What if a patient is too sick to manage their own healthcare?

[Alnitak7]

I was looking at this web article about balance billing.

http://www.ncsl.org/documents/health/HRMedicaid.pdf

"Balance Billing-How to Handle it"

As I read this I'm thinking about the amount of work that must be involved in dealing with the insurance companies and with dishonest practitioners.

I was wondering how many clients become helpless victims when they have to manage their own healthcare and have no PCP to manage this for them.

"You can negotiate the balance-billed portion with your provider. "

"You can negotiate with your insurer. "

"If you feel like you've been treated unfairly by your insurance company, follow your health plan's internal complaint resolution process. "

If you're being illegally balance billed and "your discussion with the provider does not fix the problem, complain to your insurance company... Tell the insurance company you're being balance-billed, and ask it to intervene on your behalf."

The amount of work that must go into this makes me sick just thinking about it.

What would be a patient's options when they're managing their own healthcare,

and when they're too sick to handle all this work?

What if they do not have the experience to handle issues like this?

What if they have no family member, nurse or caregiver that knows how to assist in managing their healthcare for them?

Tell them this and tell them that

Ask them this and ask them that.

If this does not work try that...

I'm not sick and this makes me tired just reading about it

Well what if the patient is not capable of handling all this work?

The media talks negatively about "the hassles" of being assigned to a PCP.

[Esme12, ASN, BSN, RN]

There is no specific list or resource. It's buyer beware...which is really sad.

[Alnitak7]

The way I understand it is that if a client chooses an insurance company that has the providers fill out the insurance claims, this must offer some protection to patients who might be denied coverage.

It seems like an insurance company would be less likely to deny coverage if it was the provider who handled the paperwork since they have more knowledge of the laws and more ability to stand up to the insurance company than a sick patient.

[JustBeachyNurse, LPN]

Generally speaking most providers submit claims on behalf of the patient/client. It doesn't mean that the provider has more legal knowledge (that is why the providers have professional practice insurance and consult with accountants and attorneys for advice on financial & legal matters). Facilities and agencies have departments that are charged with securing pre-authorization, continued authorization and maximizing revenue from insurance companies. Many hospitals have hired experienced nurses to do chart vs. insurance claim reviews prior to submission to the insurance carriers to maximize reimbursement.

It is the onus of the patient to understand their insurance plan requirements and limitations. The contract is between the insurer and the patient. There are also provider contracts with relation to discounted rates and not balance billing the patient for fees that are in excess of the contracted rates. However it happens that billing (especially when outsourced to a third party or overseas) companies don't know all the contracts and start balance billing the patient even though the provider agreed to accept the insurance contracted rate as payment in full. Some patients do not match their EOB (explanation of benefits) that clearly states what the patient is responsible for and what is to be written off by the provider to the bills mailed out by the third party billing agency.

Generally a patient submits the claim form to the insurance company only if they choose to see a non participating provider in which case they pay the provider up front and then seek reimbursement from the insurance company.

On a side note, thanks to the experienced registered nurse working in medical records/claims review when my grandmother was hospitalized. Her claim was getting ready for submission to insurance and the nurse was reviewing. Because of a snippet of information gathered in the H&P (my grandmother had tripped out of a friend's car which was actually a symptom of her increasing cardiopulmonary distress--her admission was due to acute respiratory failure secondary to acute COPD exacerbation and CHF NOTHING to do with tripping/falling out of a parked car weeks prior) The coder had added diagnosis code that would cause rejection by the primary carrier requiring the claim to be submitted to no fault auto insurance. Which was ridiculous. Tripping while exiting a car had NOTHING TO DO with ending up intubated in an ICU and massive BLE edema and pulmonary edema a month later. My mother & her sister nearly panicked when the nurse called us for clarification (my grandmother was still tubed at that point) as she didn't want to say the wrong thing. The nurse was able to explain what she needed clarified by family to have the resident correct on the chart so it could be recoded and properly processed.

[DemonWings]

I was billed once for a service I repeatedly refused. I got a bill every other week from this hospitalist service, they kept claiming that my maternity benefits did not include hospitalist services, strictly pregnancy related stuff. I had to tell them repeatedly that for 1. I bled out during a c-section and had cardiac complications as a result, which was very much pregnancy related, and 2. That I told them to call MY cardiologist and would not let said hospitalist evaluate me. Turns out she had claimed she thoroughly assessed me, ordered EKG and ECHO and interpreted the results, and ordered a series of medications. Not one of those things were true, I had no tests done, didn't even allow her in my room. Billed me for over 4 grand. When I requested my records and threatened to call the state, magically the bills stopped coming.

Oh and an even scarier scenario happened with the same hospital stay. I got billed by yet another hospitalist company who sent threatening letters, claimed I owed something like 200+ for hospitalist consult. I called multiple times and always got a voicemail. I called the hospital and they said they had no record of that practitioner. Turned out to be a scam, they had ALL my information about my hospital stay, dates of stay, details of my c-section and more.

[Alnitak7]

Generally speaking most providers submit claims on behalf of the patient/client. It doesn't mean that the provider has more legal knowledge (that is why the providers have professional practice insurance and consult with accountants and attorneys for advice on financial & legal matters). Facilities and agencies have departments that are charged with securing pre-authorization, continued authorization and maximizing revenue from insurance companies. Many hospitals have hired experienced nurses to do chart vs. insurance claim reviews prior to submission to the insurance carriers to maximize reimbursement.

It is the onus of the patient to understand their insurance plan requirements and limitations.

Generally a patient submits the claim form to the insurance company only if they choose to see a non participating provider in which case they pay the provider up front and then seek reimbursement from the insurance company.

What comes to mind is that not all patients who submit a claim to the insurance company for out-of-network care always get reimbursed.

Insurance companies are known to deceive patients and even accuse them of lying on their applications to avoid paying.

I think they would be more likely to take advantage of sick patients filing a claim on their own than to they would be with a medical office who they know are experienced with filing claims, who are not sick and who know what steps to take when the insurance company does not pay them.

I think a medical office staff who files the claim would be less likely than a patient to give up when the insurance company refuses to pay.

It makes me really afraid to get out-of-network care even if my insurance company allows it.

[nurseprnRN, BSN, RN]

The way I understand it is that if a client chooses an insurance company that has the providers fill out the insurance claims, this must offer some protection to patients who might be denied coverage.

It seems like an insurance company would be less likely to deny coverage if it was the provider who handled the paperwork since they have more knowledge of the laws and more ability to stand up to the insurance company than a sick patient.

This makes no sense at all to me. Do you mean that the provider has better resources to fill out claims forms accurately? Everything is billed by codes, and they have to be correct. JustBeachyNurse has given you a good explanation of how it works.

[cinlou, BSN, MSN, RN]

Check out the ANA on care coordinator nurses these are positions that are coming to light. The coordinator helps the patient and follows up with them on all aspects of their care.