Pay Close Attention!!! You're Probably Being Overbilled For All Things Medical!!

Billing!!  Yes, billing is what's bothering me today.  I had an episode with poison ivy that landed me in the emergency room on Memorial Day.  I went in, saw a doctor for approximately 5 minutes - he looked at me, pulled out a prescription pad & wrote a scrip for prednisone.  I walked out & that was it.

When I received the hospital facility bill, the billed amount was $2,115.75!  They made a 'contractual adjustment' of $1,344.14.  The insurance company paid $498.09, and my portion was $274.52.

Then the separate bill for the physician arrived.  That bill was $440.00.  Insurance paid $352.00 and my portion is supposed to be the remaining $88.00.

When I called the hospital to ask if I could have an itemized breakdown of how 5 minutes translated into $2,115.75 I was put on hold for a long time.  I told them I had a right to understand exactly how anything could cost that much.  Was it $1000 for the doctor to stare at me?  Maybe $1100 to pull out a pad to write the prescription on?  What exactly is the breakdown?

I was then told that they probably overbilled me!  (ya think?)  Turns out that these bills are coded according to a "level" scheme that is used as a guideline from the American College of Emergency Physicians.  My hospital bill was coded as a level 4, while the doctor bill was coded as a level 3.

When I asked what a level 4 encompassed, they said they couldn't share that with me.  Why, exactly, I don't know - but apparently everything is a big secret.  We're all just supposed to pay & shut up.

I asked her what level it would be if I had presented in the emergency room with a heart attack & she said level 5.  So, I asked how poison ivy could possibly be only one level below a life threatening condition like a heart attack & she said, again - that I was probably over billed.

I looked up the levels myself (www.ACEP.org), and it turns out that my bills most likely should have been coded as a level 2, which encompasses things like "rashes, sunburn, etc.".  Also, probably for a much more reduced charge.

I then called the insurance company so that they can flag the account, since I'm now having both bills audited.  Insurance technically should have examined it & potentially denied the claim, but the answer I got from them is that since they didn't know exactly what took place in the emergency room, they often simply pay the bill. And yes, it's true - how would they know exactly what services were provided?  They have to trust the provider to some degree, since they are administering the medical care & should be allowed to proceed as needed in an emergency situation.

So, ever wonder why everything is so expensive?  The providers are robbing the insurance companies blind, and then that cost is being passed along to YOU the consumer of health care - both in the form of higher premiums and in the form of higher portions of co-insurance.  Shameful!! 

Take this as a warning - Pay very close attention to any billing you receive - you may not owe as much as you think you do.

Health Insurance Exchange Subsidies Will Be Granted on the Honor System!––Is There Something Wrong With "ObamaCare's" Federal Data Hub?

Author of the "Health Care Policy and Marketplace Review" blog, Bob Laszewski has reported a whopper of a story on his blog about a little known change to the requirements for determining whether or not an individual applying for health insurance through the exchanges will qualify for a subsidy.  Information on income for individuals was supposed to come from the Federal Data Hub, but now that information can effectively be "ignored" if it conflicts with what the applicant is telling the navigator at the exchange!  In other words, if I think I need/qualify for a subsidy, they'll just 'take my word for it'. . . .

I think everyone really needs to know & understand that the average, honest tax payer will end up paying for the "free money" that is sure to be given out once some people understand how to manipulate the system.  No subsidy money should be given unless incomes & eligibility can be accurately verified.

Read Bob's Post on his "Health Care Policy and Marketplace Review" blog . . .

Income -- Not Assets -- Will Determine Subsidies In Online Insurance Marketplaces

As the enrollment for health insurance plans that will begin in January 2014 rapidly approaches, information about subsidies to purchase the insurance that will be offered in the new insurance exchanges that the federal & state governments are setting up, is being clarified.

Kaiser foundation published a helpful blog entry today regarding that subject.  You can read more about it here:  Questions Regarding Subsidy Eligibility

The links within the article are "live", so further information is available there.

Keep in mind that the health insurance plans referenced are for individuals and families- not businesses or people who have Medicare coverage.

There will be plans offered outside of the exchanges or "marketplaces" provided by the government, but if you need to obtain a subsidy to pay for your insurance, you have to buy the insurance through the government run marketplace.

Implementation of the Health Care Law is Quickly Approaching . . .

As the full implementation of the Health Care law draws near, I'm getting a lot of questions about what may be happening.  To date, there's not a lot to report.  I'm hoping that more concrete details will be available soon.  The carriers are working to develop compliant "qualified" health plans that will be sold inside and outside of the state based exchanges (or marketplaces).  One thing that many are not aware of is the fact that there's an "open enrollment" period being established for individual and family plans.  This is new -- currently in the individual and family market, people are able to purchase new insurance whenever they want to - they are not bound by 'enrollment periods'.

The initial enrollment period will begin on October 1, 2013 and will last through March 31, 2014.  Enrollment will be for plans with an effective date of  1/1/2014 or later.  After that, the annual enrollment period will coincide with the Medicare Annual enrollment period - which is from October 15 through December 7 of each year.  If a person doesn't sign up during an annual enrollment period, they will not be able to buy a plan again until the next one, unless they qualify for a special enrollment period.  Qualification is based on things like major life events/changes - marriage, birth of a child, etc.

There are still many questions to be answered.  One is whether or not the exchanges will be open & ready for business on October 1.  There was an interesting article about this topic and the software that will be used to sign people up for insurance.  Read about it here . . .

As more specifics are communicated to me, I will be sure to post items of note here for my clients and friends.

Health insurance and Medicare updates: Here's what's "got my goat" today about our Medica...

Health insurance and Medicare updates: Here's what's "got my goat" today about our Medica...: I had a Doctor's appointment scheduled for next week, and today got a call from the office today stating that when I come in I'd hav...

Here's what's "got my goat" today about our Medical system . . . .

I had a Doctor's appointment scheduled for next week, and today got a call from the office today stating that when I come in I'd have to bring $100 "earnest money".  I've never been asked for this before, since I have a $40 co-pay to see a specialist.  But - since the practice was sold to the adjacent hospital, they are now saying that my doctor is an "outpatient clinic" and the co-pay no longer applies.  Therefore, I'd have to pay out of pocket until meeting my deductible.

Basically, they've redefined what an office visit is or is not - simply to suit themselves.  No one cares that I've paid for my insurance & included features like co-pays because I was willing to pay the premium for them.

With the advent of health care reform arriving on the scene, I've been seeing more consolidation - on the insurance company side of the business & now on the provider side.  As providers begin to consolidate, it seems they are re-defining what certain visits are, as well as, how certain hospital stays can be billed.

One example of what's happening with 'in-facility' stays, is the new phenomenon of keeping someone overnight (mainly after a visit to the emergency room) for "observation", and giving the impression that the patient has been admitted, when in fact, they have not.  What happens here can make a huge difference to some of my Medicare Advantage beneficiaries, since they pay a daily hospital rate if they are an inpatient that includes everything that happens while they are there (all tests, surgeries, etc).  If they are kept in an outpatient status, that same Medicare Advantage beneficiary would be subject to paying 20% of everything that happens there - so it's very much like 'a-la-carte' billing - resulting in a much higher bill.

Today, the patient has to be ever vigilant & ask very pointed questions about how they will be billed prior to having procedures done.  We're entering an age where none of this is about the patient & patient care, but is all about the money and the various corporate entities that are deciding everything about how care will be administered.

Look alert!  Make sure that if you have any type of serious illness or ongoing need for care, you involve a family member or friend to advocate on your behalf.  When you become seriously ill, you just won't have it in you to fight the good fight.

As for my situation, I told them to cancel my appointment and that I'd find another doctor who would honor my insurance with the features that I've been paying for. . . .

Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care

The "observation care" designation is a thorny one - for the providers, as well as, the Medicare beneficiary.  The patient often doesn't realize that they haven't been admitted, and end up with increased financial obligations because of it.  If a person has a Medicare Advantage plan, this can be especially troubling, since in many of the plans on the market, the patient would be responsible for 20% of all outpatient services received, rather than a straight 'hospital inpatient' daily co-pay.

The difference between the two can be enormous, especially if expensive tests are done while the person is considered to be an "outpatient".  There are other implications as well, related to requirements to be admitted into a nursing home after a hospital stay.  The requirement to have coverage in that instance is that the patient has been an "inpatient" for 3 consecutive days.  Outpatient status doesn't count.  Read more in the Kaiser Foundation & Washington Post article here . . .