OMS Manual/Chapter 14

CHAPTER 14 - INSURANCE

Description

When a family member is battling OMS, many challenges exist. One of the most frustrating challenges, at times, may be dealing with medical insurance. The insurance issues will primarily fall into one of three topics:

• Insurance has not been processed and doctors and medical facilities want payment
• Insurance companies questioning the expensive treatments
• Doctors with minimal experience dealing with OMS, unwilling to prescribe those treatments

Any of these situations potentially delay proper treatment of the OMS patient and can have lasting effects. The information below is intended to provide some helpful ideas in dealing with these challenges in order to ensure the OMS warrior is getting the proper medical attention.

Organizing Your Work

* Tracking Your Bills

If you are new to OMS, get ready for the bills. You will be dealing with more doctors, labs, hospitals, pharmacies and other specialists and you will need a plan to organize and track your bills. Be ready to know what got paid, what is being reviewed by insurance, what got denied, and what is being paid by insurance. You need to know your co-pays and deductibles. Understand in-network and out-of-network and the ramifications. Some key rules are:

1. Do not pay your bill until insurance has processed it and the insurance company tells you the amount owed

2. Attach medical bills and insurance "Explanation of Benefits" (EOB) together to track easier

3. Write down what has been paid, what is pending, etc...

4. If insurance is denied, read the EOB, appeal, do not pay the provider until insurance is sorted out

* An example of a tracking spreadsheet:

Date	Location	Name	Service	Cost	Billed to Insurance	Paid by Insurance	Insurance Date	My Cost	My Paid Date	Notes
1/15/2012	Dallas TX	Dallas Hospital	MRI - 6 month check	$12,399.56	$12,399.56	$4,399.56	2/4/12	$250.00	2/25/12	Cost reduced by $7,750. My co-pay is $250. Paid in full
1/15/2012	Dallas TX	Dr Fred	Review MRI	$2,254.69	$2,254.69	$1,200.00	2/4/12	$50.00	2/25/12	Cost reduced by $1004.69. My co-pay is $50. Paid in full
1/15/2012	Dallas TX	Acme Lab Co	Processing MRIs	$5,000.00	$5,000.00	$950.00	2/4/12	$250.00	OPEN	Cost reduced by $3,800. My co-pay is $250. Not paid yet
1/15/2012	Dallas TX	Dr Judy	Pediatrician - review the results	$325.00	$325.00	$225.00	2/4/12	$25.00	OPEN	Cost reduced by $75. Mt co=pay is $25. Not paid yet.
1/15/2012	Dallas TX	Mileage to hospital	My mileage cost & expenses - Corpus Christi to Dallas - 422 miles @ 23.5 cents/mile	$99.17	N/A	N/A	N/A	$99.17	1/15/12	My mileage costs for tax purposes
1/15/2012	Dallas TX	Meals	3 meals - Mom, Dad, baby	$112.00	N/A	N/A	N/A	$112.00	1/15/12	My meals costs for tax purposes
1/15/2012	Dallas TX	Lodging	Acme Hotel	$78.65	N/A	N/A	N/A	$78.65	1/15/12	My lodging costs for tax purposes
TOTAL				$20,249.07				$864.82

* Filing Your Bills

The key is to organize your information. Place it in a folder or a three-ring binder. Keep the bills and insurance statements attached for quick reference. If you are not the organizing type, ask a friend or family member to assist you in getting it organized.

* Keeping a Log

A final step to organization is to keep a log of correspondance with insurance companies, medical providers, and human resources representatives at your company. Some of the key components to the log includes"

• Date of the discussion
• Company your called and contact information (telephone number, email address)
• The person you spoke with
• Topic of discussion
• Resolution of the discussion and action items to take place

Dealing with Insurance Companies

When battling a disease such as OMS, you need to anticipate a lot of paperwork, a lot of questions, and everyone asking for payment. Some basic steps to get you ready include:

• Get organized - keep all documents in one place
• Create a list - what, when, how much
• Align bills to insurance statements
• Pay when everything is in order

Once you get that stack of bills sorted and organized, expect the insurance company to kick out bills. Some of the main reasons for denial include:

• Did not meet the deductible
• Out-of network
• Service not pre-approved
• Treatment is experimental (yes, we get those)
• Insurance company did not have enough information
• The bill was coded wrong or not given pre-approval
• The insurance company thought you had other insurance coverage

Getting insurance denied does not necessarily mean pay the bill. It means review the bill and follow up if necessary. Many times, you will find that a coding mistake takes care of the issue. Sometimes, you just need to stay on the telephone and keep pushing back. You may need to get your OMS specialist to write a letter to the insurance company to further explain the circumstances.

* Steps to handling insurance denials:

http://www.ehow.com/how_2120395_appeal-denied-insurance-claim.html

* Acthar Support and Access Program (ASAP):

http://www.actharhcp.com/access-reimbursement-and-support/overview.html#acc-tab1

* The Basics of an Insurance Appeal:

http://www.healthsymphony.com/appeal.htm

* Patient Advocacy:

http://www.patientadvocate.org/ 

* Patient Rights, Laws, etc...:

http://www.healthcare.gov/

* Money Magazine article on Fighting Insurance Claim Denials:

http://money.cnn.com/2011/09/07/pf/insurance_claims.moneymag/index.htm

Handling Medicaid Issues

When handling administrators of Medicaid, like insurance, you need to anticipate a lot of paperwork, a lot of questions, and confusion. You may encounter at times, lost paperwork and case workers who are difficult to reach.

Some basic steps to get you ready include:

• Make copies of everything you file
• Keep a log of who you contacted and when
• Plan to follow up with the case worker
• Align bills to insurance statements

Be prepared to do extra work to get your case handled properly. You may find that you need to submit requests multiple times due to lost paperwork, find telephone calls unanswered, and may need to ultimately go to the Medicaid office and wait for them to meet with you. Some resource information to assist you is listed below.

* Medicaid Information:

http://www.medicaid.gov/index.html

* How to Apply for Medicaid:

http://www.ehow.com/how_10219_apply-medicaid.html

http://www.ehow.com/medicaid-programs/

http://www.ehow.com/topic_7400_medicaid.html

* Wiki Information:

http://en.wikipedia.org/wiki/Medicaid

Tracking Medical Costs for Tax

The IRS allows medical deductions when doing Itemized Deductions if you meet the threshhold. For more information on what is allowed when itemizing your medical costs, go to the IRS Publication 502.

http://www.irs.gov/publications/p502/ar02.html

Working with Doctors

Your local doctor, working with an OMS specialist can make a tremendous difference when sorting through insurance and Medicare issues. The doctor must be your advocate and not refuse standard treatment protocols of OMS patients such as IViG, Steroids, and chemotherapy due to costs. While treatment costs may be high, left untreated, the costs of a life of dependant care and treatable issues is higher.