Articles

Leaving the Hospital – Part Two

After reading the true stories in last week’s blog (part one), you must be wondering how to prevent discharge horrors. You realize that the term “discharge planning” is, in many instances, an oxymoron.

The discharge part is true. The planning? A little less so. It’s typically brief and fraught with gaps in communication between hospital caregivers and family members who often take over that role. All you want to do is get your loved one home. But you also want to know what you need to know. And in clear, precise terms.

Ask for a preliminary discharge meeting before the day of discharge. This allows time for you to process information and identify issues or gaps in the planning. Will you need to rent a hospital bed, for instance? Do you need to arrange for outside care? These things take time. What services and equipment will be covered by insurance?

Get a list of medications your loved one is currently taking; compare it to the ones taken prior to admission. Make sure you understand what’s been added, changed or modified. To avoid confusion, or waiting around on discharge day, call your pharmacy in advance to see if they stock the new prescriptions.

Your Discharge Planning Meeting should be with health care professionals (usually a social worker or nurse, or both) in which they:

Assess the patient’s needs: physical, social, and emotional.
Clarify the discharge plan so that the patient and family members understand each element.
Identify what resources (family, friends, community) are available to assist the patient in meeting identified needs. Are these resources sufficient?
Educate family members and friends on their new responsibilities.
Monitor and modify the plan, as appropriate, and in response to family/caregiver feedback before discharge.

Remember: You don’t have to accept a discharge plan. Express your concerns. Don’t leave without a full understanding and comfort level of your loved one’s condition and your role as caregiver. And if you feel anxious, or you’re worried about understanding everything, bring along an advocate as a “second pair of ears.”

Who’s On First?

Following up on our blog from a few weeks ago — having “double the benefits” with two working spouses and two health plans — we’re adding Medicare to the mix.

Sample Scenario —

Husband: takes retirement, is 65 or older (and/or is disabled), and has Medicare as his primary health insurance coverage.

Wife: continues working, has employer based health care benefits for her and her husband.

He goes to the doctor and assumes Medicare will cover the visit and any treatments or tests. But it ain’t necessarily so! And that’s why he MUST let his health-care providers know about his wife’s employer-based plan.

In a nutshell . . .

As a non-active employee (an individual who is retired, on COBRA or Long Term Disability), the husband would typically be covered by Medicare as his primary insurance. However, as a dependent on his wife’s insurance, the size of her employer’s group will determine primacy: if there are fewer than 20 employees, Medicare pays first; more than 20, her health insurance pays first and Medicare pays second.

The rules for coordination can be complex. Keep your health plan administrators informed of changes or other coverage. Make sure your doctors know about the dual coverage and present both cards at the time of your visit.

Questions? That’s our specialty — finding answers, determining solutions. So, call if you need us. You can also contact the Medicare Coordination of Benefits Contractor at 1-800-999-1118.

Meanwhile, just remember, the answer to Who’s on First? can be a tricky one!

Choosing the Right Health Plan- Benefits by Design -

Continuing last week’s discussion, Choosing the Right Health Plan, let’s look at how the actual Benefit Design can — and should — shape your purchasing decision.

When we say benefit design, we’re simply acknowledging that medical insurance plans come in various shapes and sizes; you need to pick one that fits you and your family.

What’s in a Name?

Everything. The name itself often represents the type of product, reflects plan rules or highlights a unique element. Example: HDHP stands for “high deductible health plan!”

HMO, PCP, Gatekeeper — these names are associated with benefit designs from health plans versus insurance companies. They generally require a referral from a primary care physician before you see a specialist. Does that work for you? Are you willing to engage with a primary care physician as part of your health care team? Open Access, on the other hand, typically means you don’t need a referral from a primary care physician to see a specialist.

Points of Service

Before purchasing a health plan, make sure you understand how it’s designed in terms of service. For instance, will you be covered — to some degree, at least — if you see a non-participating doctor?

Warning: if you call a doctor’s office to see if they participate with your insurance and you get this response, “We accept all insurance” DO NOT think it means they participate with your plan. It simply means they’re willing to accept a check from anyone. Ask more questions.

Need physical therapy? Want to see a chiropractor? Make sure these services are covered and if there are limits on visits. It’s not unusual to see benefit designs with limited coverage for these services.

There’s a lot to consider when choosing a heath plan. And the wrong decision can be costly. Check with your state’s Department of Insurance website for a list of all licensed insurance companies and health plans doing business in your state. See what’s available. And when in doubt, consult an expert for advice.

-end-

We’re New And We’re Here to Stay

“You’re a WHAT? And you do WHAT?”

It’s a typical a response from physicians who haven’t scanned the forest of health care lately to see there’s a new animal in their midst. That animal goes by the general name of “health care advocate” and the specific name of Health Champion. Our general nature is to help, guide and support individuals lost in the maze of decisions, diagnosis and insurance benefits.

Here’s an example —

The Call: We were recently retained by a family to help navigate their sister’s s journey through multiple myeloma. They called as she was recovering from surgery, having experienced the disease’s wrath in the form of bony metastases.

The Need: On a very basic level, they were seeking clarity about their sister’s condition, needing a greater understanding from the surgeon and oncologist regarding prognosis and overall treatment plan.

The Approach: We quickly established contact with their sister’s medical providers, providing each office with signed HIPAA and Representative forms, so that physicians could speak freely with us. The goal was to collect information from the various sources and then connect the dots for our client, explaining complicated information in a clear, accessible manner.

The Result: Our client and her family felt fully informed and, thereby, empowered to make smart decisions regarding the recommended treatment plan.

The Response: Because we’re newcomers, medical colleagues are often surprised by our presence. Who are we . . .where did we come from . . . what’s our intention? But, seeing that we come in peace, they’re collaborative, professional and open to the concept of advocacy. And then there are those few defensive physicians, wary of our intentions, certain our goal is to undermine and undercut, to add an unneeded layer to an already complex system. That is so not so!

They’re right about one thing: The health care system is definitely layered and complex. It’s fragmented, confusing and overwhelming. It isn’t easy being a physician in today’s insurance-based model. And it’s not easy being a patient or consumer. That’s exactly why we exist.

Our role is to support our clients and their health care team by closing gaps in communication and planning, by explaining and reinforcing the difficult messages they have may have been told, but didn’t understand, and were too embarrassed to ask for clarification.

While health care reform may be upon us, it isn’t going to fix the very things that health care advocates are hired to do. We’re on the scene, and we’re here to stay.

The Test Gets Authorized

“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”

That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed. She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).

But her insurance company refused to authorize this critical test.

Why? Was there anything we could do to help?

We went right to work and here’s what we discovered:

The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.

Lessons learned…

Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
Realize that by enlisting a private advocate, you save time and money and get results.

Alexa Ray can find get one, why can’t the average consumer?

We were sorry to hear the news about Billy Joel and Christine Brinkley’s daughter, Alexa Ray, who apparently attempted suicide. We’re deeply saddened for her and her family and wish them healing and support.

Among other things, this tragic incident once again calls attention to the disparity between the “haves and have-nots” when it comes to getting good mental health treatment. Depression and other psychiatric problems cross all age and economic boundaries. But access to appropriate care does not.

No offense to Alexa, but we bet she won’t have any problem getting the help she needs. It’s not so easy for the rest of us. Especially those on Medicare.

Private health plans are required to demonstrate credible provider networks across all medical specialties. They also have to show they have contracts in place and that appointments are available.

Medicare (original), on the other hand, is not held to similar standards. In addition, docs are leaving Medicare due to low reimbursement. The result? Inadequate networks of providers across specialties and across the country. If Medicare was a private health plan, this situation would be blatantly unacceptable.

If you’re on Medicare and having trouble finding a qualified mental health professional, here are some tips. And, if you’re uncomfortable advocating for yourself, enlist the help of someone you trust.

Explain you’re paying out-of-pocket to a provider who doesn’t take Medicare; ask for a block of sessions at a discounted price.

Contact Medicare for a list of participating mental health providers. Call 1-800 Medicare. Verify current participation.

Use these national resources:
National Institute of Mental Health Information Line:
Provides information and literature on mental illness by disorder for professionals and the general public. Call: 1-800-647-2642
National Mental Health Association:
Provides information on specific disorders, referral directory to mental health providers, national directory of local mental health associations, and a Stigma Watch. Call: 1-800-969-NMHA (800-969-6642)
Share your story. Giving voice to the problem is essential for positive change.

Advocating For Your Needs

Whether you’re trying to get through the health care maze on your own, or need to engage the services of a health advocacy group, such as Health Champion, one thing is certain: you need unbiased, credible, up-to-date information. That’s what you’ll find here.

Through this blog, our goal is to help you become an empowered health-care consumer. And, because we’re a private advocacy company — without ties to government or insurance companies — beholden to no one — you can count on us to be in your corner. We commit ourselves to honesty and integrity. We’ll share what we know, offer our opinions, help you find answers, and give you information you won’t easily find elsewhere.

Over the past few years, there has been a growing need for health advocacy, giving people somewhere to turn . . . someone who will support and promote their rights within the health care system. Health Champion is answering that call.

We’re a young company with passion and experience; all of our established health care professionals are dedicated to helping people navigate today’s complex system, finding the answers they need when they need them. We work with individuals and families on a variety of levels, privately or through their employer.

We’re excited about starting this blog, a natural extension of our commitment and outreach to health care consumers. Look for a new post every Wednesday, where we’ll write about everything from health care reform to making wise medical choices to getting the most from your benefit plan. Be prepared for topics such as Ten Stupid Things in Health Care Today, Shopping for Colonoscopies, and What Reform Will Mean to You.

We welcome your comments and look forward to a lively exchange in the months ahead

Health Champion Blog

"In Your Corner"