Author Archives: Dianne Savastano

Insurance Coverage Barriers Matter As Much As Cost

Consider these three recent client examples…

#1. Mr. Smith.

He has significant, chronic medical conditions that require care from a primary care physician and several specialists, one of whom is in a different state than where he lives. He has experienced numerous hospitalizations as a result of his conditions and has a favorite specialized unit in a specific hospital that is very familiar with his case.

In choosing an insurance product, his priority was to have coverage for all these physicians and facilities.

Mr. Smith was considering a Medicare Advantage Plan that was a Health Maintenance Organization (HMO) insurance product. I advised against this. To have coverage under this type of plan, he would be required to stay within a network of physicians and hospitals. Further, he would have to designate a specific primary care physician and obtain referrals to physicians and facilities within the network for specialist care.

Given his care priorities, enrolling in traditional Medicare Parts A and B, and supplementing his coverage with a Medicare Medigap/Supplement Plan along with a separate Medicare Part D Prescription Drug plan, was a much better option, one that would give him more choice and less worry about the future.

#2. Ms. Jones.

She was told that her insurance would not cover an MRI recommended by her physician for an acute back injury. She was in such pain that she decided to pay the $800 out-of-pocket cost for the procedure and appeal the insurer’s decision later. That’s when she contacted us.

Her insurance product denied payment because of the specific clinical criteria they follow to approve such diagnostic testing. The denial stated:

The test should be used when the pain has not improved after six weeks of treatment by your doctor and that treatment should include medications and other forms of therapy such as home exercises and physical therapy. The test was to be used only if it was likely to result in a specific change in treatment and that the change might be related to the need for surgery or a procedure.

As part of the appeal, we asked her physician to write a letter to substantiate his clinical recommendation for an MRI before more conservative treatment was employed.

An alternative for Ms. Jones would have been to wait for the MRI to be approved, following her physician providing up-front, additional clinical documentation to substantiate his recommendation. Such prior approvals are often successful but delays in care result.

#3. Mr. Johnson.

We helped Mr. Johnson overcome numerous delays on the way to being diagnosed with severe sleep apnea. His physicians were optimistic about the good clinical outcomes he might experience from consistent utilization of continuous positive airway pressure therapy (CPAP) to help him breathe more easily when he sleeps.

Unfortunately, his Medicare Advantage Plan only covered a small list of approved medical equipment providers. Of these, the only local one required much additional documentation and was booking appointments 4-6 weeks out. In the end, it took us an additional four months(!) to work through the administrative issues we encountered.

These are just three examples of the kind we experience every day on behalf of our clients. As you can see, the type of plan one chooses plays an important role in determining coverage. Medicare Advantage Plans often appear to be less expensive up front, but the limiting of choice, administrative barriers to accessing care, and out-of-pocket costs as you access that care can be problematic.

Some Practical Suggestions

As much as I wish our healthcare system were easy to manage, it is complicated and something we must learn to live within. With that in mind, here are some ways you can be proactive, taking control where you can and reducing worry.

Anticipate. Every insurance product has administrative barriers. Expect that yours does too.

Learn. Read about your coverage. Call your insurance company before you access care — to verify that providers are in-network, to ensure coverage levels are what they seem, and to fully understand which diagnostic tests and procedures require prior authorization.

Document. Bring necessary documentation with you to your physician practice. Share what you know regarding steps your physician must initiate to assist with authorization for care. During encounters with your physician’s office and insurer, document the date, time, who you spoke with and what they said (this can be very helpful if you experience delays and/or receive inconsistent information and must escalate a concern to a manager).

Identify. In many healthcare practices, there are designated team members who assist with administrative issues and prior authorizations. Identify these people and develop a relationship so that you can follow-up often and directly.

Ask. When buying an insurance product, call the sales department before you purchase. Ask specific questions regarding scenarios you might encounter. For example…

Regarding networks… “I prefer to receive my care from University of MA Medical Center in Worcester MA. If I access care there, will I have coverage? Will that coverage be considered in-network?”

Regarding prior authorization… “I have a condition that might require an orthopedic out-patient surgical procedure in the next year. How will my benefits work?”

Regarding vendors… “I have Type I diabetes and use an insulin pump. What will I need to do to access my supplies and replacement pumps in the future on this plan? Under what benefit will my supplies be paid and how much of the cost will be covered? Are there specific vendors I must use?”

Whew! I know, it’s complicated and it can be frustrating. Fortunately, as the examples and suggestions above illustrate, there are many things you can do to gain control and reduce worry — not to mention time spent and cost!

Recommended Reading: #justdontgetit

#justdontgetit

As I listen to some of the rhetoric about the incidence and the severity of COVID-19 infections in certain demographics, I feel frustrated and find myself constantly saying, “just don’t get infected in the first place.”

Just this past week, Dr. Anthony Fauci said: “From a clinical standpoint, the thing that is the most perplexing to me as a physician is the extraordinary range in spectrum of disease severity.”

I hope these articles about “long-haulers” impact your decision making as we approach the fall and move inside to more confined spaces:

For Some, COVID-19 Symptoms Linger for Months

Long-Haulers are Redefining COVID-19

‘They’re Not Actually Getting Better,’ Says Founder Of COVID-19 Long-Haulers Support Group

Recommended Reading: Health Insurance

These two articles demonstrate how confusion around health insurance is beginning to play out:

Coronavirus survival comes with a $1.1 million, 181-page price tag

I Didn’t Have to Pay a Penny of My $320,000 COVID-19 Hospital Bill. Is That a Good Thing?


This article, “When 511 Epidemiologists Expect to Fly, Hug and Do 18 Other Everyday Activities Again,” helped me in my own decision making about partaking in these activities, now and in the future.

Coping With COVID-19

In previous newsletters, I’ve related personal experiences with my older adult parents as a means of sharing my views on how best to manage a variety of healthcare obstacles and situations. The COVID-19 Pandemic is no exception.

One of the many factors resulting in my decision to cancel a vacation was my need to be within reach (i.e., in the United States) to care for my 84- and 85-year-old parents in the event one or both became ill. I also wanted to be present to meet the needs of clients and their families — supporting, educating and (hopefully!) influencing their behaviors.

Here are some of the things I have been sharing…

Physician visits

We suggested avoiding trips to healthcare organizations whenever possible. We made decisions together to postpone elective appointments and diagnostic testing that could wait.

For those who had urgent problems, we made phone calls to the physician practice in question, to inquire about precautions they were taking. We were so pleased to hear that many of these had already instituted thoughtful and careful steps for protecting patients.

Pharmacies

We recommended avoiding pharmacies but had to be specific about where clients were in the cycle of receiving refills on their medications. Calls to pharmacies and insurance companies were needed to ensure extended supplies of medications where possible.

In some circumstances, clients had someone in their lives who could pick up their medication for them. In other cases, pharmacies were delivering. Those that had to go out, first checked with the pharmacy about picking up via drive through and/or going early, when there were fewer customers.

Greetings

Limiting hand shaking, hugging and kissing, especially with children. We discussed the use of a wave, bowing our heads, or elbow bumps as a means of showing affection.

Appropriate handwashing, how and when

This topic, although being espoused by everyone, had to be elaborated on as most people have never received formal training about how to do this appropriately. Many found the singing of the “Happy Birthday” song twice as an easy guide they could employ.

Everyone laughed when I relayed my sexist attitude about men on this topic. I joked that it was from an observational study of watching the most important men in my life — my husband, father, and grandson — that I have concluded that men don’t wash their hands adequately. A little humor always helps!

Not touching one’s face

This topic was a hard one as everyone reacted with how difficult it is to do. Raising our consciousness was a place to start. My parents have begun reminding each other when they observe this behavior, with the hope they can train themselves to resist the urge.

Staying home

This was a tough conversation with my parents, particularly regarding church attendance. They thought it would be okay because they attend with friends and know everyone who sits near them. I struggled with their desire to attend and to respect their choices.

At the same time, I know that how well you are acquainted with someone has little to do with their potential for infection. In the end, being able to point out that Catholic Bishops all over the country were providing dispensation from attending mass came in handy!

Social Isolation

Many articles and television segments have been devoted to the potential for loneliness as a result of social distancing. I always encourage my mom to be more social, and now I am telling her to do the opposite!

Yes, there are other ways to stay connected. But we must all be conscious of the limitations many of the newer technologies may pose for the less tech-savvy older adults among us. I am fortunate that my parents have each other, and we created a plan to speak twice each day by phone.

Final Thoughts

We must plan to manage the care of our loved ones should they require hospitalization, particularly if they are not local to you. I refer you to previous newsletters — here and here — that describe how to prepare, by having a HIPAA compliant medical release form on hand, along with a Personal Healthcare File.

Unfortunately, we cannot rely on medical record systems to interact with each other, so we must plan to be the conduit of information about our loved ones, representing their baseline level of health and functional abilities. I highly suggest that you take the time to organize your information, just in case.

So much has changed in just the past 24 hours since I sat down to write this newsletter. Please care for yourself, so that you are able to care for others. And, as you reach out to care for the older adults in your life, remember to listen to what they are thinking first and plan from there, constantly adjusting to the crisis at hand.

Health Insurance — What Exactly Am I Buying?

Many of our clients complain about their inadequate health insurance coverage. Often, the cause is a lack of understanding regarding the true costs of coverage, as well as the inherent administrative barriers that exist.

Our goal, always, is to educate our clients. This way, they can make informed selections about Medicare coverage and/or purchases on the Open Market and avoid unwelcome surprises. Of course, when it comes to understanding the role of insurance, there are many factors to consider.

In our experience, these three things have the greatest impact…

Where you access care

When researching options, it is critical to identify the insurance networks in which your primary care physicians, specialists and preferred hospitals participate. Often, this is less straightforward than it may at first seem.

Consider the example of Joe, a recently retired 62-year-old man. Not yet 65, he was ineligible for Medicare. He wanted to purchase an insurance product that allowed him to seek care from a group of physicians associated with a hospital system that he had just retired from. He narrowed his choices to two Preferred Provider Organization (PPO) options. Although he was positive his doctors were in-network for both products, closer examination revealed a different story.

Many insurance products have “Select” networks; these are a subset of a larger provider network. As it turned out, for one of the company’s products, Joe’s doctors did not participate. He identified this only after some painstaking research — first, by looking at the provider network the insurance product listed online; next, by calling the business office of each physician; last, by calling the insurance company directly.

Because the difference between an in- and out-of-network benefit can be significant, verification of this kind can save you a lot of money. In Joe’s case, it meant the difference between 100% coverage with an in-network provider and just 50% out-of-network.

When you access care

At this time of year, we find ourselves reminding clients about deductibles — the set amount you must pay out-of-pocket at the beginning of a plan year, prior to your plan paying benefits. Deductibles are reset annually and can significantly impact your out-of-pocket cost until their requirements are met.

In the case of our client Joyce, and since she is enrolled in a Medicare Part D plan with a $435 yearly deductible that we calculated she would meet in March, we suggested she wait until then to obtain the Shingles vaccines. This way, her out-of-pocket copay for the vaccines will be significantly less than if she obtained them sooner.

How you access care

Joe’s insurance product required prior authorization for any in-patient surgical procedures. Joe knew this because he read the Evidence of Coverage document that accompanied his policy.

After speaking with his insurance company, Joe also learned that it was his surgeon’s responsibility to make the authorization request, so he assumed he was all set. (I think you can guess where this is going.)

Surprise. The day before the scheduled procedure, his doctor’s office called to cancel because there was no prior authorization. As it turned out, the surgeon’s office had not followed through as required.

In the end, and thanks to some last-minute assertive scrambling, the surgery occurred as planned. But it’s our premise that Joe should have confirmed well in advance, to make sure everyone had done their part.

Some Practical Suggestions

As you begin your new insurance plan year, be sure to do the following:

Read the fine print. The Evidence of Coverage outlines all the details. But we know, it’s a lot to read (often more than 100 pages). Another option is to call your insurance company, describe the scenario, and ask what needs to be done to ensure the most comprehensive care. Make sure to document the conversation in your notes and ask the customer service representative how they plan to do the same in their system.

Don’t make assumptions. Your physician is not in the insurance business. Don’t assume they know the specifics of your coverage or what the administrative requirements may be. Sometimes, a three-way call between you, your insurance company and a member of your provider’s business office is necessary. Ask the customer service representatives to outline the specific language in the Evidence of Coverage that addresses your issue. Again, document everything.

Verify and re-verify provider participation in a network. Network participation can change. Make sure your providers continue to be covered by your insurance products!

Summary

Few people enjoy learning about health insurance coverage and its impact on cost and treatment. But it is a reality with which we all must live.

Please, make it a practice to read information about your insurance in advance of receiving care and take advantage of the knowledgeable customer service representatives available to speak with you.

These actions can save you a lot of frustration, anxiety and cost, and allow you to focus on what really matters: taking the best care possible of yourself and your loved ones.