Emergency care

Posts Tagged: Emergency care

How to Start a New Health Plan Off on the Right Foot

Welcome to a new year, with new health benefits. You just chose a new health plan and now it’s in full effect. But most people don’t have a full understanding of how their benefits work. This means that many of them end up losing money in their spending accounts, paying more for care, or getting claims denied.

Follow these tips to make sure you start off 2013 right.

Plan for your Deductible
Guess what–deductibles have gone through the roof over the years, so that often means more cash out of your pocket. If you are one of the 65% of people who have a high deductible health plan, it’s especially important for you to plan your spending. High deductible health plans (HDHPs) come paired with Health Savings Accounts (HSAs), or accounts where you can save money just for medical expenses free from taxes. To be best prepared, you should plan to save at least the amount of your deductible in your HSA as soon as possible.

Network It
Most health plans have some restrictions on what providers you can see or they cover much more on visits to in-network providers. Find out the type of plan you have and whether you have a provider network. HMO plans are the most restrictive–don’t even think about going to a non-network provider unless you want to pay the full cost. PPOs have some more flexibility, but services in-network will be less expensive. POS plans give you more freedom, but often involve more paperwork for out-of-network visits. And finally, FFS plans allow you go to any provider you want, but few companies offer this option anymore.

Get Spent
Did you sign up for an FSA or HRA? Don’t forget about the money in your account. These funds disappear if you do not spend it by the end of the year. Do some planning now by finding what eligible expenses you expect this year so that when they come up, you’ll know to pay with your FSA or HRA, insteading of other funds. If you have an HSA, the same “Use it or lose it” rule does not apply. Your savings will roll into the next year.

Practice Prevention
All health plans must cover a list of dozens of preventive care services, all free of cost. Get your money’s worth by checking out the list and asking your physician what they recommend. Even if you have a high deductible plan and you have not met your deductible, you can still get these services completely covered, as long as you don’t have a pre-existing condition that already required one of these tests or screenings. Learn more about preventive care here.

Have a Non-Emergency Plan

What do you do on the weekend or in the middle of the night when you’re not sure if a medical condition is serious enough for the ER or can wait for a doctor’s appointment?  Most health plans have a variety of options for these uncertain situations such as nurse advice lines or extended-hours urgent care. Know your options so that if you’re caught in the situation, you can choose to avoid an expensive ER visit. Of course, always go to the ER if you are having a life-threatening emergency.


How to Choose the Cheapest Health Plan that Still Meets your Needs

This post appeared earlier on Mint.com. 

Maybe it’s Open Enrollment time or maybe you’re starting a new job that offers health benefits.  What’s the key behind all the terms – HMO, PPO, HDHP—and what can they tell you about how much that plan will really cost you?

The two most common terms, HMO and PPO, have to do with physician choice. And a HDHP is about the deductibles. As a general rule? HMOs will offer greater savings than PPOs, but at the cost of less choice and control. And HDHPs can save you even more money if you are healthy and don’t get frequent medical care.

So which plan fits you?

People with an HMO

  • Pay lower monthly premiums
  • Have to go through a primary care physician for everything
  • Have to get a referral for specialty care

People with a PPO

  • Pay higher monthly premiums
  • Can generally go directly to specialists
  • Will usually pay more for specialty care when they do get it

People with a HDHP (High deductible health plan)

  • Pay lower monthly premiums
  • Have a high deductible—you’ll be responsible for at least $1,200 out-of-pocket before your plan pays anything
  • Can open an HSA (health savings account) to save money specifically for health care costs with big tax advantages
  • Are usually younger and healthier

Some things are consistent across HMOs and PPOs – both have to cover preventive care at no cost to you (and that’s even if it’s an HDHP, and you haven’t met the deductible yet!), emergency care at out-of-network hospitals at the same level of coverage as in-network hospitals, and both have the same annual and lifetime out-of-pocket maximums.

Prescription coverage will vary by the plan.

If you’re overwhelmed about choosing the best plan for you, try focusing on two things: Physician choice and how often you need health care. Are willing to pay more to get easier access to specialty care when you want it? And are you willing to chance having to pay a higher deductible to have lower monthly premiums?

For many people, simplifying it to these two preferences will help lead you to the right plan.


Avoiding Big Bills in a Medical Emergency

No one really wants to be thinking about health plan rules in the middle of a family emergency. But then again, no one’s ever excited to receive a big unexpected bill for a trip to the ER—especially when it could have been avoided.

The key is to be prepared with knowledge about your health plan before you need it. So if an emergency does come up, you’ll know what to do:

Decide if you really need the emergency room.

Up to 25% of visits made to the ER are not actually emergencies—they are cases of allergies, coughs, or sprains and strains, which could have been treated in the doctor’s office. Yet when treated in the emergency department, the same care can cost three to four times more. There is also no guarantee you’ll get faster or better service in the ER. Depending on how busy they are, and how urgent your condition is, the average ER wait time can be up to four hours.

Call your plan’s nurse advice line.

Most plans offer this service for free, 24 hours a day. Not sure or want a second opinion? Call back. The benefit is yours, and you’ve paid for it.

Try an urgent care clinic.

 If your condition is not life threatening but also can’t wait for your regular doctor, this might be a good option. While most clinics are not open 24 hours, the costs will be a fourth or a fifth of what an ER would charge. Also be aware that health plans have varying rules on how they cover urgent care visits, so find out before you go.


If you do need to go to the emergency room:

Avoid the ambulance.

Unless the situation is life-threatening, or a person has a neck or spine injury, you may get care just as quickly in your own car. Ambulance fees can be high, and some plans will not cover them if the situation was not actually an emergency. What defines as an emergency can be tricky. According to federal regulations, an emergency is what a “prudent layperson” would determine to be a situation requiring emergency attention. But insurance companies don’t always have the same opinion as Joe on the street, and may refuse to pay a claim. This kind of denial can be appealed, but can be difficult to win. So if the urgency of the situation is unclear, but driving on your own is definitely safe, avoid the ambulance altogether.

Learn your authorization rules.

Some plans require you to notify them before you go to the ER. Others may require that you obtain authorization from your primary care provider first. Under the health reform bill, newer plans can no longer require prior authorization, but plans that were created before the bill was passed in March 2012 (grandfathered plans) are exempt from this rule.

Question your bill.

Start by asking the hospital for an itemized bill. Go over each of the expenses to see if they look right—for example multiple charges for the same thing, services that never happened, or incorrect diagnoses. Since ERs can be chaotic places, with multiple physicians handling one patient, it is not uncommon for a diagnosis to be changed or recorded incorrectly, or for a test to be ordered but never completed. Be aggressive in asking the hospital about charges that don’t make sense or appealing to the health plan if they refuse to cover certain services.

Beware of balance billing.

Most plans are now required by the health reform bill to cover emergency care at the same cost shares for you, whether the hospital was in-network or out-of-network (grandfathered plans are exempt). But in situations where a plan does not have a contract with individual physicians staffing the ER, the plan might reimburse physicians at lower rates than the doctors normally charge. So the physicians then turn around and bill their patients the difference—a practice known as balance billing. Each state has different laws around balance billing when it comes to in-network versus out-of-network providers and HMOs versus PPOs. Find out what the laws are in your state to make sure you are not being improperly billed.

Remember, Simplee does not give medical advice – only financial. If you are unsure about the urgency of your medical situation, always be sure to seek the care you need.


One Patient’s Story: the Cost of the Surgeon’s Glue Gun

Whenever we are telling people about Simplee we are struck by how everyone always has some story about getting overcharged by a provider, rejected by an insurance company, and generally bumped around in a system that is decidedly customer unfriendly.

This story comes from Baat, who was pretty surprised when a doctor turned “surgical adhesive” into “surgery” and charged her $900 to fix a small cut on her son’s head.

Our story begins last March, when our 5 year-old fell and bumped his head on the ground. Nothing major, a little bit of blood, but I decided to take him to the Palo Alto Medical Foundation Pediatric urgent care, to clean it properly, and evaluate the damage.

We were seen first by the assistant, who cleaned and inspected the wound, and then the doctor examined it and determined it to be a minor gash. She also performed a physical examination to make sure no additional issues were caused by the fall (concussion, motor skills, etc.).

Since the wound was still mildly bleeding, we were offered to have a small amount of glue applied to his injury, as it was too small for stitches. The alternative was a bandage, but that seem difficult to keep in place on his head, so we asked for the glue. The actual procedure took about 5 min (although 15 min was spent waiting for the local anesthetic to absorb to take away the sting of the glue). Our entire visit (most of it spent waiting) was under an hour.

We currently have a High Deductible Health Plan (HDHP), which means this type of treatment comes out of our pocket. I was therefore curious to get the bill, hoping it wouldn’t be high.

A few days after the treatment I received an email from my Simplee account. I was shocked to see the bottom line: $888. In addition, we noticed the insurance company classified it as “surgery”.

Being notified so close to the event by Simplee (rather than waiting for weeks for the bill), while I have all the details fresh in my mind, helped us compose a letter to dispute the charges with the care provider. We basically wanted them to classify the treatment differently, since we didn’t see how a situation that was offered a bandage as a treatment, could become so expensive, and carry the title of “surgery”.

Today, our case is still in dispute, but last I heard from PAMF, they will change the classification of the bill.

In an ideal world, knowing (even ball-park numbers) how much a visit to the doctor could cost us, or the cost of using glue versus a bandage, would empower us to make better decisions. Had I known such a visit would result in hundreds of dollars, I probably would have cleaned the wound myself put a bandage at home.

From a financial perspective, doctor visits feel like walking in the dark. You have no clue of the associated costs, and you let the care-providers and insurance companies run the show. But as we are encouraged to move to HDHP, and incur more out-of-pocket costs, creating a more transparent system is crucial.

Simplee’s approach, of notifying users quickly after events occurred, and having all the details in one place, showing costs, where the money is going, and hopefully one day alternative options, is a big player in empowering health-consumers. This bottom-up approach, letting users have the information they need to make smart decision is an important step in fixing this broken beast we today call “our health and insurance system”.

One way of looking at this is to say the system is working—the idea behind high-deductible plans is that by pushing more of the expense on consumers they will make people pay more attention and drive costs down.  However, as Baat points out, the consumers in this equation have very little information and very little power.  Finding mischarges takes time and attention, and fighting them takes tenacity.

Simplee can’t change what providers charge, but we do try to make it easier for you to dispute claims.  Next to each claim detail we provide the contact information for your provider and your insurer so you can contest the bills you disagree with.  And of course getting the info in a clear and timely manner is very helpful.  So make sure to check each claim as it comes in to see that everything is kosher… and surgery-free.


The Patient Protection and Affordable Care Act and What it Means for Consumers

By now you have probably already heard more than you wish to digest about the Patient Protection and Affordable Care Act (ACA). Regardless of whether or not you are a supporter or an opponent of the new law, implementation of provisions that will affect you and your family is already underway, and it is important for consumers, like you and me, to know how and when we will be affected.

The ACA means so many different things for providers, the insurance industry and regulators, but what does it mean for you and me, the consumers? I will spare you the nitty gritty details of every single provision in the health care law, and perhaps we can start with the top ten provisions that I think consumers should be aware of.

1. Coverage cannot be denied to individuals with pre-existing conditions. I have heard horror stories from consumers who were denied health coverage because they were diagnosed with acid reflux disease or had freckles or even because they were pregnant. Under the ACA, insurance companies will no longer be able to refuse coverage to individuals with pre-existing medical conditions. Although this provision doesn’t kick in for adults older than 19 until 2014, insurance companies are prohibited from limiting or denying coverage to children with pre-existing conditions as of 2010. In the meantime, the law establishes funding for a temporary subsidized high-risk pool that provides coverage for uninsured adults with pre-existing conditions until health insurance exchanges are created in 2014.

 2. Free preventive care. We all love freebies, and under the ACA, those of us with new policies will be receiving a major one. Effective as of 2010, new health policies from private plans must offer preventive care such as mammograms, colonoscopies, vaccinations and preventive screenings for free. So that means no co-pays, no deductibles and no coinsurance for these services.

3. Coverage cannot be rescinded. In addition to hearing countless horror stories about consumers being denied coverage due to pre-existing conditions, I have also heard stories that are just as horrific about consumers being dropped from their coverage once they become sick. Effective already is the provision that prohibits insurance companies from retroactively canceling consumers’ insurance coverage unless they can provide proof that the consumer intentionally committed an act of fraud. Of course, determining intent can be very subjective, especially if the insurance company is making that decision. Fortunately, for consumers, the ACA also creates new review boards that decide objectively what constitutes fraud.

4. Restrictions on imposing limits on insurance coverage. Some of us have insurance plans that include something like a $100,000 limit on coverage. That sounds great, right? Wrong! Anyone who has been diagnosed with a serious condition or who has experienced a medical emergency knows that $100,000 in health expenses can disappear very quickly, and once you have reached that limit, you are on your own and out of luck. Currently, under the new law, insurance companies are restricted from imposing lifetime dollar limits on coverage, and by 2014, they will be restricted from imposing annual limits on coverage.

5. Consumers will have more options to appeal coverage decisions. Many consumers have had to deal with the headache of receiving a letter stating that their insurance provider has denied their claims and in addition, they will not be able to appeal the decision. The new law ensures that consumers have access to an effective internal and external appeals process. In other words, consumers have the right to demand that their insurance provider reconsider a decision to deny payment for a medical procedure. Additionally, consumers can also make an external appeal to an independent reviewer.

5. Medicare beneficiaries can say goodbye to the “donut hole.” If you are a senior or if you have older family members or friends, then you are probably familiar with the Medicare “donut hole.” The “donut hole” represents the gap in prescription drug coverage that Medicare Part D beneficiaries have to account for. To clarify,  once a Medicare beneficiary reaches around $2,250, in prescription drug benefits, then he or she will be responsible for paying the next $2,250 toward prescription drugs before Medicare coverage kicks back in. For some seniors who are already on fixed incomes, this means, cutting pills in half or deciding not to take medications altogether. Beginning in 2010, Medicare beneficiaries who hit the “donut hole” will receive a $250 rebate. Each year, that rebate will get larger until the “donut hole” is closed completely by 2020.

6. Consumers will be provided with tools to understand their health plans. Navigating insurance plans can be incredibly confusing and discouraging, especially when insurance companies fail to disclose information that can be important and helpful for consumers. When consumers do not understand what their plans include or what they are purchasing, they can be vulnerable to falling into medical debt. The ACA provides funding to states to establish or expand offices of health insurance consumer assistance in order to help individuals file complaints and appeals and understand their benefit packages. In addition, insurance companies will be required to publicly post consumer health insurance information.  

7. Insurance companies will be prohibited from issuing unreasonable rate hikes. In 2010, insurance company rate hikes caught the media’s attention. Consumers were receiving notices informing them that their rates would be increased by up to 33% and that insurance companies have the right to issue rate increases more than once a year. Consumers were outraged, especially when insurance companies were unable to justify the rate hikes. The ACA creates a grant program to support states in requiring health insurance companies to submit justification for all requested premium increases.

8.  Young adults can stay on their parents’ plan until age 26. Although some young adults are fortunate enough to land a job that offers them good health benefits right out of high school or college, the reality is that the majority of young adults are not this fortunate and have difficulty purchasing expensive private insurance plans on their own. Under the ACA, parents have to option to add or keep their children on their health policy until they turn 26, even if their child is not claimed as a dependent, lives in another state or has a full-time job.

9. No more penalties for using out-of-network emergency rooms. When you are suffering from a medical emergency, the last thing you want to be doing is worrying about whether or not your health plan will cover the emergency room services you are receiving. New health plans will be prohibited from requiring consumers to get prior authorization before seeking emergency room services from a provider or hospital outside a plan’s network. In addition, they will also be prohibited from requiring higher co-pays and co-insurance for these services.

10. The individual mandate. Most consumers are aware that by 2014, they will be required to have health insurance coverage. Without the individual mandate, the health reform law would not have been as viable.  Younger, healthier individuals might opt out of coverage and the insurance pools would be disproportionately utilized by people who are older and sicker. As a result, premiums would be raised for everyone. Furthermore, because insurance companies are no longer allowed to deny coverage due to pre-existing conditions, the individuals who initially opted out of coverage can opt back in once they get sick. The mandate ensures shared responsibility among consumers. The ACA also includes subsidies for purchasing insurance for consumers who qualify and exemptions for reasons such as financial hardship, religious objection and immigrant status.

What we covered here is just the tip of the iceberg when it comes to the ACA, but hopefully this will serve as a starting point in understanding how you, the consumer, could be impacted by health reform. For more details about health reform and what it means for you, a good site to start with is www.healthcare.gov.