Receiving a life-threatening or life-altering medical diagnosis is one of the most difficult experiences. Despite the technological advances in today’s world that have made our lives so much easier, such as cell phones that operate like mini-hand held computers, navigating the health care system remains archaic in many respects, even with the advent of telemedicine.
Patients often experience a two-fold burden: (1) battling their illness; and (2) navigating a complex healthcare care system when a fast response is their best chance at survival. Being sick is hard enough, coping with symptoms, potential side effects, and the emotional toll, while also juggling the process of familiarizing oneself with the healthcare process: (i) attaining pre-authorizations for treatment; (ii) referrals for in-network providers; (iii) understanding both coverage and treatment options, (iv) facilitating the transfer of records; and so on.
It can be surprising to “first time patients” facing a serious illness how much of the legwork the patient and/or their families and loved ones will undertake to line up medical providers and attain the required insurance authorizations each step of the way, as opposed to being managed or obtained for the patient by a doctor’s office or your primary provider.
Understanding Pre-Authorizations, Denials, & Appeals
For example, although your doctor may order an MRI, you may find out when you try to make the appointment that this test requires a pre-authorization (“PA” or “prior authorization”) from your insurance. A pre-authorization is a restriction placed on certain medications, tests, or health services that require your doctor to first check and be granted permission before your plan will cover the item. This extra step helps both your doctor and the insurer feel comfortable that the medical item is needed and medically necessary for your care.
In practice, obtaining a pre-authorization can be a frustrating and time-consuming process, and requires active communication, solid documentation from your doctor’s office, and persistence by the patient to follow-up with both the insurance company and the desired treatment provider. Continuing with our MRI example above, the process typically looks like this:
- The imaging center will not schedule or confirm the appointment until a “pre-authorization” for the scan is obtained
- The imaging center will not schedule or confirm the appointment until a
“pre-authorization” for the scan is obtained
- Insider tip: PPO plans are “easier” to obtain pre-authorization approvals than HMO’s. If you have an underlying or pre-existing condition, a PPO is likely a better option. Having a PPO does not guarantee less denials, but by nature, these plans permit a larger network of providers and are not as cost restrictive focused as an HMO.
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The patient calls their primary doctor to fax the MRI order form, plus substantial medical documentation
explaining the necessity of the test, and why other tests are insufficient to achieve the required result,
to
the patient’s insurance company.
- Insider tip: ask your doctor’s office to request an “expedited review” of the pre-authorization, especially when an urgent medication treatment or urgent diagnostic test is needed
- Provider’s office faxes the required paperwork to patient’s insurance
- Both the provider seeking the PA and the patient will be informed whether it is
granted or denied. Timing varies by the insurance company’s ability to review, which can include requests
for additional information.
- Insider tip: insurance companies have their own on-staff and/or medical professional contractors tasked with reviewing the patient’s medical records and the doctor’s PA request.
- If the PA is granted, the patient can schedule the appointment.
- If the PA is denied, the patient will have the opportunity to appeal. The appeal
processes generally has three levels:
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First-Level Appeal —This is the first step in the process. You or your
doctor contact your insurance company and request that they reconsider the denial. Your doctor may
also request to speak with the medical reviewer of the insurance plan as part of a
“peer-to-peer insurance review” to challenge the decision. Objective: prove that
your service meets the insurance guidelines and that it was incorrectly rejected.
- Insider tip: “Peer-to-peer insurance review” is an especially effective method, but requires more of your doctor’s time, because of long wait times, and the game of “phone tag” that can arise.
- Filing timing: this appeal must generally be completed within 30 days if for a service you haven’t received yet.
- Decision timing: A final decision about your appeal must be issued as quickly as your medical condition requires, and at a minimum of within 4 business days after your request is received. This final decision can be delivered verbally, but must be followed by a written notice within 48 hours.
- Expedited option: Ensure your doctor marks your appeal as “urgent” if the situation is appropriate to ensure the quickest response time.
- Second-Level Appeal — here, the appeal is usually reviewed by a medical director at your insurance company who was not involved in the original claim decision. Objective: prove that the request should be accepted within the coverage guidelines.
- Independent External Review — here, an independent reviewer with the insurance company and a doctor with the same specialty as your doctor assess your appeal to determine if they will approve or deny coverage. People often turn to an external review if an internal appeal is not possible or is unsuccessful.
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First-Level Appeal —This is the first step in the process. You or your
doctor contact your insurance company and request that they reconsider the denial. Your doctor may
also request to speak with the medical reviewer of the insurance plan as part of a
“peer-to-peer insurance review” to challenge the decision. Objective: prove that
your service meets the insurance guidelines and that it was incorrectly rejected.
Co-Pay Cards
Other names include: (1) copay savings programs; (2) copay coupons; or (3) copay assistance cards, and these are issued directly by the medication manufacturer to serve as a savings program. Objective: reduce the out-of-pocket costs for patients by reducing their out-of-pocket costs for expensive prescription drugs that they would otherwise struggle to afford.
Copay coupons are typically for expensive, brand name drugs that lack a generic alternative. However, uninsured individuals can also find various options to control costs.
For example, a brand name medication such as Humira, which may be prescribed for monthly use, and thus trigger a monthly co-pay amount for the patient that varies by insurance plan. Thus, although a patient’s insurance may reduce the amount the manufacturer can charge and then cover the bulk of the charge, the patient may still have a sizable amount left to pay, upwards of $100 per use. These costs add up quickly and stretch already thin budgets and add to patient stress, and can actually worsen a patient’s condition, if a patient feels they have to skip doses to reduce their costs, which only causes further health problems.
This is where co-pay cards help patients. The co-pay card in most cases will cover up to $11,000 of out-of-pocket costs for the specific medication on an annual basis. The patient can contact the medication manufacturer directly to request a co-pay card and will be given instructions on how to register it. These cards do not carry any cash value, even if you receive what looks like a credit card in the mail. In order to activate the card, call the manufacturer and create a profile with them.When ordering one’s medication with the eligible pharmacy, provide the number on the co-pay card, which will reduce the amount you have to pay further.
Often, a doctor’s office that frequently prescribes brand name generic medications, especially if their office is part of a large university hospital system will have special relationships with the largest manufacturers, and can often help you fill out the paperwork in their office. If the manufacturer does not provide a co-pay card, but does have a co-pay card program, the manufacturer will have a reimbursement form you can submit with your explanation of benefits and receipt that you’ve paid, and will send you a check to reimburse you. In both cases, you must first contact the manufacturer to create an account and share your insurance information. Please note that government health insurance, such as Medicare and Medicaid, are ineligible co-pay card subsidies.
Be sure to tell the pharmacist you have such a co-pay card, because they don’t always ask. As a reminder, GoodRx and similar “discount” offerings are not the same as a manufacturer’s co-pay card, which in the case of brand name specialty medications that lack a generic version, are the more financially sound manner to secure savings.
Informed Consent
Informed consent is a necessity to receive treatment from a provider – whether seeing a physician for an annual physical exam, undergoing a diagnostic test such as a blood draw or CT scan, or having a surgical procedure, such as a colonoscopy or heart stents. Informed consent is the process in which a medical care provider communicates and provides the patient with appropriate information so that the patient can voluntarily decide whether to accept or reject the proposed treatment. There are both legal and medical ethical standards involved.
Standard components of the medical provider’s disclosures to the patient include the following:
- The nature of the decision/procedure
- Reasonable alternatives to the proposed intervention
- Relevant risks, benefits, and uncertainties related to each alternative
- Assessment of patient understanding
- The acceptance of the intervention by the patient
Generally, medical providers have patients sign a “Consent for Treatment” form prior to each appointment, as well as prior the actual performance of the agreed upon procedure, diagnostic, and/or treatment.
Insider tip: in addition to the disclosures for treatment from your medical provider, if the treatment occurs in a university-system hospital or similar teaching institution, there will be additional disclosures in the forms you sign. Typically, these are all non-negotiable provisions that you consent to by signing on a digital signature screen – be sure to read over the printed out forms first (and be prepared to ask to review the forms first or have them printed out for you to look at. It is common practice for the laminated forms to be at the check-in desk, but the receptionist will instruct the patient to just sign in the box without giving the patient time to read the forms or pointing them out. Be sure to also ask for a printed copy of the signed forms for your records.
Examples of common items that you are consenting to that are also included in the extensive paperwork are:
- Teaching hospital
- A disclosure that physicians, nurses, and other health care personnel in training may participate in diagnostic, therapeutic procedures, and/or operation under supervision of other staff
- Patient consent to photography or recording
- A disclosure that still or moving pictures, videos, or similar documentation may be taken of the patient’s condition as well as medical and/or surgical procedures to document the patient’s condition for scientific, educational, or research purposes without any specifically identifiable information.
- No Hospital Consent to Photography or Recording
- A ban on any photography, filing, or audio recording on the premises or of personnel.
- For example: if the patient feels they are being mistreated by a staff member and takes out their phone to record the incident, the medical provider will point to this clause to prevent its use in any potential legal battle.
Leftover Biospecimen Research Bank:
This is a separate form typically included as part of that general consent for treatment documents, which asks for patient permission to use any leftover specimen’s, such as blood, body fluids, or tissue, to be used by the medical facility and its researchers, whether on-staff and on-site, or at third-party commercial medical/scientific companies, for research purposes.
These leftover specimen samples and the associated clinical information will be anonymous when released to the researchers. Clinical data, which may include: genders, age, diagnoses, treatment history, and test results, are released as coded data from a computer program; researchers will not be able to trace back the patient’s identify from any of these data points.
Sample Health Insurance Terminology Definitions (To be expanded)
Allowable Charge
The maximum amount a health care plan will reimburse a doctor or hospital for a given service.
Annual Deductible
The amount you are required to pay annually before reimbursement by your health care benefits plan begins.
The deductible requirement does not apply to preventive services.
Annual Limit
An insurance plan may limit the dollar amount it will pay during one year for a certain treatment or service, or for all benefits provided in a year.
Benefits
The health care items or services covered by an insurance plan. Your insurance plan may sometimes be referred to as a “benefit package.”
Catastrophic Plan
The health insurance exchange will include a catastrophic plan option. Catastrophic plans have lower premiums, but begin to pay only after you’ve first paid a certain amount for covered services, or just cover more expensive levels of care, like hospitalizations. Catastrophic plans are an option to consider for young adults and people for whom coverage would otherwise be unaffordable.
Claim Form
A form you or your doctor fill out and submit to your health care benefits plan for payment.
Claim
An itemized bill for services provided to a member. The patient will receive an “EOB,” which stands for “explanation of benefits” which itemizes any discounts applied to the submitted charge amounts that lower the amount the patient/member will have to pay out-of-pocket.
COBRA
This stands for Consolidated Omnibus Budget Reconciliation Act of 1985. This federal act requires group health care plans to allow employees and covered dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, termination of employment, a child becoming an over-aged dependent, Medicare eligibility, death or divorce of a covered employee.
Coinsurance
The percentage of the costs of a covered health care service or prescription drug you pay after you’ve paid your deductible. You pay 100 percent of the full allowed amount until you meet your deductible.
Contracting Hospital
A hospital that has contracted with a particular health care plan to provide hospital services to members of that plan.
Copay (Also Known As Copayment)
The set dollar amount you pay for a covered health care service at the time you receive care or when you pick up a prescription drug.
Cost-Sharing Reduction (CSR)
A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits.
Covered Person
The eligible person enrolled in the health care benefits plan and any enrolled eligible family members.
Covered Service
A service that is covered according to the terms in your health care benefits plan. These services result in the lowest out of pocket costs for patients. Uncovered/ineligible services are not covered by your health care benefits plan resulting in large out of pocket costs; occasionally, one can attain a special override to have such a service covered.
Deductible
The amount you pay for most covered services before your health plan starts to pay. When you go to a provider that is in the plan’s network, before you meet the deductible you may pay a discounted amount that has been negotiated with the provider. The deductible resets at the beginning of the calendar year or when you enroll in a new plan.
Dependent
An eligible person, other than the member (generally a spouse or child), who has health care benefits under the member’s policy. A member is the policy holder of the insurance.
Open Enrollment Period
The period of time set up to allow you to choose from available health insurance plans, usually once a year.
Out-Of-Network
Services you receive are considered out of network when you use a doctor or other provider that does not have a contract with your health plan. When you go to an out-of-network provider, benefits may not be covered, or may be covered at a lower level. You may be responsible for all or part of the bill when you use out-of-network providers.
Out-Of-Pocket Maximum
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays and coinsurance, your health plan pays 100 percent of the costs of covered benefits. The out-of-pocket maximum doesn’t include your monthly premium payments or anything you spend for services your plan doesn’t cover.
Outpatient Services
Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
Participating Provider Option (PPO)
A health care plan that supplies services at a higher level of benefits when members use contracted health care providers. PPOs also provide coverage for services rendered by health care providers who are not part of the PPO network, however the plan member generally shares a greater portion of the cost for such services.
