Talk: "Financial Considerations" by Adria Gross

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This information came from the same seminar that the talk on the late effects of treatment, 2nd annual "Life Beyond Cancer", 20 September 2014, held in Newburgh, New York; organized by the Hudson Valley Cancer Resource Center of Montgomery, New York. Ms Gross operates Medwise, an insurance advocacy company in Monroe, New York, that helps patients and professionals with denied claims, evaluating bills, negotiating payments, etc.

Financial Considerations (from notes taken):

Know what you are entitled to ---

- Read and re-read your insurance policy to check on benefits, exclusions, rights granted, co-payments required. If you don't understand something, call the company and ask.

- Check your potential doctor and healthcare facility's grade on treating the condition you have. [Look at sites like www.vitals.com, www.healthgrades.com, www.hospitalsafetyscore.org, www.medicare.gov/hosptalcompare, www.consumerreports.org, www.health.usnews.com, www.qualitycheck.org/consumersearchORC.aspx# {The Joint Commission on Hospital Accreditation}. There are more sites to look for.]

Ways to reduce your medical costs ---

- ALWAYS check then double check that the doctor/hospital/lab/etc takes your insurance - it's up to you to know this, it's not the responsibility of the facilities.

- Always call your insurance company yourself to confirm that pre-approval has actually been given to the doctor or medical facility.

- What optional test or procedure can the doctor order that will be less expensive while still giving accurate information?

- Schedule all pre-tests for the same day. Facilities sometimes like to spread them out in order to bill more.

- Make sure that professionals who work through a hospital and may potentially work on you or with you are either employees OR if not, do they also accept your insurance (for example, pathologists may be hospital employees OR they may belong to a private group that contracts with the hospital).

- Generic medications cost much less than brand-named ones. Ask your pharmacist if switching to a generic is right for you.

- There are many medications that cost the same price whether the dosage is 10mg or 20mg. Ask your pharmacist if you take a medication where this is the case and if it can safely be cut in half. If so, the med will automatically cost you half the price. The pharmacist will instruct you or your doctor how to write the prescription.

- Use a less expensive pharmacy - call local stores to ask for price quotes, ask if a pharmacy will price match another store, consider Costco online (even when there's no store near you) www.costco.com/Pharmacy/home-delivery?storeId=10301&catalogId=10701&langId=-1, or consider a Canadian pharmacy (you must use a US pharmacy to buy controlled medications; beware as many foreign online pharmacies that claim to be Canadian are not) www.cipa.com/ {Canadian International Pharmacy Association - recommened on the AARP site}.

- Check for double billing. For example, did the hospital bill for pathology services and did you also get a bill from the pathologist, too?

- It's estimated that 80% of hospital bills have at least one error. ALWAYS read the bill carefully.

- Call a variety of medical facilities to ask for cost estimates. They can vary widely. [The Medicare site supposedly has lists of standard prices for test, procedures, hospitalizations, etc, but I can't find it on their site. Let me know if you do.]

Billing problems ---

- The MD/hospital/test facility/etc doesn't submit the claim to your insurance company on time as many comapnies impose a deadline.

- The facility doesn't handle follow-up if they don't hear from the insurance company in a timely manner or the claims are declined - they leave it up to you to take care of it.

- Many facilities now utiliize foreign billing services (takes more time, language errors can crop up, the billing service can handle a very large volume of claims).

- The facility utilizes a diagnosis-related group (DRG) code that gives the insurance company a way to decline the claim.

What to do ---

- Get the hospital to re-submit a declined claim with an amended, more appropriate DRG code.

- If there is an unfair situation in which you are getting nowhere, copy all the related documents and send them in an explanatory letter to 1. The state insurance department, 2. state consumer affairs department, and 3. state Attorney General.

- If you end up owing a lot of money to a hospital or other medical facility, try negotiating for a lower fee.

- Engage a service like Ms Gross' to evaluate the bills and medical records, evaluate medical liens, contact the companies and state offices involved for you, negotiate a lower fee for you, etc.

 

 

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A prime example of more professionals who aren't "in-network"

I was listening to the Leonard Lopate Show on NPR today. He was talking with a New York Times medical reporter, Elisabeth Rosenthal, who has been writing a series on the US "system" of medical costs called "Paying Till It Hurts".

They discussed a man who needed a bulging neck disk repaired. He researched everything he could think of about doctors and hospitals and his insurance company. He chose a surgeon and negotiated a price with him. After he had already been pre-sedated, he was approached by someone asking him to sign a consent and agree to pay for an out-of-network service. During neurological surgeries, there is specialized monitoring that the hospital contracted to the manufacturer of the equipment. He refused to sign for the price being quoted to him. So - on a stretcher on his way to the OR, he negotiated a lower price with this technician, THEN signed.

Wait! There's more!

The man's surgeon agreed to receive $6,000 or so for the operation. The patient then received a bill from a doctor he never met before for $117,000. It turns out that this was an assistant surgeon the operating surgeon brought on board, but who didn't accept the man's insurance. Needless to say, he was outraged and refused to pay.

If you want to hear more about this scary tale: http://www.wnyc.org/story/surprise-medical-bills-and-other-major-health-care-costs/