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