Your Right To Appeal

Health care and the processing of claim is not a perfected science. Claims get coded incorrectly by providers’ offices, sent with incorrect ID information, or processed incorrectly through benefit plans. For health care consumers, it can take some digging and effort in order to get these matters corrected. Sometimes, it even takes an appeal (or multiple appeals).

Based on a recent article by Money Magazine:

·         15% of health claims are denied

·         14% of denied claims are appealed

·         50% of appeals are successful

As patient advocates for our clients, the McGohan Brabender Customer Care Team acts as the patient advocate – mentioned in section 4 – to help identify errors, craft appeals, and escalate the battle when necessary.

Make sure to check out Money Magazine’s article for more information on your right to appeal!

Anthem's Radiology Shopper Program

Recently, Anthem launched a new Radiology Imaging Shopper Program for the following counties in Ohio:

Belmont, Butler, Carroll, Clark, Clermont, Clinton, Columbiana, Cuyahoga, Delaware, Erie, Fairfield, Franklin, Fulton, Geaga, Greene, Hamilton, Hancock, Holmes, Huron, Jefferson, Lake, Licking, Lorain, Lucas, Madiosn, Mahoning, Medina, Miami, Montgomery, Muskingum, Pickaway, Portage, Richland, Ross, Stark, Summit, Trumbull, Tuscarawas, Union, Warren, and Wood.

With this tool, members can compare costs for the same procedure at multiple locations in their area. For more information on this program and how if can help to keep your health costs down, check out this flier from Anthem!

Top 5: Causes of Changing Prescription Costs #1

1. How often your prescription plan carrier reviews the pricing of medications

The price of prescription medications is constantly changing based on a variety of factors. Anthem has compared the rise and fall of prices to gas or hotel rooms. The frequency that your insurance carrier audits the cost of prescriptions can mean significant impact for you.

For instance, some carriers only check the price of medications on a bi-annual basis while others check on a monthly basis. As a member, this can impact the total out of pocket throughout the year.

	Prescription Cost	Price to Member with bi-annual review	Price to member with monthly review
January	50	50	50
February	75	50	75
March	100	50	100
April	100	50	100
May	100	50	100
June	100	50	100
July *biannual review month	100	100	100
August	75	100	75
September	25	100	25
October	25	100	25
November	25	100	25
December	25	100	25
Total Cost		950	800

In this example, the member on the bi-annual plan has more consistency in their cost, but their final year out of pocket is $950. The member on the monthly review plan has costs all over the place, but their final year out of pocket is only $800. This can go either way for the member, but the frequency that the plan reviews this cost can impact the consistency of the prescription pricing as well as the out of pocket cost to the member.

For more examples of the causes of changing prescription costs, check out our Top 5: Causes of Changing Prescription Costs and check back often for articles explaining further each of these examples.

Top 5: Causes of Changing Prescription Costs

One of the more common questions that our team receives from our clients is: I just went to the pharmacy, and the cost of my medication nearly doubled from last month; what is going on?

Many factors can play into the cost of a prescription, but over the next few weeks, our team will be looking into what we see as the Top 5 Causes of Changing Prescription Costs. Keep checking in over the next few weeks for articles elaborating on the following causes:

1. How often your prescription plan carrier reviews the pricing of medications

2. Patents on medications and patent extensions

3. The availability of and introduction of generic medications

4. FDA approved uses of prescriptions

5. Manufacturer rebates and the net cost of a prescription to your plan

In the meantime, you can also check out the nice article that Anthem put together explaining some of these causes.

Controlling the Cost of Healthcare – for the Employer

The cost of healthcare seems to always be on the rise, both for employees and their employers. Various plans have been introduced throughout the years to help control these costs – from front end deductibles to high deductible/HSA plans. Recently, United Healthcare and McGohan Brabender partnered to launch a new, innovative program and product to help employers earn significant trend and rate adjustments for their renewals call Bend the Trend.

The easiest way to understand how the program works is to break the program down into Years 1 and 2.

Year 1 establishes the foundation for the Bend the Trend Program at the employer level. To "get on the field to play," employers agree to some basic strategic commitments in the following categories: wellness, optimal plan components, outcomes-based plan design, diabetes prevention/control. Don't worry, it sounds a lot more complicated than it actually is -- and chances are good that you're probably already doing some of it or all of it already. If you are an existing UHC customer, you can go ahead and start at year 2.

For meeting each employer strategic commitment, points are awarded Click Here to Download PDF Chart . The more commitments you meet, the more points you earn. Thus, the greater the premium discounts.

Beginning with your Year 1 start date, the Year 2 clock begins ticking. Now we need your employees to get involved. Do you remember those four strategic buckets we started with at the employer level? Well, we take those same four buckets and add some employee activities to them. Some are very simple, and others may require a little more effort – but that's ok. Our goal is to get your employees to own their health care plan…not rent it!

Just as with the employer commitment, employees earn points. Some of the points are awarded for participation while others are based on outcomes.

At the end of Year 1, your Year 2 rate adjustments are determined. This is done by adding up your earned Year 1 and Year 2 points. The greater your points, the greater your rate adjustment.

Want to know more about this program? Check out the Bend the Trend website for a potential financial impact calculator, wellVibe trailer, and a contact form!

Top 5: Ways to Control the Cost of Healthcare #5

5. Get pre-authorizations or predeterminations of

benefits done when necessary

Pre-authorizations are prior approval from an insurance carrier for a procedure. These are not guarantees that the claim that comes in will be covered, but it is a statement that the insurer intends to cover the service. Many non-emergency medical procedures and services require a pre-authorization, and it is important to ask your physician if a prior-authorization is needed before a procedure. Most physicians will be generally aware of procedures requiring a pre-authorization, and they will call into the insurance carrier for review. Without a pre-authorization, some claims that might have been covered will be denied. If you want to be certain that a procedure does or does not require a pre-authorization, you can always get the procedure coding from your provider and call them in to your insurance carrier to verify.

Predeterminations of benefits are similar to pre-authorizations, but they are not required. Often, they are done for procedures in which a provider must prove that a patient meets medical criteria for a procedure before it can be performed. For instance, treatment of varicose veins is often denied as not medically necessary. However, if a physician does a predetermination of benefits with the insurance carrier and can provide documentation proving that the member meets the medical criteria, the procedure could be covered.

While it is always important to consider your health and the advice of your physician first, you can also help to control the cost of your healthcare by ensuring that the necessary steps (such as getting a pre-authorization or predetermination of benefits) are taken before any major procedure.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #4

4. Ensure that your lab work is being completed by an in-network/participating lab

Just like in network providers, it is important to utilize in network (or participating) labs in order to receive the highest benefit from your medical coverage. Just like going to an out of network provider, using an out of network lab can result in higher costs, balance billing, and claims going towards a higher, out of network deductible.

For instance, let’s say that you have the following benefits and have already met your in network deductible for the year.

Covered Benefits	Network	Non-Network
Deductible (single/family)	$500/$1000	$1000/$2000
Out of Pocket Limit (single/family)	$3000/$6000	$6000/$12000
Preventive Care Services Services include but are not limited to: Routine exams, pelvic exams, pap testing, PSA tests, immunizations, annual diabetic, eye exam, vision and hearing screenings ·         Physician Home and Office Visits (PCP/SCP) ·         Other Outpatient services @ Hospital/Alternative care facility	$25/$50 20%	40% 40%

You go to your physician for your annual preventative visit. You have run a check on your insurance carrier’s website, and you confirm that your physician is in network. During your annual preventative exam, your physician runs some bloodwork and sends it off to their lab. Your physician’s bill processes through insurance, and since you have already met your in network deductible, you only owe a $25 copay.

However, your lab work was sent to an out of network lab. They bill $100. The contracted rate for these services is $50, and your insurance carrier applies this to your out of network deductible, which you have not yet met. Since the lab is not contracted, they are able to balance bill, and you are responsible for $100.

Had you requested that your physician send your lab work to an in network lab (which you can find a listing by doing an search on your insurance carrier’s site), then the lab work would have been adjusted to the contracted rate of $50, of which you would have only been responsible for 20% (or $10 – a difference of $100 for you).

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #3

3. Opt for generic or lower cost drug alternatives when available

Many factors play into the costs of prescription medications: cost of ingredients, costs of research and development, patents, etc. Often, brand name prescriptions have an initial higher cost for healthcare consumers to offset the cost of developing the medications during the window of time when their patent allows for the company to have control over the distribution of the medication. After this time, other companies can create generic alternatives to the brand names.

As the US Food and Drug Administration states:

Generic drugs are important options that allow greater access to health care for all Americans. They are copies of brand-name drugs and are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use.

Health care professionals and consumers can be assured that FDA approved generic drug products have met the same rigid standards as the innovator drug. All generic drugs approved by FDA have the same high quality, strength, purity and stability as brand-name drugs. And, the generic manufacturing, packaging, and testing sites must pass the same quality standards as those of brand name drugs.

Since the companies creating the generic medications do not have to invest as significantly in the research and development of the medication, they can sometimes offer it at a discount rate.
While your primary decision on medications should be the advice of your physician, opting for generic or lower cost drug alternatives is another way to control the cost of your healthcare, and you can ask your provider about your options.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #2

2. Choose the right care facility (Primary Care Physician vs. Urgent Care vs. Emergency Room)

There are lots of options when it comes to where you go to receive health care services, and those options have different purposes as well as different financial implications.

Duke Health offers the following explanation of when to use each type of health care service:

Primary Care Provider

Unless you are experiencing a life-threatening emergency, primary care centers are the best places to start. Primary care providers are physicians who deliver basic care for common illnesses. They are your first stop for most undiagnosed health concerns.

You should visit a primary care center for illnesses such as colds, flu, and sore throats; minor injuries, aches, and pains; or routine health exams. You can schedule appointments with primary care providers during the week, and they are available by phone anytime for advice about health problems.

Urgent Care Center

If your primary care physician is not available and you need quick medical attention for a non-life-threatening problem, visit an urgent care center. Urgent care centers have similar resources to primary care facilities, but they provide comprehensive quality care on a walk-in basis with extended hours.

Go to an urgent care center when you need immediate medical attention or have non-emergency health concerns after hours. Examples include ear infections, sprains, simple cuts and burns, and eye injuries.

Emergency Department

Life-threatening emergencies and late-night trauma require an immediate visit to the hospital. Emergency rooms offer inpatient care, emergency services, trauma services, and more. Emergency clinicians are able to recognize, diagnose, and make recommendations for a wide array of medical issues.

Call 911 or drive to the emergency department at your nearest hospital whenever conditions cause severe symptoms and/or put your health at serious risk. Examples include heart attacks, poisoning, severe bleeding, and broken bones.

While life threatening emergencies require a visit to the emergency room, other illnesses or injuries do not and can offer significantly lower cost options for care.

For instance, let’s say that your benefits are as follows and you have already met your deductible year to date:

Top 5: Ways to Control the Cost of Healthcare #1

1. Utilize in-network/participating providers with your plan

Most insurance carriers create ‘in-network’ or ‘participating’ provider groups for their plans. These are providers that meet certain criteria and contract through the carrier to accept certain pay rates for their services. By going to an in-network or participating provider, you can help to control your healthcare costs and ensure that you are getting the highest possible benefit for your care.

For instance, if a provider is in-network for your plan and they bill $100 for an office visit but your insurance carrier has a contracted rate of $75, you will only be billed for $75, which will be applied to your deductible. However, if you were to go to a provider for the exact same service and they bill $100 but are out of network you will still owe $100 because they are not contract to accept the $75 rate. Additionally, only $75 will go towards your deductible. This is called balance billing, and if there is no agreement between the insurance carrier and the provider, the physician is allowed to bill you whatever amount they choose to charge.

Also, some plans are set up to have different deductibles for in and out of network claims. For instance, your benefits summary might look like this:

Covered Benefits	Network	Non-Network
Deductible Family coverage requires the family deductible to be met before coinsurance applies. The single deductible does not apply to family coverage. Network and Non-Network deductibles are combined.	$1000 individual $2000 family	$2000 individual $4000 family
Out of Pocket Maximum	$1000 individual $2000 family	$2000 individual $4000 family

Let’s say that these are your benefits and you go to an in network emergency room because you are having chest pains. After the visit, testing, and discharge, you are billed $3000. You provider adjusts this to their contracted rates for your services to $2000. Since you have individual coverage and no coinsurance after your deductible, you will owe $1000 to meet your deductible, $1000 will be paid by the insurance carrier, and $1000 will be a contracted write off for the emergency room. However, had that emergency room been an out of network facility and you were billed $3000, the insurance company would have applied the full $2000 of the contracted rate to your higher out of network deductible. Since this facility is not contractually obligated to accept their pay rate for the services, you will owe to full $3000.

In order to make sure that you are going to a participating provider, it is best to call the number on the back of your ID card or search your carrier’s directory for participating providers on your plan. If you are asking your provider, it is important to specifically ask whether or not they are contracted with your insurance carrier on your specific plan.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.