You’ve reviewed the letter from your insurance company that says they’re not going to pay for a service you or a loved one has already had. When the rage has cooled and you re-read the letter, it states the reasons they denied payment, which may or may not make sense to you. Terms like “Didn’t meet medical necessity” or “More information is required” or “Pre-authorization wasn’t submitted.” It may reference pages in a document you’ve never seen or heard of but sounds important.
Carla’s* mother had been hospitalized for a week for a hip replacement, and discharged to a skilled nursing facility for rehab. Three weeks after her admission, she received a notice that her mother’s Medicare plan was denying payment for her care because she wasn’t participating in therapy.
Dave* had foot surgery that required the implantation of a new type of manufactured material. The surgery had been pre-approved, but his insurance denied payment for the manufactured material.
Elena’s* ovarian cancer had advanced, and her oncologist felt that the next medication she should try, which in his experience had shown some good results, was only FDA approved for breast cancer, not for ovarian cancer. Her insurance denied coverage for the use of this medication.
Back in the glory days of black and white television, Dr. Welby walked into a hospital room, provided a diagnosis, and told his patient what to do. As patients insisted on more of a role in decisions that affect them, often we now find ourselves in the position of our physicians providing options and asking (rather than telling) us what we want to do.
On the one hand, shared decision making is an important part of informed consent. On the other though, many patients find themselves thinking, “I’m not a doctor. How could I know what’s best for me?”
While the answer will be different for every patient, there are two tools often used to facilitate coming to a hard medical decision you can feel good about.
The first is comes from the book by Jerome Groopman and Pamela Hartzband, Your Medical Mind. How to Decide What is Right for You. They describe 3 scales of how we perceive healthcare.
Here’s the graphic:
Understanding how you feel about these perceptions is vitally important in assessing options that your physician presents to you. Keep in mind though, that where your perceptions are today, may not be where they are tomorrow. It’s OK, for example to find that where you might once have been aligned with a more technological orientation, for a given situation you may find yourself leaning toward a more natural orientation. The key is simply being aware of what feels right to you for the decision you have to make.
The second tool that can help with tough medical decisions is called the Ottawa Personal Decision Guide (OPDG). Developed by the Ottawa Hospital Research Institute in Canada, this tool helps people identify their decision making needs, plan the next steps, track their progress, and share their views about the decision with other people involved with their care.
While not everyone will want to write down their responses to the questions this guide poses, it can be an extremely useful tool to frame a decision based on your values, goals, and expectations. It helps to identify gaps in order to make a decision whether they’re related to knowledge, clarifying values, or identifying support that’s needed to make a decision that works for you.
Studies show that patients that are engaged in decisions about their healthcare are more satisfied with their overall care than patients who simply defer to their doctor. If you were thoughtful in making the best decision for you you could at the time, there’s less chance of experiencing those dreaded “I wish I had….” feelings.
One last thought: If it’s not an emergency, take your time! Even if you sense your doctor wants you to make a decision in the moment, if you’re not comfortable, you can always step back to re-assess, and schedule another appointment when you’re clearer on what else you need to know, as well as the downstream effects of your decision.
Medical decision-making can be daunting, but it doesn’t have to be. An independent patient advocate can help.
What you don’t know might cost you!
The air has already gotten a bit crisper on some of my morning walks. While that may mean apples and candy corn for some, it also signals open enrollment for health insurance for many of us.
We have the most complicated healthcare system in the world, largely because of the role insurance plays. Insurance is a legal contract and for non-attorneys, the language is crazy-making if you even read the fine print (and most of us don’t).
Knowing even a few key things about health insurance can make the difference between feeling in control and finding yourself facing unexpected bills.
OK, it’s not as sexy as the Top 10 places to travel in 2019, but if you want to test yourself on our Top 10 Health Insurance Questions to see how you stack up, give it a try!
Test yourself. True or False?
- If I don’t follow the open enrollment instructions for my plan, my coverage could be dropped.
- If I don’t have health insurance, a hospital is obligated to care for me without charge.
- If I miss a monthly premium payment, I can make it up next month.
- Long Term Care Insurance is the same as Long Term Disability Insurance.
I may be one of the few people on the planet who invested my second language studies in Latin. And yes, it probably would have been more practical to study a language people actually speak!
While having a working knowledge of Latin has been helpful for crossword puzzles, at other times my intellectual curiosity simply gets the best of me. A recent call about a hospital discharge experience piqued my curiosity about where the words “hospital” and “patient” and come from. Hospital comes from the Latin word “hospes,” which essentially means a guest or stranger. It’s also the root for words like hostel, and hospitality. “Patient” comes from the Latin word “patior,” to suffer. So from these Latin roots it’s easy to understand why we might consider hospitals to be “a special place of care for guests/strangers who are suffering.”
This word study also sheds light on why some hospitals have become more “hotel-like” fueling our expectation that they have an obligation to take care of us when circumstances prevent us from taking care of ourselves. At the same time with the increasing cost of care and demands on hospitals, especially at discharge, too often we experience them as not such caring places.
Marilyn’s sister, Annie,* fell on a Saturday afternoon. Annie had been disabled for some time from multiple sclerosis and depression, but was living alone in her own apartment. Marilyn called Annie’s primary care doctor, and was told to go to the nearest ER. Annie’s ankle was broken. Instructed not to put any weight on her leg, as she was being discharged, the nurse gave her the name of a medical supply company to order a wheelchair, and scheduled Annie to see an orthopedic surgeon late the next week.
Marilyn was panicked. Annie’s apartment wouldn’t accommodate a wheelchair, and the only shower was in a bathtub. Marilyn worked full time and knew that Annie would not be content to sit on the couch all day, unable to get to bathroom on her own, or to stand to prepare food. And the accident had really made her MS symptoms and depression worse.
She asked the emergency room doctor why they were sending Annie home – after all her ankle was fractured, she was obviously going to have to be in a wheelchair and there was no one to take care of her at home. Wasn’t the hospital responsible for keeping her until arrangements could be made?
Being treated in the emergency room isn’t the same as being admitted to the hospital. While hospital emergency rooms are mandated by law to provide care to anyone who walks in the door without regard to their ability to pay, they don’t have a legal obligation to manage or support what happens after that care is delivered.
In Annie’s case, after the usual wait to be seen in the ER, she was X-rayed, and a diagnosis was made. A splint was applied, and a follow up doctor’s appointment was scheduled. Thus endeth the ER’s obligation to Annie.
The fact that she lived alone, and that a wheelchair wouldn’t get through the front door was essentially immaterial. Marilyn and Annie were on their own to figure out what to do. Unless.
Unless Annie had been admitted to the hospital after she was seen in the emergency room. Let’s say she needed immediate surgery on her ankle. She might have been prepped for surgery and taken straight from the emergency room. Surgery completed, she’d be taken to a room and her in-patient care would begin.
In this case, when the hospital admitted Annie for in-patient care, modeled largely after Medicare guidelines, most assume an obligation to make sure that the patient has a “safe discharge.” While this is an ethical standard, the laws governing this vary from state to state. So as you might imagine, what exactly defines a safe discharge is somewhat open to interpretation.
Hospitals have to evaluate the capacity of the patient to make an informed decision about their care, whether a patient has a reliable caregiver at home, and if not, what other resources can be applied to assure the patient’s safety. It’s a complicated process. Patients and their caregivers want to be prepared, but this report from Kaiser Health News makes clear it’s the exception rather than the rule.
If a hospital discharge has been “sprung” on you or a loved one, and you know there will be issues with safe and adequate care consider these options:
It looks like a horse. It smells like a horse. It rides like a horse. It must be a horse, right? Well, maybe, unless it’s the Famous Mr. Ed. For those of you too young to remember, Mr. Ed was a talking horse who could only be heard by his owner, and was a bit of a troublemaker. He looked like a horse, but he didn’t behave like one.
I found myself thinking about him when I saw this sign posted at an intersection a few weeks ago. Health insurance is health insurance is health insurance, right? Not if you were Melissa.*
Melissa got the renewal notice for her individual health insurance policy. She was stunned when she saw what she was going to have to pay each month. She called her insurance broker who suggested she could buy a different insurance policy that would cost a lot less, have no deductible, and allow her to see any doctor she wanted. Just like the sign I saw. It sounded like a good deal to her, and it was literally hundreds of dollars less a month. She had to complete a health history, but otherwise didn’t have to do anything but sign on the dotted line and pay the bill each month.
Three months later, she woke up with chest pain and went to the ER. She was having a heart attack and thankfully got there in time. She left the hospital with no damage to her heart, but with bills in the mid 5 figures. The hospital filed the bills to her insurance.
Imagine her surprise when she got the letter that said her care wasn’t covered? How could this be?
When the Affordable Care Act (sometimes referred to as Obamacare) passed in 2011 there were several provisions that changed the landscape of health insurance significantly. Two of those provisions provided some protections to consumers that could be really important to you.
The first is that you can’t be denied coverage if you have a pre-existing condition. The monthly premium can only be based on your age, your sex, and whether you smoke…attributes that can be applied easily to anyone. Many people, especially those who had health conditions and would have been denied health insurance altogether before the ACA were now eligible for coverage.
The second was that ACA-compliant policies had to have limits on what you could potentially pay out of pocket. The bronze, silver, and gold designations help communicate how much you could be responsible for each year, with bronze having the biggest out of pocket expenses, and gold the lowest. (Conversely you pay less per month for a bronze policy and more per month for a gold policy). For ACA-compliant policies, so long as you get care from an in network provider, the provider has to accept the insurance payment as payment in full. So as a consumer, your total financial risk each year has a defined limit. Easier for financial planning.
Plans like Melissa bought are sometimes referred to as short term health insurance plans, and they don’t have to comply with the ACA requirements. The monthly premium payments for these plans are considerably less than they are for an ACA-compliant plan. Like Melissa, you might think this sounds like a good deal. But is it?
The details are always in the fine print.
1) Short term health insurance plans exclude pre-existing conditions. Now to you and me, if a condition wasn’t apparent at the time you buy the policy, it isn’t pre-existing. She wasn’t having a heart attack when she bought her plan. Other than high cholesterol, for which she was taking medication, she’d had no indication whatsoever that she had heart disease. However, Melissa’s plan argued that because she had a risk factor and heart disease doesn’t develop overnight It was pre-existing. Therefore they had no legal obligation to pay on bills for a heart attack.
2) Based on what the doctor or hospital charges, short term health plans reimburse you from a fee schedule. Because the doctor or hospital doesn’t have a contract with the insurer, they aren’t required to accept the insurance payment as payment in full. You are still on the hook for the entire amount they billed you regardless of what the short term policy pays.
Virtually no one pays the “billed” amount that hospitals and doctors charge, except patients without insurance. Or now, patients with short term health insurance policies. Hospitals and doctors can and do balance bill patients with these policies. This isn’t critical for an urgent care visit, but it can be a terrifying exposure for hospital care.
So what happened to Melissa? Her policy didn’t reimburse her a cent for her care. The hospital and doctors agreed to a small reduction in the fees they charged based on the fee schedule from her plan, but she walked away owing $30,000 bill and a ding on her credit while she paid the bill over 5 years.
Why are these policies so much less expensive than ACA-compliant policies? Essentially because they can and do deny payment for care for pre-existing conditions (and they get to define what constitutes “pre-existing”), and they don’t negotiate fees with providers. BTW, if you “follow the money,” insurance sales people often get larger commissions for selling short term plans than they get for selling ACA-compliant plans (if they get a commission at all for selling them.)
Insurance of any kind doesn’t make risk go away; it’s a tool to help make risk bearable. At some point in our lives we all will need healthcare, although that likelihood increases with age. Short term insurance policies are described as a way for healthy consumers to not have to pay ACA-compliant policy premiums. In fact, for some healthy (and lucky) consumers these policies can and do result in lower out of pocket costs for their healthcare. But the issue is how you’ll manage if you need insurance that looks and acts like insurance, and doesn’t cause trouble like Mr. Ed.
If you’re unsure about what kind of health insurance might be best for you, call us before you sign on the dotted line. We can help.
*Name and some details changed to protect patient confidentiality.