Brian,
In addition to helping my friend, I'd also like to extend assistance to patients and families who are struggling with medical bills. I work in the industry...specifically with reimbursement issues for hospitals and I know how complex and frustrating they can be. Sometimes just understanding what you've been billed for and why is a chore. I would also add that the bills can be so complex at times that it is difficult to determine if you've been billed correctly. I also know that there are a lot of resources out there that most folks are not aware of to handle these bills. If I can be of any help, please have folks email me directly and I would be happy to see what I can do to help them.
Thanks,
Amy

Could I have used you when I was dealing with all this.... none of it ever made sense to me, and the amount of double billing, wrong billing, etc. was unbelievable. It was a full time job to sort it all out. Your offer to help people with this is very generous. At a time when lives are at stake, the extra emotional burden of dealing with complex insurance and reimbursement issues really weighs on people. Thank you for posting your offer.

My pleasure Brian. I'm happy to try to help.
Amy

I'm sure this is not top-of-the-mind when faced with a cancer diagnosis, treatment, survival, etc. but I did want to try to pass on what I hope to be useful tips...I will try to post tidbits that might be of use as I stumble across them.

Be sure to check your insurance coverage for rules regarding use of contracted (in network) and non-contracted (out-of-network) physicians and healthcare facilites. Most of the time there is a difference in the amount of reimbursement you receive...more/better if your provider is in network versus a lesser amount if your provider is out-of-network. This can impact the amount you have to pay out of your own pocket even after you've met your deductible and maximum out-of-pocket requirements. And this can happen regardless of whether your coverage is a group or individual policy.

While I would never advocate choosing a provider based solely on their contracted status with an insurance carrier, it may be an important consideration for some. If your provider of choice is not contracted with your insurance carrier you can ask them to consider contracting. Reimbursement is very tough and rapidly decreasing these days but some doctors will do this for their patients. Keep in mind that it will not help you retrospectively (no credits to services already provided) but it can help you moving forward if your physician does end up contracting.

If your physician or healthcare facility is contracted with your carrier and you are concerned about the charges and amount of out-of-pocket you are paying, please feel free to contact me and I will do what I can to help. There could me a plethera of explanation beyond this one.

Let me also add that some carriers are regulated at the federal level and some at the state level so there may be differences in laws, regulations, and how they are applied depending on the state and carrier.

I hope this is helpful...if not tell me to shut up and I will stop.
Amy

Amy,

Please don't stop!!! My insurance (BCBS) changed our coverage this year. Last year undergoing diagnosis and radiation I had 100% coverage for all...thank goodness.

This year for my second round that includes chemo, it has changed to 90% in Network...I am in Network (except for the physical therapist for my trismus)

I'll never understand my bills for my percent of the payments. Ugh!!! Of course I don't know that I would know what to ask you, but I'm glad you are here.

I also think it's a good thing to make comments on this thread so it will stay bumped up for new people.

Take care,
Dinah

Thanks Dinah. Do you have or have access to a secondary insurance? This could make up the 10% you are facing this year if you do. If you don't already have it you may run into some pre-existing condition issues but it may be worth a shot.

Also, be sure to check your bills very carefully. Believe it or not hospitals, physician offices, and payors make a lot of mistakes...even the most reputable cancer treatment centers in this country have billing office issues. If they didn't I wouldn't have a job! They may over charge you, charge you for things you didn't have, or try to pass on costs that have been denied by your insurance company as being unnecessary, etc. These things can often be refuted or appealed by you, your doctor, and/or the hospital. If you have any questions or concerns about this please feel free to ask.

I also wanted to add for folks who may not have any insurance coverage at all, there are options in many states to help out. Let me know if this is an area of concern for you and I will try to help.
Amy

Amy, the assistance and tips you are offering are wonderful. This is most generous of you and I am sure will be a help to many people. One of the things I am thankful for is extremely comprehensive coverage (and a background to wade through it) but I remember unscrambling bills for my parents, and at present, for my 80 year old neighbors. Your presence on this forum is a true gift! Thank you very much.
Joanna

Medicare coverage...

I thought I'd pass a couple of items of note regarding Medicare along to those of you with this type of coverage.

Currently Medicare's coverage of PET scans is limited. In April, the Centers for Medicare and Medicaid Services (commonly known as CMS or HCFA)announced they will expanding coverage to include treatment of patients with thyroid cancer.

Another hot topic of late for Medicare recipients is that of medical necessity and Advanced Beneficiary Notices (ABN). Please understand that it is the physician's responsbility to identify and ensure you are informed of any procedures or treatments that s/he intends to order/administer that are not covered/reimbursed by Medicare. Of course s/he gets assistance from other clinicians, staff, and computer programs but ultimately it is the physician who orders and must understand what tests/procedures are allowed with which diagnosis. What does this mean to you? If a test/procedure is ordered that is not supported by your diagnosis you will likely be asked to sign an ABN. This means that you will be responsible for payment. Talk with your doctor about this prior to signing. You must be given ample opportunity to understand, question, and decide whether or not to have the test/procedure (and sign the ABN). Healthcare providers cannot make you pay for something that Medicare denies for payment if they do not have an ABN on file, signed by you for that specific service. Healthcare providers also cannot present you with an ABN if it is not warranted (blanket ABNs are not allowed).

Also, please be aware that healthcare providers can appeal denials (refusal to pay) from Medicare if the physician feels the test/procedure you received is clinically warranted whether or not you signed an ABN. So if you receive a bill for something that you feel should have been covered by Medicare, talk to your physician or hospital billing office about it. I have heard of cases where cancer patients were asked to sign ABNs for chemotherapy treatments for recurring cancer treatments. If your physician determines chemo is warranted and beneficial to you, any denial can be appealed.

P.S. This ABN stuff applies to all healthcare services provided to or offered to Medicare patients. Also, be aware that ABNs cannot be offered unless the patient is stabilzed and able to understand (in other words asking a trauma victim with Medicare coverage to sign an ABN when they arrive at the ER would be higly inappropriate).

Let me know if I can help or if there are any other topics of interest.

Amy,

I have one question about insurance - Is it possible for a patient to find out the "correct" contracted charge of the service he/she received.

The reason I asked this question is that I have received different charges for the same service. I had 20 hyperbaric oxygen treatments early this year, for the final 10 treatments, the statement from the insurance company showed a much higher contracted charge than the initial 10 treatments, although the hospital has claimed same amount for all 20 treatments. Because of this increase of contracted charge, my resonsibily also increased considerably for the final 10 treatments.

I called insurance questioning why I had different charge for the same treatment. Spent more than a hour on the phone with the representative, she reviewed all the original claims from the hospital and told me that the hospital has filed everything OK, the last 10 treatments were incorrectly coded by the insurance and they will adjust(lower) the statements.

One month later, realizing that no adjustment has been made, I called again and I was told that as a matter of fact the charge for the final 10 treatments were correct, it was the the charge for the initial 10 treatments that were wrong. The representative indicated that the mistake was due to an "old" provider contract.

For us as patient, is there anyway to find out what the contracted charge should be for a particular service ? Is this information confidential ? Do we simply pay whatever the insurance company said, or there is a way to verify ? What about insurance company made mistake on the charges, how do we find out ?


Sorry for the long post, thank you very much for your help.

WZ,
First, I apologize profusely for the delay in responding to you. You've hit on one of those areas that is controlled at the state level (except for Medicare). You didn't mention what insurance company you are dealing with but under Kansas state law (I assumed this was where your coverage is from your profile so please correct me if I am wrong) insurance companies are not required to share their fee schedules with insureds/patients. Your physician however, could try to call on your behalf in advance of your procedures to determine the reimbursement amount. Please be aware that reimbursement is largely determined by the procedure and diagnosis codes that your physician or hospital assigns to your visit (these may change beore your final billis sent ot hte insurance company or while at the insurance company if they reject the coding, etc) I would be happy to look at the coding on your bills for you if you'd like. Please email me directly and we can talk further.
Thanks,
Amy

Amy,

Thank you very much for your response. It looked like I have no way to know what the reinbursement should be.

My first phone call to the insurance company was pretty lengthy, the representative is very nice, she went through all the records, then told me that the code they have used for the initial 10 treatments was 99183 (hyperbaric oxygen treatment) but they have used another code (hospital service ?) for the final 10 treatments, so it caused problem. She agreed with me 100% that for the same hyperbaric oxygen treatment, 99183 should be used for all of the service.

However, the insurance did not adjust the statement. When I called again, the story changed, they said that correct code has been used for all the treatments, but
they have mistakenly used the "old" provider contract for the initial 10 treatments.

So far, I have made about half dozen phone cals times regarding the issue, talking to several representatives, spent long time explaining to each one of them of what had happened but always got a different answer, that is why I started question what should be the correct answer.

I guess if I was overcharged consistently from the very begnning, I would have paid the bill without any doubt. Right now, I know there are discrepancies, and the story kept changing, it is quite frustrating for me being unable to find out the truth but to believe whatever I was told.


Thanks for your help

WZ,
Your insurance person is correct about using 99183 to identify/charge the hyperbaric oxygen therapy session. 99183 is specifically defined as physician attendance and supervision of hperbaric oxygen therapy, per session. Be careful though because other codes can be added to this that can change the reimbursement for your visit. For example, if you had an examination or other procedure in the hyperbaric oxygen treatment facility in conjunction with a therapy session other codes would be reported for those procedures, etc. If you really want to get to the bottom of this I would call your physician's office and ask them for copies of the claims submitted to your insurance company and pair them up with the explanation of benefits (EOB) you got back from your insurance company (by date of service). Compare the codes by visit and between the claima nd the EOB and note descrepancies. I would be happy to review those with you and help you determine who to talk to at the insurance company and what to tell them you need/want.
Amy

Hello all,

I wanted to post a few tips that we have learned through Heather's ordeal. And I thought it would be a good idea to bring this topic back to the front page of the forum. These tips aren't exactly about bills, but they are about insurance.

#1. Find out if you can have a Case Manager at the insurance company assigned to you. It is much easier when you can talk to the same person all the time. I feel you get much better service.

#2. Don't assume that because something was paid for while you were in the hospital, it will be paid for when you are at home. The meds to bring Heather's blood counts up were paid for 100% when she was in the hospital. Once we got home, the ins. co. wanted them to go through her prescription plan. Her plan only pays 50% and we are talking about shots that cost $2700 each!!!

#3. Don't assume everything is written in stone. Because we talked to the right people and because we had a personal Case Manager, we got the ins. co. to pay 100% for the shots. The doctor needed to write a Letter of Medical Necessity, which was reviewed by the medical director at the ins. co.

#4. Don't be shy. We pointed out that we were saving the ins. co. thousands of dollars by caring for Heather at home. And that it would be easy to re-admit her to the hospital, because her health is still in a very precarious state. They could pay for a few shots or pay for her to go back to the hospital. I think they decided that a few $2700 shots was a lot cheaper than another hospital stay.

More later. Happy 4th, everyone!

Rainbows & hugs,
Rosie

Hi Rosie,
Great advice. All lessons hard learned I am sure. It makes me even more grateful for Kaiser Permanente HMO which covers almost 100% of everything. $5.00 deductible for doctors and prescriptions ($15.00 if no generic). In hospital, chemo, radiation, free. Any test I need, they just order it, no debates, just efficiency -I was always moved to the front of the line for all the scans. Years ago I had Kaiser and I hated it -they have really cleaned up their act. Since I also see a doctor at UCSF (radiation oncologist) they pay 100% of that also. It certainly is an advantage to have coordinated health care, rather than going to a bunch of individual providers scattered around town. In the cancer arena, comprehensive cancer care centers make a lot of sense (and I am refering to ones on the NCCN list, not that new age "...of America" thing). http://www.nccn.org/

Rosie,
All great advice!! And the key word is persistence...one that I'm sure many of you know well. All too often insurance companies take advantage of patient's lack of knowledge about their rights and the healthcare world we live in. Speak up! If something doesn't feel right it probably isn't.
Amy

Hi Amy and everyone else,
I hope I'm posting this properly. My mom's oral surgeon offered to send a claim to Medicare. Because the biopsy came back positive for SCC, the excision was deemed medically necessary. However, unknown to my mom, the oral surgeon is not a Medicare participating provider. Therefore, Medicare doesn't want to pay the claim. I intend to appeal the claim because there's no argument of necessity, the problem is bureauacracy. Do you have any thoughts on how to structure this claim? Do I complain to the oral surgeon? Any thoughts would be appreciated.
Thanks.
D

Didier,
I responded in detail to your email to me on this same topic. I did want to post something here however becasue I think you've raised some good points that others could benefit from. Some of the best cancer centers in the country have great diffculty getting reimbursed for oral procedures. Causes of this range from dentist performing the procedures rather than an MD to physician participation (with medicare) issues to beneficiary coverage issues. There are different types of Medicare and coverage does vary. Also just because a physician is nonparticipating does not mean the beneficiary can't be reimbursed for services or that an assignemnt of benefits can't take place. Didier, if you'll respond to my questions that I emailed you, I will be glad to help you structure your appeal letter.
Amy

A note about DDS's (doctors of dental surgery)...

I spoke to CMS about DDS's today. DDS's are a recognized provider but they have to enroll in the program much the same as MD's do. DDS's are not eligible for the opt out option under Medicare (but DDS/MDs are) so they can either enroll or not enroll (they can't contract privately with a beneficiary)...and if they enroll they then have the option to participate or not participate. There is no law, rule , or reg that says non-erolled DDS's have to inform beneficiaries that they are not enrolled in Medicare (but they should if they want to do the right thing). If your DDS is not enrolled in Medicare, CMS says you can still be reimbursed for the biopsy (excision of the oral cavity, etc) because it is a covered service BUT the beneficiary will have to submit the bill for reimbursement themselves. CMS cannot reimburse the DDS directly if he is not enrolled.