Author Archives: Dianne Savastano

Taming Healthcare’s Administrative Barriers (and the Frustration that Accompanies Them)

As healthcare consumers manage illness or chronic disease, and as they access diagnostic testing or treatment, they often experience anxiety and fear about the potential of pain and the uncertainty of the future.

On top of that, they are forced to live within the confines of their insurance policy, something which – often for the first time – requires them to pay close attention to what’s covered, what’s not, and what the parameters are in accessing care (e.g., referral requirements, staying within a network of doctors and hospitals).

Ideally, consumers would pay close attention to this when they enroll in an insurance product. But let’s be honest with each other … reading the details of an Evidence of Coverage document is not all that exciting.

And that’s why, at the intersection between accessing care from providers and living within the confines of insurance coverage, that frustration begins to bubble up.

A frustrating summer with long, long periods of time on the phone

When my parents became snowbirds, their change of address necessitated a change in theirMedicare Advantage Plan. Because they spend five months of the year in New England and come home for the major holidays, I purposely chose a national company that had a “Passport Program,” something that would allow them to access in-network care while home so that they could maintain relationships with physicians who’d treated them for years, and I could continue to accompany them to appointments.

And so as we planned for my dad’s total hip replacement this past June and some specialist care for my mom, we knew what we needed to do to enact their Passport Program. And yet it took at least an hour on the phone, per parent, to make this happen. We specifically asked if any referrals were required and were repeatedly told no. We were also told that no prior notification or authorization was necessary as we planned for dad’s surgery.

Despite that knowledge, I still had to make more phone calls and spend at least another five hours on the phone with various entities, one of which was a member of the administrative team from my dad’s surgeon’s office. Not only did I have to convince her of the requirements of the plan, continuously reiterating that a referral and prior authorization were not necessary, I had to deal with the threat of cancellation of his surgery if I did not obtain a referral.

We got through it, the surgery was not cancelled, dad is doing well, and all the bills have been paid.

My point, however, is that even with the knowledge and experience I have, the administrative barriers are sometimes so onerous that it can take hours of your time and lead to feelings of frustration.

Taming the administrative beast

Here are some things you can do to prevent frustrating experiences of this type:

  • Pay attention to what you’re buying

    As you enroll in employer-sponsored plans, Medicare plans, or buy insurance on the open market, be sure to pay attention to what it is you are purchasing. A great way to educate yourself is to call the insurer ahead of time and state you are contemplating buying a particular plan but, before you do, you want to know how it’s going to work in real life. Present a situation such as, “What if I need knee surgery in the year ahead that may include having an MRI and staying in the hospital for a day or two? How will the plan work?” Specifically ask what you need to do, what the provider needs to do and how you can expect claims will be paid.When I’m reviewing policies, I focus on the items listed below. If you review the same things when purchasing a plan, you’ll be ahead of the game.

    • The premium
    • The deductible
    • The out-of-pocket maximum
    • The network I have to live within
    • How big-ticket items like hospitalizations will be paid
    • Whether any out-of-network benefit exists and at what level those claims are paid
    • Are my doctors and hospitals in the network
    • Are there referral requirements
    • Are there prior notification rules
    • Are there prior-authorization rules
  • Pick up the phone and call

    The realist in me knows that even if you did a comprehensive job when purchasing your plan, you may not remember when you go to access care. So I suggest you do the following:Ask the business office representative in your provider’s office what their understanding is of how your plan works.

    They often know when a referral is required or prior notification or authorization is needed. Bear in mind, however, that they may not always be right. As noted in the story about my dad, the representative was insistent upon certain things that were not necessary (because of his Passport Program). And while she later acknowledged that this product was not one she was familiar with, in the meantime, she caused me a great deal of angst the morning of surgery when she said we might need to cancel. (I did not share that with my dad as I spent yet more time on the phone; he had enough to worry about that day.)

    Using the information you get from the provider’s office, call to verify.

    When you call, have your Evidence of Coverage in front of you and ask the representative to reference the page and paragraph that addresses your question. That way, if you are in disagreement with what your provider thinks, you can reference the actual paper policy.

    If there is disagreement, arrange a three-way call between you, the insurer and the provider’s representative.

    This isn’t always easy to pull together, but I must compliment the insurance company representative who helped when I was troubleshooting for my dad. She was amenable to getting the provider’s representative on the phone and we finally got things cleared up.

Conclusion

Although insurance policies do not make for the most interesting reading, be sure to pay attention to what you are buying and to the rules you must follow when using the plan to access care.

Remember, should the administrative process fall apart, you are the one who will feel the impact. Being pro-active in this regard can save you a ton of time, effort, phone calls, and frustration in the future.

Medicare Open Enrollment – Two Reasons To Reassess Your Plan Each Year

Medicare Open Enrollment occurs each fall, lasting approximately seven weeks, from mid-October through early December, with coverage taking effect on January 1st. There are a number of important decisions to be made and for most people, this first time enrollment is a big event, as it should be.

Unfortunately, many older adults (and the children who help them through the process), fail to reassess their specific plans and coverage on an ongoing, annual basis. Instead, they simply allow last year’s decisions to roll over for another year.

There are two reasons why this can have negative consequences:

First, your healthcare situation may have changed.

When I help someone to enroll in Medicare, I begin by asking the following questions:

  • What medical conditions are you managing?
  • What specific medications do you take, including dosages?
  • What’s your current utilization level of the healthcare system? For example, what is your frequency of physician visits and hospitalizations?
  • What’s your anticipated use of the healthcare system? Will you be having any diagnostic testing or elective surgical procedures in the next year?
  • Where do you prefer to access your care?

Answers to these questions can then be superimposed on the Medicare options available,helping one understand how their insurance will work as they use it, as well as what the associated costs for premiums and out-of-pocket expenses will be.

But here’s the wrinkle: your situation may have changed.

For example, maybe when you initially enrolled, you were managing minimal medical conditions. Today, however, you may be planning for two, total knee replacements over the next calendar year. With that in mind, you’ll want to reassess and review the options available.

When you do, carefully consider these additional factors:

  • Your monthly premiums
  • Your deductible, if there is one (because you’ll be paying it)
  • The hospitalization benefit (because you’ll be using it). How many days are covered and at what level? Is there a daily co-insurance and, if so, for how many days?
  • The skilled nursing facility benefit, in case you need it. How many days are covered and at what level?
  • The cost for diagnostic testing and, in particular, X-Rays, CAT Scans and MRIs
  • Is a referral required? If so, you must follow the rules to receive any coverage.
  • Does a specific network need to be considered? If so, is your doctor and/or hospital in that network? If not, are there any out-of-network benefits and how much will that cover?

As you can see, upcoming health-related events can have a significant impact on the Medicare coverage you’ll need. What you had before may no longer be what is best.

Second, your healthcare plan may have changed.

Although insurance companies are required to notify you if your plan has changed in any way, I find that most people pay little attention to the written notifications they receive during the course of a year. It’s easy to ignore paperwork and think that if you don’t do anything, you’ll be re-enrolled.

That’s true. But if you don’t pay close attention, you may be quite surprised by your “new” coverage.Benefits may change and you could find yourself with out-of-pocket expenses you had not anticipated.

For example, a new client called me when she found herself paying $100.00 more for each MRI, a diagnostic test she requires fairly often to manage a medical condition. She also discovered that her co-pay for two different medications she takes regularly is now $95.00 instead of the previous $50.00. Yet another medication was no longer even covered. Lastly, she now had to pay higher out-of-pocket expenses for the hospital at which she routinely received her care (she could pay less if she switched hospitals, but that’s not what she wanted to do).

All changes that resulted from modifications to an existing plan in which she was re-enrolled.

So what should you do to guard against such changes? Here is what I suggest:

  • Revise your list of medical conditions and your comprehensive medication list.
  • Consider the care you will need in the upcoming year and identify which benefit will cover it. Investigate what the coverage level is for that benefit.
  • Check to see if your doctors and hospitals are still in the network. Be sure to ask about your specific plan and not just the company. Although a physician may take Tufts or Blue Cross, they may not take the specific Medicare Advantage Plan you have or are considering from that company.
  • Use the Medicare website. Go to Find Health and Drug Plans and enter your data. The algorithm will sort plans for which you are eligible to enroll, from the lowest cost to the most expensive. But don’t stop there; pay close attention to specific benefits and coverage levels.
  • If you are interested in a specific plan, go the company’s web site and search for the following, specific documents for that plan. Then read them carefully, keeping your individual needs in mind:
Note as well that different insurance companies may refer to these documents using slightly different labels and not every company publishes this detail online. If you can’t find what you need, call and request it.

Conclusion

I find insurance and Medicare to be very confusing to the average consumer. It’s even confusing tome, and I work in this area every day and have done so for many years.

Overall, be sure you pay close attention and ask lots of questions specific to YOUR needs. If you have an older individual in your life, check in with them to be sure they are adequately covered and that they understand the products in which they are enrolled. The devil is definitely in the details; time and effort spent up front will hopefully result in smooth sailing in the year ahead!

Are Your Older Parents Healthy… But Socially Isolated?

When gathering information from an older individual about his or her health status, in addition to asking about medical conditions, surgeries, hospitalizations, medications and their healthcare team, I also ask them to describe a typical day.

What time do you get up? Do you shower and get dressed on your own? What do you typically eat for breakfast? Then what do you do? How about lunch? Afternoon activities? Dinner? After dinner? How well do you sleep?

I find the answers to these questions to be so revealing. Not just about one’s ability to perform activities of daily living, such as bathing, dressing and eating; it also gives me an indication of the degree of engagement an individual may have with other people in their lives.

Red flags in conversations with baby-boomers

Much has been researched and written about older adults and the relationship between depression and sociability. And although depression can arise for anyone at any age from things like declining health, death of a spouse or lack of social support, I find this population, in particular, facing numerous changes that challenge their sense of self and their capacity to live happily.

Many older adults, as their worlds become less busy, continue to find great joy in a structured day that includes simple things that bring them pleasure and connection. It’s important for us to guard against projecting our own values about what these things may be.

What if mom gives up her license?

Consider this statement: “Mom shouldn’t be driving anymore.” Given my work, of course, I hear this frequently. And while it may or may not be true – and there are ways to assess capabilities that I’ll discuss later – what astounds me is the typical lack of sensitivity about what such a change would mean to the older adult. Although I know the adult child is motivated by safety concerns, children often fail to think about the impact that such a move would have on their parent.

A client of mine who was in her nineties, drove daily to visit her sister who lived in a nursing home; had her hair done once a week; and picked up some groceries on the way home. She also attended church on Sunday followed by a coffee hour with parishioners.

Overall, she struck me as a very content woman, spending significant time alone maintaining her home, reading and doing jigsaw puzzles. But her daily interaction with others, including her sister, was crucial to her emotional well-being. Taking away her ability to independently engage in such activities could be potentially devastating to her.

What if dad’s wishes don’t make as much sense now as they did then?

Another client of mine lives in a continuing care retirement community; he was diagnosed with mild cognitive impairment three years ago at the age of 90. With some in-home support from a private caregiver, he remained socially engaged in the community until fairly recently when we all began to notice a reluctance to participate in scheduled activities. When we asked him about this, he stated that at the age of 93, he’s slowing down and if he doesn’t want to get up in time to attend an exercise class, he has a right to make such a decision.

He’s been adamant with his family about his desire to remain in his independent apartment and that he would use his assets to pay for in-home support. As his professional advocate, I continue to fully appreciate and support his wishes and have worked tirelessly with his family to help execute them. However, based on his recent behaviors, I find myself wondering if the structured socialization of an assisted living environment might not be beneficial. I know that his children and the social worker in the community have thought about this too.

Some suggestions

The examples posed above are just two of numerous real-life dilemmas that require careful consideration and discussion with the individual, health care professionals, retirement community personnel and others. Everyone tends to focus on safety (so do I). But we can’t lose sight of the necessity of social connection.

Here then are some practical suggestions…

  • Take a step back and assess the degree to which your loved one is socially engaged with others. How often does it happen in the course of a day or week?If you feel they are (or are becoming) socially isolated or experiencing depression, talk to your loved one about your concerns.
  • When making suggestions or helping to structure activities for a loved one, think about what is important to them and what brings them the greatest pleasure in life. If changes must be made, identify ways to maintain the independence they had before.For my driving client above, we hired a companion to drive her to see her sister every day, and included a stop for grocery shopping. We combined this with The Ride to get her to church every Sunday. Ultimately, she was willing to surrender her license because she knew she could maintain her previous schedule without placing undue burden on her children.

Conclusion

Having older adults in our lives is a wonderful privilege that carries with it major responsibilities. Social engagement is as important as physical health, so please be as conscious of the former as the latter. As always, there is no one, right, answer for everyone; be prepared to be thoughtful about dilemmas you encounter along the way.

Rudeness In Healthcare… And What To Do About It

The NY Times article noted the negative effect that intermittent stressors can have on our bodies and how these can lead to a host of health problems. When surveyed, people stated they were overloaded and had no time to be nice.

But does being nice and treating someone with respect really require extra time? I don’t think so and I have to believe that if people were aware of how their tone and non-verbal behavior was coming across to others, they would change it. I also believe that employees reflect the culture of the organization in which they work and it is the role of an effective leader to set the tone for how customers should be treated. (See my April Newsletter for a discussion of leadership practices.)

Distasteful experiences

I’m always careful to give others the benefit of the doubt and in my experience, most healthcare situations do not involve rudeness. That said, when it happens, I find it so unpleasant as we are already feeling vulnerable and powerless from being ill ourselves or managing an illness for a loved one.

It is my fantasy, therefore, that every professional we encounter would be empathic, able to place themselves in our shoes and skilled in shepherding us through each experience, educating as they go. It can go such a long way towards easing our anxiety and to creating a positive customer experience with the organization from which we are seeking care.

Noted below are a few experiences that were not so positive and how I overcame them.

Inpatient hospitalization

A client of mine was recently hospitalized; I called to speak with the nurse on the inpatient unit. Prior to calling, I had already spoken with the receptionist and faxed a medical release form granting permission for health information to be shared with me, thus eliminating the administrative barrier related to the nurse releasing protected information.

The nurse shared some information but when I said I’d call back to coordinate the discharge (I’d already heard from the doctor that it might happen later that day), she vehemently objected and said she had too many patients to care for and that I should not call back. I was floored. When I regained my composure, I said the following:

“I fully appreciate how busy you are caring for all your patients including my client. It is my understanding that he may be leaving your facility later this afternoon. I must notify his family and the staff at the assisted living facility in which he lives so we can arrange for transportation and we can be there to receive discharge instructions. I’d really like to work together on this as I know I can be very helpful to you.”

She received my message fairly well and I proceeded to call her back a few hours later to firm up the plan. But I was left feeling disappointment about this treatment and was glad my client’s family did not have to be exposed to such unprofessionalism.

Physician office staff

I’ve been told that glass windows between a patient and a receptionist are for privacy purposes, but I don’t buy it. That’s why I am so pleased to see many new office designs eliminating these physical barriers to communication. In addition to the unwelcoming experience of glass, I’ve encountered receptionists who continue to look at their computer screen and not acknowledge me as I stand there. Again, I find the behavior to be rude.

In the past I just waited, but when I did that, I found my negative feelings about the experience quickly surfacing. Now I say something like, “It appears you are finishing something up. I’ll wait right here until you’re done.” A simple looking up, smiling, saying I’m just finishing something and I will be right with you can go such a long way at creating a positive encounter.

More suggestions

In the event you experience rudeness in a healthcare-related setting, you must be the leader and “Model the Way” for those you encounter. Although you may not think it is your responsibility, it sets the tone for what you expect and can leave you feeling more positive, thus relieving your stress and its negative effects on your health. Here are some things you can do and say:

Before making a call or approaching someone in a healthcare setting, be prepared in the following ways:

  • Approach any encounter with a smile, warmth and kindness demonstrating respect for whomever you are interacting with. I can feel this approach even during a phone call
  • Be sure to make eye contact whenever possible
  • Have the name, date-of-birth, medical record number or insurance ID number ready to go
  • Be prepared to identify who you are as the patient, family member, friend or advocate
  • Succinctly express what your need is

For example, when speaking with a physician over the phone:

  • Hi, my name is Dianne Savastano and I am a healthcare advisor to Mr. Jones. I’ve faxed a release form to your office that Mr. Jones signed granting me permission to speak with you on his behalf. I’m calling to discuss the plan of care that was outlined in his previous appointment as there have been some new developments and he needs additional guidance from you.

When speaking with a physician during an appointment:

  • I fully appreciate that you must document our encounter using the computer. I find it easier to communicate if someone is making eye contact with me. Could we please talk before you begin documenting?

When greeting a new physician:

  • Hi, my name is Dianne Savastano and I was referred to you by my primary care physician, Dr. Jacobs who felt you were the best person to assist me. I’ve spent time preparing for our appointment today and have a written agenda and some prepared questions to help guide our discussion. Could you please review it before we get started?

Other helpful tools

Recognizing that we may be anxious and fearful in a healthcare situation can help us be aware of how we may be coming across to others; acknowledging that to professionals can be helpful. For example, you might say:

  • I am frightened by the prospect of pain as I embark on this treatment plan and therefore, I’m counting on you to help me with that. I do well when I know what to expect so please continue to educate me along the way.

Position yourself as an equal member of the team by saying something like:

  • As the patient (or family member), I appreciate that I have a great team working alongside me. How can we best work with each other?

Be curious and name the behavior:

  • You appear rushed and a bit impatient. Am I reading you correctly? Is there a better way for us to communicate?

When you can’t seem to overcome rudeness

Although I’ve not had to do this often, I am always prepared to ask for help from a supervisor or manager if my needs aren’t met and/or I encounter rudeness.

If my negative experience is with a nurse on an inpatient unit, and I’m not able to overcome it directly with that person, I ask for the nursing supervisor, nursing director or the administrator on call.

If the negative encounter is with a resident physician, I ask for senior resident or the attending physician.

If the encounter is in a physician office, I ask for the practice manager.

When I get to the next level, I clearly and succinctly describe my experience saying something like:

  • Hi, my name is Dianne Savastano and I asked for you because I had a difficult and unsatisfying experience with __________. I would appreciate your help. Here’s what I need… Can you help me?

Conclusion

Although I hope you never experience a negative encounter with any professional in a healthcare setting, you should be prepared with how you will react should the situation arise. By always treating others with respect – even if you find yourself angry – you’ll experience a better outcome than by succumbing to a negative approach.

Remember, it is up to us to Model the Way for how we expect to be treated!