Sunday, February 3, 2019

MANAGE NURSING CARE AT HOME, "...Reducing Your Medical Bill"

How to Manage Nursing Care at Home

                            (from Gross and Cooper, 2015)

     This chapter consists of various topics, guidance, and suggestions to potentially reduce your medical expenses.

How to Cut Your Medical Bills
     Know your rights / be aware of your medical benefits.

     It is not an easy task to understand your medical bills and the Explanation of Benefits. But to know your rights and be aware of your medical benefits, you must scrutinize your medical insurance policy. 

     Know what you are covered for and what your exclusions are.   Exclusions in an insurance policy list what you are not covered for.

     Call the hospital and medical providers.  Check to see what the fees will be.  Also check, “What was the doctor’s grade for my disease?” 

Is This Test Required?  Why is This Test Required? Save Money!
     Sometimes, especially if you feel that you are being over-tested or charged too much money for a procedure, ask the medical provider, “What options might be less expensive to get the information you need to accurately diagnose my problem?”

     If a doctor is recommending a test, it is best to call your health insurance carrier and ask whether the test might require pre-approval.  An example is an endoscopy. 

     Make sure your doctor or hospital has insurance pre-approval before the procedure is performed.
     Also make sure by contacting the insurance carrier that the medical provider has a contract with your insurance carrier.  I also recommend that you ask for this in writing.  I hear so many cases where the provider’s office states that there has been an approval or the medical provider verbally informs you that they have a contract with your health insurance carrier, and they do not.

     If you are about to have surgery and pre-tests are required before the main procedure, make sure your health insurance carrier has agreed to the services and that they have a contract with the pre-test companies.   Location of services and medical provider must both be approved.

     Ask the provider if you are required to have someone drive you home after the procedure.

     If you learn that multiple tests are not required, you will save money.  On the other hand if multiple tests are required, it is best to have them performed on the same day and location.  Many medical providers are against that since they are able to make more money if the procedures are on different dates. One of the major reasons for the Affordable Care Act, ACA, was to require all hospitals and medical providers to share medical information via electronic medical records, hopefully reducing the number of duplicated tests.

     Many insurance companies hire an outside company that does the approval for pre-certification. 

     If you are informed that the medical provider is not approved, ask your health insurance carrier who the approval company is and if they if they know which other doctors the pre-cert company might approve.
     Perhaps it goes without saying that you will also try to assure yourself of the qualifications of the doctor who you are seeing, to avoid the situation depicted by a cartoonist who depicts one patient saying to another, “Yes – that’s my surgeon – the one who cuts himself shaving.…”

Options for the Uninsured and Underinsured
     Medicare has an 80/20 agreement; therefore, if you have a hospital bill of $30,000 do you want to be responsible for 20% of the $30,000, which is $6,000? That is the reason why, if you are able to afford it, it is often best to have either basic Medicare with a supplementary health insurance coverage or one of the  Medicare Advantage Plans, which often have rules different from the 80/20 rule.  

     If your employer offers a plan, find out what you are covered for and determine whether you would want additional health insurance through your spouse or partner.  Also, discuss with your and / or your spouse’s employer what options are available to you.  Sometimes they might have different insurance carriers to choose from or different levels of coverage.  If there is no coverage, contact the state to see what it might offer. For example, in New York State, go to

     Medicare Advantage Plans are health plans that are approved by Medicare and provided by private companies. Medicare sets the rules for Medicare Advantage Plans and regulates the private companies who operate the Plans.  See our chapter on these plans.

     Medicare Advantage Plans cover Medicare Part A and Part B, sometimes including vision and dental care.  You pay a copay and/or a deductible; you still pay Medicare premium and might need to also pay an additional premium. 

     Typically you are required to see the plan’s network doctors and you cannot buy a Medicare supplement to help pay out-of-pocket expenses.

     Sometimes it is advantageous to go out of the United States for medical care, but precautions need to be taken.

Health Insurance Portability and Accountability Act of 1996: Privacy
     HIPAA mandates all health insurance companies that are covered entities make the transition to ICD-10. Workmen’s compensation and property and casualty insurance companies are not covered entities.

     For example, I see a new doctor for the first time due to a cold.  The procedure code is 99201 (new patient, office visit), the ICD-9 code is 460 and the ICD-10 code is J00, a cold.   I go back to the doctor a few days later due to conjunctivitis, the procedure code is 99211, established patient; the ICD-10 code is H10.   

     What this means to all of us is: beginning October 1, 2014, if your diagnosis does not begin with a letter, question your doctor, otherwise your insurance company will deny the claim.

Who Is Processing Your Medical Bill?
     Many hospitals and individual doctors hire outside companies to handle all of their medical bills.  Either the bill is handled by the medical provider, hospital, doctor, laboratory company or it is sent to an outside medical billing company that is hired by the medical provider.      
     Where do problems occur?
     The problems occur if the billing company or the medical practice:
1. does not handle any of the follow-ups,
     2. does not submit the bills to your secondary or tertiary insurer,
     3. is incompetent to bill correctly,
     4. sends your medical bills to overseas medical billing companies,
     5. does not have the prior pre-approval for the necessary procedures,
     6. makes errors with pre-authorization, or
     7. if the bills are not submitted within the insurance company’s allowed time period.

How to Decode the Bill?
     Most of the bills are now submitted electronically and when done so, the same information that is on a CMS 1500 form is required. 

What To Do With The Bill Once Decoded?  Is The Bill Within Reasonable And Customary Charges?
     All bills, when paid by Medicare, Medicaid or a commercial health insurance carrier are determined according to procedure codes. Commercial insurers follow Medicare except normally on a higher payout percentage.
     Medicare and Medicaid also add a Diagnosis Related Group code, called a DRG code, when determining the payment for hospitalization as an inpatient. 

     To find the Medicare Allowable Usual, Reasonable and Customary codes, look at the Medicare website.  You will find the listings under:

The Buck Stops Here 
     Fight and never be afraid. If you disagree with the bill, fight it before you pay it.

Tying It All Together
1. Know Your Rights - Be Aware of Your Medical Benefits.
2. Don’t You Just Love a Bargain?  Compare Prices for Tests at Hospitals and Medical Facilities.
3. Ask the Right Questions.
4. Check Options for the Medically Uninsured and Underinsured – Call Your State Department of Insurance.
5. Look for Discounts on Your Medication.
6. Don’t Assume Your Bill Is Correct.
7. Check All Your Medical Bills for One Visit and Make Sure You Were Not Overcharged.
8. Determine Who is Processing Your Medical Bill.
9. Learn How to Decode Your Bill.
10. Make Sure the Bill is Within Reasonable and Customary Charges.
11. Take Action In Order To Decrease Your Bill.
12. Fight It Before You Pay It, and Never Be Afraid!

A Medical Insurance Advocate Can Help You Recoup Money You are Owed, and Keep You from Paying What You Don’t Owe
     Regardless of how good your health insurance plan is, you are bound to bump up against issues regarding payments for services you thought were covered, overpayments, wrongful billing, and denied medical claims at least once in your life.

     Many baby boomers are also confronting their aging parents’ mounting medical needs, healthcare costs, and navigating the murky waters of Medicare, Medicaid, secondary insurers, and ignored medical bills. Depending on their age, they could also be dealing with these issues for themselves.

     Working with a medical insurance advocate can relieve a lot of this burden, and provide much-needed support to individuals and families who are fighting with their health insurance carriers or healthcare providers over medical bills and claims—or simply need help wading through, organizing, and prioritizing a growing mountain of them. Even if you are well, as a busy entrepreneur or business owner your mind is on other matters related to your business—not on figuring out if you paid too much, if your coverage is right, or if that denied medical claim has merit.

What a Medical Insurance Advocate Does
     Let’s face it: when someone is dealing with an illness or recovering from surgery, and those bills start flowing in from multiple physicians, hospitals, and rehab centers, it doesn’t take long for the situation to become overwhelming and confusing. Sorting through the explanations of benefits and trying to understand exactly what is covered and what is not—often revealed once those unexpected charges come through—can become a burden very quickly.

     Insurance advocates act as the expert liaisons between patients and providers. They work with patients regarding their health insurance coverage, medical bills and claims, and can handle all communication and paperwork with the insurance carriers as well as medical facilities or service providers. They are the bridge between patients and health insurance companies, acting on their clients’ behalf to get claims passed, to ensure the highest coverage allowed (depending on the health plan), and to enable patients and their families to rest easy knowing their insurance matters are in expert hands.

     Many medical insurance advocates also work with elder law and personal injury attorneys to make sure that all their clients’ medical claims are processed and paid correctly.

     These experienced professionals sort through and resolve clients’ medical bills, lien claims, insurance pre-authorizations, denied medical claims, and medical letters of appeal. They can explain those bewildering explanations of benefits and advocate for patients regarding any insurance issues that require expert or objective attention.


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

Our book is available from,, and How to Manage Nursing Care at Home

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