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# 10 Medical Paperwork & You

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Had to chuckle, when I read this article. Many people that sign papers, of contractual nature, read a line or two , and then sign. They gotcha now. Well, I drive the people, asking me to ” sign here “, nuts. I actually read the stupid fine print. I have actually ” crossed out and initialed “, that which I had crossed out, from a given legal type document. Of course I receive the ” Oh, you can’t do that “, reply, “that is our standard form “. My reply, mostly has been ” Yes, so what! ” ” Well you are not allowed to change the form “, they reply. So the verbal battle continues. Have gone through group heads, supervisors, managers, lawyers, and administrators. Did I win all my battles, no, not always to my full satisfaction, but mostly, I get what I want, and is what I can ” honor “.
Everything is negotiable. Why sign that, which you cannot honor? One interesting episode went like this:
” We can’t release her until the bill is paid in full”.
” Bye “.
” Where are you going “.
” You said you can’t release her until the bill is paid in full, I’m unable to pay the full bill”.
” What about her! “
” Keep her until the bill is fully paid, bye “.
” Wait, lets talk this over “.
So read this article and you will see some of the things, I’ve done and battled over.
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Making Medical Paperwork Easier
Medical bills are incredibly complicated and expensive, even for those with health insurance. But here’s what you may not know: Hospital bills aren’t “unavoidable” in the same way as, say, taxes and death. The number at the bottom of the bill may not be the amount you have to pay at all. In fact, there are a number of things you can do to protect yourself from unfair medical charges, including working with a professional “medical billing advocate.”
For information on this I called Nora Johnson, CCP (Certified Compliance Professional), a medical advocate with her own company, Med-X (Medical Expense Review & Recovery), and director of education and compliance for Medical Billing Advocates of America. Though most of these strategies relate to those with health insurance, which fortunately is still most of us, Johnson assured me that she has plenty of advice for both groups — insured and uninsured.
BE SURE YOU GET WHAT YOU’RE INSURED FOR
Here’s Johnson’s first rule for those with health insurance: Know thy policy. It’s boring as anything, she acknowledged, “so most people never bother to find out what their policy covers and — often even more important — what it doesn’t.” If you know in advance that a treatment or procedure you need is not covered, you can negotiate the price with the physician or facility beforehand, while you still have some room to do so. Most health care policies exempt emergency room doctors and procedures from needing to be “in network.” But emergency coverage is policy-specific.
Another common trap for the insured is inadvertently going “out of network,” she says. Say you are having gallbladder removal, which is typically an elective surgical procedure. You’ve chosen a surgeon covered by your plan and he’s chosen a team, including the anesthesiologist and pathologist, all of whom you assume are on the plan as well. However, that’s not necessarily true, says Johnson. Often radiologists, anesthesiologists and pathologists are out of network or even do not participate with any insurance companies. Always confirm by calling your insurance company (the published list of participating providers may not be up to date) before a procedure and confirm with the physician. If a provider is not covered, you have the right to one who is. Ask for the names of participating providers in your area and request in writing that the hospital use one of them. If the hospital refuses, tell them you will sign an agreement for the provider(s) they want to use on condition those providers will accept the out-of-network fee from your insurance company as payment in full. As further protection, Johnson suggests noting on the back of the hospital admissions form that you are responsible only for participating providers’ billing. On the same form there will be an item that says you will pay all “usual and customary charges.” Cross that out, she says, inserting the words that you are responsible only for “fair and reasonable” charges for anything your insurance does not cover.
WHAT’S “FAIR AND REASONABLE”: DECIPHERING THE CHARGES
This brings us to a brief discussion of what hospitals charge. They say they charge all patients the same rates, says Johnson, which is basically true — but what’s also true is that not everyone has to pay the same fees. When negotiating for clients, she bases what they should pay on that same phrase mentioned above, “fair and reasonable,” which is the reimbursement most commonly accepted by that hospital, usually from Medicare. Rule of thumb: The hospital’s billed charge is the gross charge and it is more than the hospital accepts from most other payers for the same service, she says.
Further confusing matters, all medical billing is based on three coding systems — ICD-9-CM, CPT and HCPCS — used for reimbursement, and she estimates that about one-third of all billing errors result from incorrect coding, such as entering a code for a procedure you never had. While these codes aren’t available to the public, you can and should request an itemized bill from your hospital, which includes explanations. Review it carefully, and if you’re confused or see an error, ask for clarification from the hospital’s billing office. Pay close attention to seemingly minor billing incidentals such as IV start kits (quoted cost, $57… real cost, 61 cents). Medicare does not allow independent charges for such incidentals, so it stands to reason that you should not have to pay them either. Reason: Supplies are calculated into the room/unit/procedure charge. Therefore they are duplicates when billed again for a separate dollar amount.
If there are mistakes in your bill, Johnson says you should address them immediately. If your insurance company refuses payment for something, figure out where it went wrong — perhaps the statement was miscoded or the doctor’s office filed incorrect information. Talk to both the insurance company and the doctor’s office to learn if there is an error, and then correct it. Medical Billing Advocates of America say 90% of medical bills contain errors.
People with high deductible policies have one more consideration — the hospital may charge its full (and inflated) fee up to that amount. Don’t let them get away with that. Insist instead that fees against your deductible are the discounted rate (at least 35%) — not the full — charges.
EMERGENCY ROOMS CAN’T REQUIRE PAYMENT IN ADVANCE
Nearly all emergency rooms cannot, by law, withhold emergency medical treatment based on payment issues. The Emergency Medical Treatment and Active Labor Act requires all hospitals accepting Medicare to not withhold screening, stabilizing treatment or appropriate transfer of patients, regardless if patients are on Medicare or have no insurance or ability to pay. Some hospitals will attempt to get a credit card number up front in order to ensure payment. If this happens, warns Johnson, ask that they put the demand for payment prior to rendering treatment in writing, specifying whatever the amount or percentage they are requesting. Simply say “I won’t pay unless you put it in writing.” By asking for them to request payment in writing, you will find they quit bothering you for payment before service, since Federal law mandates that hospitals render emergency treatment that is medically necessary to save lives regardless of inability to pay. After that, if you feel you are being overcharged, you can get the official hospital policy about payment requirements in writing, which you can then take to an advocate for help in negotiating. Patients can also inquire about “charity care,” says Johnson. All hospitals that participate with Medicare have to provide a certain amount of charity care to patients who qualify. Get the charity care forms from the hospital, fill them out, make copies and return them to the hospital.
WHEN TO CALL IN BACK-UP ASSISTANCE
If you have been unsuccessful at resolving your billing problems or feel that the fees charged are truly unreasonable, it may be time to call in a professional advocate to help. These professionally certified and trained specialists will advocate on behalf of individuals to combat unreasonable and/or outrageous medical fees. Although hiring an advocate to fight your battle might at first seem as though you are just adding another cost to already high expenses, in reality their training and negotiating savvy can actually reduce costs. The depth of their knowledge and experience working with complex medical billing enables advocates to negotiate fair fees for virtually everything including CAT scans and other imaging procedures, as well as hospital and doctor bills and fees. Johnson advises calling a medical billing advocate after you have reviewed an itemized bill yourself if you think it is not fair — say, $6,000 for two stitches in the emergency room.
Advocate fees vary. Johnson says they charge by the hour or a percentage of the money saved. They aim to be “reasonable” and always negotiate up front to spare you yet more stomach-turning surprises. To find an advocate, you can go to the Medical Billing Advocates of America Web site http://link.dhn.bottomlinesecrets.com/h/D9G9/44FT/UP/LYS48, or call 540-387-5870.
Source(s): Nora Johnson, CCP (Certified Compliance Professional), medical advocate with her own company, Med-X, (Medical Expense Review & Recovery), in Caldwell, West Virginia, and director of education and compliance for Medical Billing Advocates of America, Salem, Virginia.
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Need to contact us? http://www.bottomlinesecrets.com/cust_service/contact.html

1 comment to # 10 Medical Paperwork & You

  • Laurie the Insurance Warrior

    I’ve taken these concepts a few steps farther. I had to, or I wouldn’t be here to pontificate about it.

    I am the Insurance Warrior.

    Know thy policy? WRONG. Everything in your policy is negotiable, except one thing. Know what it is? Your lifetime maximum.

    I had a sky-high deductible, huge out of pocket amount, and NO out-of-network benefit. I made my insurer pay every penny for my $345,000 out-of-network treatment.

    How? I figured out that the purpose of the written appeal is NOT to educate, but to intimidate.

    I have gone on to win twenty-eight appeals for others, then to write the book about it, and get it funded by a cancer foundation.

    Laurie Todd
    @www.theinsurancewarrior.com

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