Has ANYONE ever looked at an EOB (Explanation of Benefits) and thought “oh, this is easy to understand?” I bet very few people would say that. EOBs are definitely not written in plain language. There are codes, there are a bunch of numbers in different categories, sometimes the numbers do not even add up correctly. When you try to compare it to the billing statement from your health care provider, the terms used aren’t identical and the billing statement generally has very limited detail. How do you know if your claim was processed correctly and if you are paying the right amount?
Estimates are that up to 80% of medical bills have an error. Therefore, it’s important to look at your bills and your EOBs and make sure that everything is correct.
Also, know that an EOB is NOT a bill. Wait to receive a bill from your provider before making any payment. But be sure to look at the EOB before paying the bill.
Here’s an example of an EOB (with identifying information blacked out):
Bottom line: Compare your EOB and billing statements; request an itemized billing statement from your provider. If you have questions, call the customer service number listed on the EOB or the back of your health insurance card. I’m happy to help as well!
A few months ago, my friend’s daughter, a freshman in college, had a health scare. Fortunately, everything turned out okay! But my friend hadn’t had her daughter fill out any of the necessary forms to allow the doctor and hospital to release information to her or even to speak to her about her daughter’s medical concerns. Trying to get a busy (and uninterested) college student to fill out the necessary forms while in another state in the middle of a semester was not quick, easy, or painless.
There are privacy laws (HIPAA) that restrict what a health care provider can share about any adult 18 years or older. Yes, this applies even if your adult child is still on your health insurance plan. Please refer to this article with advice about what forms you should have your 18+ year-olds sign. You can complete these forms on your own or meet with an estate planning attorney. (Special thanks to Emily Rozwadowski of Spencer & Rozwadowski, LLP for reviewing this information.)
Briefly, the four important documents are:
If your adult child is attending college in another state, it may be safest to fill out forms for each state. Some colleges have their own forms as well (e.g., the University of Illinois has this authorization to release confidential health information form); this is something worth asking about at parent orientation.
Once you’ve filled out the forms, keep them in a secure place. Also, be sure to scan them so you can easily access them from your phone as well as from your child’s phone.
So, while you’re checking towels, sheets, comforter, etc off of your college packing/to do list this summer, please add “fill out important forms!"
I’m still bothered by a conversation I had last month with a hospitalist (a hospital-based doctor) at a prominent hospital in the Chicago area. I was speaking to him on behalf of a client’s family members who were already very frustrated. Repeatedly during the 10 minute conversation, he said that he had done all he could for the patient “given the constraints of insurance.” I finally asked him what he would do for the patient if there weren’t any insurance constraints. Frankly, he stammered and gave a lame response.
We all know that insurance and other financial incentives drive many health care decisions, but for a doctor to flat out, dispassionately admit to a private patient advocate that insurance was what was driving his medical decision-making? It was shocking.
The sad reality is that this happens all the time in our healthcare system. Insurers - private as well as Medicare and Medicaid - make decisions about what treatments they will cover, how long a patient can be covered in a hospital or skilled nursing facility, what medication can be prescribed, and more. Some of the common ways this is done is through prior authorization for procedures and step therapy for medication. Note that the decision of an insurer not to cover something doesn’t mean you can’t get it, it means that your insurance company will not pay for it. Yet the reality is that most people cannot afford to self-pay for expensive treatments.
What can you do about this?
Know your insurance policy. Your insurance policy is a contract between you and the insurer. Of course it’s a unilateral contract that you have no ability to change - or even look at before enrolling, but it is a contract. It’s not fun reading, but you should know what it says. Use the language from the policy to make your argument for why something should be covered.
Know what your rights are as a patient. The American Medical Association (AMA) has published physician and patient rights and responsibilities. Medicare beneficiaries have legal rights, including related to hospital discharge. Most major healthcare organizations have their own set of patient rights and responsibilities; you should be able to find this online. I recently worked with a family and the case manager at the facility was giving them the run-around about setting up a family meeting with the physician; after some back and forth, I ended up quoting directly from the facility’s patient rights document and - like magic! - a Zoom meeting was set up for later that afternoon.
Be persistent. I like to say that insurance companies are bigger and badder than us and are counting on us to feel overwhelmed, intimidated, and just give up. Stick with it. Know the facts: what does your policy say; what is considered best practice and what peer-reviewed evidence is there; what are your rights as a patient/member.
Advocate for yourself. Use the above tips to advocate for yourself or a family member. Be polite but firm and persistent. Enlist the assistance of your healthcare providers. Go up the chain of command.
Please contact me if I can help
Last spring, when I first wrote about navigating the health care system during the restrictions due to Covid, I never thought I would still be speaking and writing about that topic now! But it’s still extremely relevant as visitor restrictions are still in place for inpatients, patients in emergency departments, outpatients, and long-term care residents. I spoke on this topic recently as part of the North Suburban YMCA’s Adult Education Series. Basically, the guidance to be prepared and focus on good communication applies more than ever. The video also includes tips regarding telehealth appointments.
Regarding being prepared, think about these two questions:
I’ve blogged before about the importance of creating a health information binder. It’s critical to do so AND to make sure that someone knows where it is so they can access the important information and advocate for you.
Communication is different as you may have to rely on phone and video communication when your loved one is in the hospital. Key points include:
Choosing the right health insurance plan can be overwhelming. It may be tempting to just keep the plan you currently have rather than look at spreadsheets and dense, hard-to-decipher descriptions of coverage options.
That’s a mistake. Whether you’re over 65 and inundated with advertising about Medicare open enrollment options or getting your insurance through the Marketplace or working for a company whose annual open enrollment is taking place this fall, it’s imperative that we review our current plan and see what our options are for 2021.
Here are some things to keep in mind regardless of where you get your health insurance:
Medicare Open Enrollment started October 15 and you can’t watch TV these days without seeing commercial after commercial about different Medicare insurance options. During Medicare Open Enrollment you can:
A few tips:
Health Insurance Marketplace and Employer Health Plans
Bottom line: Be sure you understand your options, get your questions answered, and know your preferences (cost, access, convenience, willingness to accept risk, etc.) before you make a decision. Contact me if I can help answer questions or conduct an analysis for you.
Medicare is complicated. There are a lot of “parts” as well as rules, enrollment periods, etc. I’ve started making 1-2 minute videos to explain different aspects of Medicare including what is open enrollment, what isn’t covered by Medicare, Parts A, B, and D, what is IRMAA, and more. I'll be adding to this "Medicare collection" periodically so subscribe to my YouTube channel to stay up to date.
Thank you Betsy Phillips, Realtor, Baird & Warner, for having me on your "Let's Chat" series to talk about patient advocacy!
Medicare's annual open enrollment period starts this month and that means there are A LOT of commercials urging people to switch plans. Here are some of my thoughts after seeing yet another one of those commercials...
Write something about yourself. No need to be fancy, just an overview.