in this country, the U.S. government has our backs now, more than ever.

Stay informed. Stay positive. Stay healthy.
- The Patient's Advocate
   medicalclaimsfilingexpert@gmail.com

Health Care Exchanges and the Affordable Care Act

One of the many new features of the Affordable Care Act (commonly referred to as ObamaCare) passed in 2010 and taking full effect in 2014, is the creation of Health Care Exchanges. These state established organizations will make it easier for the approximate 30 million individuals currently without health insurance to obtain affordable coverage regardless of their health conditions, including any pre-existing conditions.  Each state will be responsibility to set up its exchange.  For those states which opt out of the process by Nov. 16th, the Federal government will assume this responsibility in that individual state.

According to Julie Rovner at NPR News, "So far, nearly 30 states haven't formally said what they'll do. Just over a dozen states have passed legislation to take on this task themselves. Governors in another handful have said they want no part of it. That means federal officials will step in and run the state exchanges for them. There is a third option: States can partner with the federal government to run the exchange. And now states can wait until as late as February to decide if they want to do that." For more on the NPR report click here:  http://www.northcountrypublicradio.org/news/npr/164979697/health-insurance-exchanges-explained

Here's an additional breakdown from Fox News: http://www.foxnews.com/politics/2012/11/13/obama-reelected-states-face-quick-deadlines-on-president-health-care-law/

So what will possible health insurance look like from one of these Exchanges?

When an individual or employee chooses to shop for insurance using an exchange, he will be able to purchase a "bare bones benchmark" policy.  The law states that an employer need only pay for 60% of the costs, leaving the remaining 40% to be paid by the employee. Presently, most plans pay for about 85% of the costs with employees paying the remaining 15%.  Employees who want more coverage will have to pay a greater amount each month under their employer health plan. Of note, individuals who purchase health insurance through the exchange are eligible for a subsidy if they earn up to 400% of the federal poverty level.  The subsidy is given in the form of a tax credit on a sliding scale based on income.

Another significant feature of the Health Exchange provision relates to employer groups with less than 25 employees.  These groups may be able to get tax credits up to 50% of their cost to help offset their insurance cost.  Presently, the tax credit allowance is up to 35%. This actually benefits smaller employers and gives them a greater incentive to provide coverage to their employees.  Under the new plan, employers with 50 or more employees who do not offer affordable health care coverage are subject to financial penalties. For more information click here: http://healthreform.kff.org/the-basics/employer-penalty-flowchart.aspx

While each Exchange will vary from state to state, The National Association of Insurance Commissioners has established some uniform criteria for all the state's Exchanges:

1. All plans provided through the Exchange must provide an "essential" benefits package which, at a minimum, includes ambulatory services, emergency care, hospitalization, prescriptions drugs and pediatric services.  
2. A Small Business Health Options Program must be set up by each state to help employers enroll their employees.
3. Exchanges must offer a variety of plans with different coverage levels from catastrophic to more basic coverage.

The bottom line is that the Affordable Health Care Act is the new law of the land and the Health Care Exchanges will be an integral part of shaping the landscape for future affordable and accessible  health care to all. Americans.

Stay informed. Stay positive. Stay healthy.
- The Patient's Advocate
   medicalclaimsfilingexpert@gmail.com

Prepare for Medicare Open Enrollment

From October 15th to December 7th, Medicare beneficiaries will have the opportunity to switch or enroll in Medicare Private Health Plans (Medicare Advantage Plan) and Prescription Drug Plans (PDP), as well as switch back to traditional Medicare A & B.  The Open Enrollment Period (OEP) is a risk free time to evaluate your current plan. New choices can be made regarding plans that would be effective as of January 1, 2013.

Specifically, here are the available options you have during the OEP:

(1) Dis-enroll from a Medicare Advantage Plan (MAP) by enrolling in a Part D-PDP. This automatically allows you to go back to the original Medicare Part A & B, and then purchase a Medicare Supplement.

(2) Change from your present PDP to another PDP.

(3) Enroll in a MAP with Prescription Drug coverage.

(4) Change from your present MAP to another MAP.

Let's explore these scenarios in more detail.

(1)  Dis-enrolling from a MAP and purchasing a Medicare Supplement. What goes into the process of effectively selecting a supplement? The first thing you should understand is that Medicare Supplements, sold by private insurance companies, are standardized.  This means that all the supplement plans labeled A to N have the same benefit structure regardless of the company selling the plan. For example, if you chose Plan F from the "X" insurance company, the benefits for Plan F are exactly the same for any other insurance company selling Plan F.  Once you decide on the appropriate benefits, you are selecting a plan based on  the service and price, which varies from one company to another.  You may also want to consider those plans that cover the additional 15% charged above the Medicare approved amount by those providers who do not accept Medicare assignment.

(2) Selecting the right PDP for you can be tricky. 

For example, Florida has 16 different insurance companies offering 34 different PDPs!  All Plans are not equal. In selecting a Plan, you should do an analysis of Plans in your geographic area by going to https://www.medicare.gov/find-a-plan/questions/home.aspx. 

Do not choose a PDP based on premium only.  The total annual cost is the best indicator for decision making. Other variables to consider are the deductibles and co-payment amounts. The latter can differ among plans, as well as among pharmacies, depending on whether the pharmacy is part of a preferred network.  Not all drug plans cover the same drugs equally, so some of your drugs may be covered under one plan; but not another. In select instances, you may also need mail order options for some of your drugs.  Not all Plans make this option available.  Also, certain drugs need pre-approval.  Finally, learn how to file an appeal if the PDP doesn't pay for your drug. ALWAYS APPEAL DENIED CLAIMS AND DRUGS.

(3)  If you decide to enroll in a MAP, you should be aware of the trade-offs involved.  

In most cases, these plans limit the availability of providers to a specific network.  As long as you stay in the provider network, you may only be subject to the Plan's co-pays and deductibles.  However, if you go out of the network, in a worst case scenario, you may not have reimbursable coverage. At the very least, your co-pays and deductibles will be greater than if you stayed in the network.  

MAPs operate in sharp contrast to the original Medicare Part A & B which allows freedom of choice. 

If you have original Medicare Part A & B and a Medicare Supplement that covers the 20% not covered by Medicare, and your provider accepts Medicare Assignment, you should never have any out-of-pocket costs with the exceptions of those few services not covered by Medicare.  

If you see a provider who does not accept Medicare Assignment, then you are subject to an additional 15%  charge above the Medicare approved amount.  This cost is a real out-of-pocket expense to you.  

If you see a provider who has opted out of the Medicare program entirely you would have no coverage and all charges would be out-of-pocket.  

The bottom line:  If you have original Medicare and want no out-of-pocket costs, you must obtain a Medicare Supplement that covers the 20% Medicare does not allow, and only visit providers who accept Medicare Assignment.  If you see providers who do not accept Medicare Assignment, be certain that your Medicare Supplement covers the additional 15% charged above the Medicare approved amount. Call your medical supplement to verify.

(4) Changing from one MAP to another should only relate to network availability and co-pays.  Perhaps your doctors and hospitals are in one MAP provider network and not the other.  These factors, along with premium costs, are the key considerations when selecting one MAP over another.

Remember, once you make your decision to enroll in a new plan effective January 1, 2013, you are locked into this Plan for the coming year, until the following Oct. 15 of every year, when you once again can re-evaluate and make any necessary changes through December 7th. As always, the more knowledge you have the easier it becomes to navigate the selection that is best for you..

Stay informed. Stay positive. Stay healthy.
-  The Patient's Advocate
   medicalclaimsfilingexpert@gmail.com

Improving America's Health Care System

While health insurance coverage, including accessibility and availability, is currently at the forefront of political debate, often overlooked is how you improve the actual care we receive.  At the core of the health industry crisis in this country is fixing a system that will ultimately be more efficient and at the same time, provide better health care to patients at lower costs. America's health care is ailing and needs critical treatment, now.

As reported in a recent New York Times article, the Obama administration is setting up a new service for consumers to report issues and problems related to their health care.

http://www.nytimes.com/2012/09/23/health/new-system-for-patients-to-report-medical-mistakes.html

A lot of folks thinks government should stay out of the private sector entirely, but this is a perfect example of a public agency seeking to protect its citizens. Nancy E. Foster, VP of the American Hospital Association says "it's a great concept. The idea is welcome." Anything that makes hospitals and doctors more accountable helps minimize errors and makes health care safer.

However, the role of government in our health care system raises another important question for this country. Is proper health care a luxury item or an entitled right? The answer is not necessarily a political one, but a moral one.  Where do you stand on it? How do you view your health care? And at what cost?

The United States is the most powerful, most advanced and most recognized country in the world; yet, its health care system ranks 37th according to the World Health Organization's 2000 rankings. A lot of factors went into the ranking; but above and beyond anything else, the most significant factor was expenditure per capita.

Kaiseredu.org breaks down the costs of care from 2010.

How is the U.S. health care dollar spent?

Hospital care and physician/clinical services combined account 
for half (51%) of the nation’s health expenditures.

National Health Expenditures, 2010

Total = $2.3 Trillion

What is driving health care spending?

While there is broad agreement that the rise in costs must be controlled, there is disagreement over the driving factors.  Some of the major factors that have been discussed in cost growth are:

• Technology and prescription drugs - For several years, spending on prescription drugs and new medical technologies has been cited as a primary contributor to the increase in overall health spending; however, in recent years, the rate of spending on prescription drugs has decelerated.[1]  Nonetheless, some analysts state that the availability of more expensive, state-of-the-art medical technologies and drugs fuels health care spending for development costs and because they generate demand for more intense, costly services even if they are not necessarily cost-effective. [6]
• Rise in chronic diseases – Longer life spans and greater prevalence of chronic illnesses has placed tremendous demands on the health care system.  It is estimated that health care costs for chronic disease treatment account for over 75% of national health expenditures. [7]  In particular, there has been tremendous focus on the rise in rates of overweight and obesity and their contribution to chronic illnesses and health care spending.  The changing nature of illness has sparked a renewed interest in the possible role for prevention to help control costs. 
• Administrative costs – At least 7% of health care expenditures are estimated to go toward for the administrative costs of government health care programs and the net cost of private insurance (e.g. administrative costs, reserves, taxes, profits/losses).[1] Some argue that the mixed public-private system creates overhead costs and large profits that are fueling health care spending.[8]

ACA and Cost Containment

The nation’s efforts to control health care costs have not had much long-term effect [9], prompting a debate over what proposals are actually able to reduce costs for the long-term.  Approaches are largely divided by debate over a stronger role for government regulation or market-based models that encourage greater competition.  Costs emerged as a central element of the national health reform debate that ensued before the passage of the Affordable Care Act (ACA) of 2010.  Major ACA measures aimed at cost containment include[10]:

• Greater government oversight and regulation of health insurer premiums and practices
• Increasing competition and price transparency in the sale of insurance policies through Health Insurance Exchanges
• Payment reforms that aim to reduce payments for treatments and hospitalizations resulting from errors or poor quality of care
• Funding for comparative effectiveness research (CER) that compares different interventions and strategies to prevent, diagnose, treat, and monitor health conditions.[11] The Patient-Centered Outcomes Research Institute (PCORI) was established by the ACA to commission CER guided by patients, caregivers, and the broader health care community. [12]
• Refocusing medical delivery systems to be patient-centered and improve the coordination and quality of care (e.g. ACOs, medical homes). [13]

Other proposals and practices directed at controlling costs exist, such as support for wider use of health IT in the delivery system, increasing consumer out of pocket costs, improving health efficiency and quality of care, reforming the tax treatment of health insurance, and a single payer plan.  As the nation struggles with a faltering economy, health care costs will surely continue to be at the forefront of policy debates.

Regardless of your position on health care as a right or privilege, we can all agree, the greatest challenge we face together, is how we continue to improve quality and lower costs. The Obama administration's new plan to monitor and track personal health care is a step in the right direction.

Stay informed. Stay positive. Stay healthy.

-  The Patient's Advocate

The Future of Medicare and Your Options

One of the most important debates for the upcoming Presidential election is centered around Medicare. Democrats and Republican maintain vastly different opinions on the best way to provide coverage to the Medicare eligible population.  Before you can begin to participate in this debate, it is essential to have an understanding of the current Medicare program. 

Do you know your A-B-C's?

The Wall Street Journal's Ellen Schultz, recently wrote an excellent article explaining the various Medicare options, including Parts A, B, C and D.  "A New Medicare Strategy" can be found at the link below.

http://online.wsj.com/article/SB10000872396390443713704577603191913817830.html?mod=WSJ_RetirementPlanning_RetirementPlanning_2

As informative as the above article is, two critical areas were not addressed. Medicare providers who do not accept Medicare Assignment and Medicare providers who have opted out of the Medicare program.  If you already have provider relationships and want to continue to see them as a Medicare patient then you'll need to keep reading.

First, you should confirm whether or not your provider accepts Medicare Assignment.  When a provider accepts (Medicare) assignment, he agrees to accept, as payment in full, the amount the insurance company (Medicare) approves. The difference between the approved amount and the full charged amount must be written off.  You cannot and should not be charged for these differences.  Anytime a provider "balance bills" you for the difference between the approved and charged amounts, they are in violation of their contractual agreement with Medicare.  Do not pay these charges!  This scenario is mostly applicable to the traditional Medicare program, Part A and B.

If you are enrolled in the alternative to the traditional Medicare program, Part C, the Medicare Advantage option, then only certain providers participate in this restricted network. You should be aware of this trade-off, knowing that you are limiting your access to providers in exchange for what is usually a much less expensive alternative to the Medicare Part A and B and Medicare Supplement and Part D drug program.

So what happens if you visit providers who DO NOT accept Medicare Assignment?  This means they do not have to accept the Medicare approved amount as full payment.  They are allowed to charge 15% above the Medicare approved amount.  This additional 15% may not be covered by your Medicare supplement.  Most supplements will pick up the 20% left after Medicare pays 80% of the approved amount.  This 15% is in addition to the 20%. If your Medicare supplement does not cover the 15%, this will be an out of pocket cost for you. You will have to pay the remaining balance. It is important  for you to ask your provider if he does or does not accept Medicare assignment.

However, providers who no longer participate with or have opted out of the Medicare program present a different concern: They will not see Medicare patients!  If you wish to continue to see them, your claim will not be filed to Medicare; and therefore, you must pay your provider directly and pay whatever they may charge. You will not be reimbursed one penny through Medicare!  This is why it's paramount to ask your provider if he/she  participates with the Medicare program prior to services.  More than ever, physicians are opting out of the Medicare program. Physicians are concerned about lower reimbursement from the Medicare program.  However, by encouraging this opt out behavior, seniors will ultimately be prevented from seeing their physician of choice because of the additional out of pocket expense.

OK, so now that we understand how the system works what is the real difference the two plans set forth by the Democrats and the Republicans? And how do these affect you, the patient?

The Democrats continue to favor maintaining the present system of Medicare while the Republicans would require a voucher based system.

According to a Huffington Post article by Terry O'Neil "The Romney-Ryan plan claims this major Medicare overhaul would not go into effect until 2023, so that people 55 and over wouldn't be affected; but that's significantly misleading. Despite the delayed implementation, if this plan were to be enacted, along with repeal of Obama Care during a Romney-Ryan administration, out-of-pocket costs for all people on Medicare would start going up almost immediately."

(http://www.huffingtonpost.com/terry-oneill/medicare-romneryan-budget_b_1844950.html)

The privatization of the present Medicare program that Republicans advocate would lead to higher costs for individuals across the board. Their proposed voucher system would make Medicare individuals purchase an insurance plan from the voucher they receive from the Government.  The amount of the voucher used for health insurance would not come close to purchasing a plan that is as good as their present traditional Medicare program.  If the individual wants a better plan, it would be an out of pocket expense to move up the line for better coverage.  Thus, health care costs for Medicare patients would be greater for the same benefits and coverage enjoyed under the present Medicare program.

The Democrats' plan is not a do nothing approach as some of have claimed.  For one thing, the Affordable Care Act would continue to close the gap in the doughnut hole under Part D Medicare.  The repeal of the Affordable Care Act under the Republicans would potentially do away with key features that presently eliminate  pre-existing conditions and lifetime maximums.

The reason the Democrats feel so strongly about government intervention into healthcare is because the insurance industry, to-date, has not been able to efficiently manage medical costs in the "free" marketplace environment. While the health care business is very much a business, it does not operate like a typical one. In part, because health care becomes a necessity and not a luxury to those in need of it. Except, the Republicans believe health care should be treated as a luxury item...just like a flat screen TV or fancy new car. This is the basis for their entire argument. 

The main reason Obama and Democrats fought so hard for the passage of the Affordable Care Act is because they maintain healthcare is a moral issue and should be a fundamental American right, protected by the government, and not simply an item or service exchanged in a free market and viewed as a privilege.

The proposed changes to the present Medicare program will have significant implications for patients in terms of accessibility to their providers and the charges for which they will be billed.  If you're rich you probably don't have much to worry about, but if you're on a limited budget like 99% of us then you should be concerned.

In the end, you must be your own best advocate in developing an understanding of the options available to you and the cost implications. And recognize the moral issues each party favors.

Stay informed. Stay positive. Stay healthy.

-  The Patient's Advocate

The Affordable Care Act and Rejected Insurance Claims

The Huffington Post recently ran an article about a cancer patient whose claim was denied because he had exhausted his lifetime limit of $300,000 for coverage.  AETNA Insurance initially denied the claim, but agreed to pay after significant pressures from the patient who initiated an online campaign.  The article, linked below, continues to point out the absurdities in dealing with health insurance companies who reject millions of dollars of claims annually.  In many cases, these claims are rejected erroneously and cost the patient dearly, both emotionally and financially.

http://www.huffingtonpost.com/2012/07/31/arijit-guha-cancer-patient_n_1724478.html?ncid=edlinkusaolp00000003

The report clearly addresses the lifetime maximum coverage benefit exhausted. Fortunately, this will no longer be a reason for insurance companies to reject future claims because one of the key components  of The Affordable Care Act (ObamaCare) is that it will be illegal for Insurance companies to place limitations on lifetime coverage by 2014.  No one thinks about these seemingly high limits until they actually get seriously sick and the bills quickly start adding up. With today's ever skyrocketing costs of medical care no limit is out of reach and no amount of personal wealth can be enough to cover all potential costs.

Actually, this provision already went into effect for existing health plans beginning on, or after, September 23, 2010. The complete timeline for the implementation of the Affordable Care Act for the Act's provisions through 2014 can be found by clicking here. http://www.healthcare.gov/law/timeline

Insurance companies reject claims for a variety of reasons far too often. According to a recent American Medical Association (AMA) survey reported by its immediate past Chairman, Dr. Robert Wah, 20% of insurance claims were processed incorrectly in 2011. This is different from the simple rejected claims which do not fit under the patient's specific coverage. These falsely processed claims were inaccurately paid,  meaning the insurer frequently underpays, leaving the insured with a larger medical bill than they should have. 

The most recent Government Accounting Office (GAO) study on health insurance claims reveals that nearly 40% of claims from six large insurers operating in a single state were rejected. The study also reports that when these original denials were appealed, almost 60% were overturned in favor of the insured patient!  http://www.gao.gov/assets/320/316706.pdf

The lesson to learn here is to appeal any claim that is rejected, regardless of the reason. Odds are in your favor it will be overturned and that you're more covered than you thought.  Never accept the myriad of reasons why insurance companies reject your claims.  Always appeal!

Patients also need to be aware of why claims can be rejected and how to properly appeal these rejections.  In no particular order, the most common claim rejections arise from Pre-existing Conditions, Wrong Diagnosis Codes, Duplicate Claims Submission and Limited Benefits, such as mental health and those claims deemed "not medically necessary."

Let's take a look at each common claim rejection individually.

Pre-existing Conditions

Under ObamaCare coverage cannot be denied because of it. Previously, insurers could pick and choose who they can provide coverage for based on an applicant's medical history. No more. Thanks to President Obama everyone is now eligible for coverage.

Wrong Diagnosis Codes 

Typically, services are coded as "screening" or "diagnostic" and depending on the patient's history, these services may be paid under one, but not the other. It's not uncommon for your provider to miscode; either accidentally or due to poor knowledge of your history.

Duplicate Claims

This occurs when the insurance company feels that multiple services of the same kind took place on the same day.  While this may be the case, in most circumstances, patients should still verify from the provider that these "duplicate" services were ordered more than once for legitimate reasons and if so, should be reimbursed accordingly as separate services.  

Limited Benefits

In many instances this type of rejected claim is very difficult to appeal because the insured is contractually bound. Typically, mental health conditions do not receive the same kind of insurance treatment as other illnesses. All "diseases" are not looked upon equally. On occasion, insurance companies will make exceptions on a case by case basis, so do not be discouraged. With a little fight and help from your Doctor you can still appeal these rejections. Many states have already mandated mental health parity for Group enrollment. 

"Not Medically Necessary"

Any time a service is branded "unnecessary", patients should request from their Provider an authorized letter documenting the medical necessity for the service or treatment. 

Regardless of the positive initiatives of the Affordable Care Act YOU, THE PATIENT must still work to understand all your rights. Ask questions. Read articles. Follow this blog! You can be your own advocate. An informed, knowledgeable patient is the best way to maximize your entitled benefits and minimize your healthcare costs. 

Stay informed. Stay positive. Stay healthy.

-  The Patient's Advocate