PRESENTED BY: LAYTON LANG

Become a Better Healthcare Consumer

What is Healthcare Consumerism?

To empower individuals with information and financial responsibility to support a position of ownership.

Most employers are well aware of cost containment tools such as risk assessments, disease management and wellness programs.

What about a strategy to engage in the purchase decisions regarding medical products and services to reduce employee out-of-pocket expenses?

Learn your plan’s rules

Learn how to access a primary care or specialtist physician; referals and authorizations

Fully-Insured or Self Funded Plan.Understand your plan’s pharmacy formulary.Promptly respond to any claim questions your

health plan may send you. Request for medical records Subrogation Request Pre-existing Medical condition Coordination of Benefits

Network vs. Out-of-Network providers

Verify provider and facility are in your network plan.

Learn which facilities are in-network when preparing for emergencies.

Know how your plan will pay an out-of-network provider: Usual and Customary or a Proprietary Formula. Emergency Care or Network Inadequacy

Remedy for hospital-based providers billing you for out of network charges: Texas House Bill 2256

Out-of-Network Scenario

Hospital Provider Bills $2500Your plan benefit is 80%/20%  

  Billed Amount Allowed  Deduct Coins Amount paid

Blue Plan $ 2,500.00 $ 1,500.00 $ - $ 300.00 $ 1,200.00

Red Plan $ 2,500.00 $ 2,500.00 $ 500.00 $ 2,000.00

Prescription Drugs

Use “Preferred’ Brand Name MedicinesPurchase Generic DrugsBuy in bulkAsk for Samples or Drug Savings CardsIf you don’t have a pharmacy benefit then

shop around.

Medical Services

Inquire about Cost-Effective Medical Options Cutting-edge devices or procedures may not be the

most worthwhile . Ask whether provider has a financial interest in

preferred facility or equipment.

Global Periods In- office procedures allow for 10 days free follow up

care. In -hospital procedures allow for 90 days free follow

up care.

Facility Costs

Diagnostic Studies- Over the past 5 years, the price variance between

studies performed at a hospital owned facility vs. an independent is 2 to 3 times greater.

Procedures and Surgery Physician office Free-standing surgery center; not affiliated with a

hospital Hospital facility

Hospital vs. Medical OfficeCardiac Stress Test Study

Hospital vs. Medical OfficeCardiac Nuclear Study

The Medical Bill

Ask for the cost of the procedure/service along with the CPT codes.

Example:  Patient decides she wants a nevus mole removed from her neck. The general dermatologist agrees to perform the surgery and bill 11401 and 12032 CPT codes which pay $415.58. The patient requests a second opinion and visits a dermatologist specializing in MOHs surgery, who states he will remove the mole and bill a 14041 which pays $765.34. Both dermatologists agree to perform the procedure but each receives a different payment amount from the same carrier under the same benefit plan.

Medical Bill Audit

U.S. Government Accountability Office states 9 in 10 hospital bills contain overcharges.

Medical Bill Audit

As hospitals and medical groups consolidate medical billing operations, staff and service become less sophisticated.

Example: Employee was balanced billed $1309.00 by the emergency room physician because the carrier denied the claim for diagnosis not substantiating the care. Employee contacted the emergency physician’s third party billing company and discovered they had failed to pull the correct diagnosis and never appealed the claim. He contacted the provider’s office and advised them to pull the emergency room records to locate the other diagnosis. They complied by correcting and refilling the claim which was subsequently paid.

Medical Bill Audit- What to look for

Compare services rendered to what was claimed

Verify provider filed with all insurance plans and exhausted appeal rights

Examples that Merit Medical Bill Review

  Insurance company did not apply the correct benefits: fee

schedule, edit logic, co-insurance, deductible. Insurance company has never responded or paid claim. Insurance company denied claim because it was not

medically necessary or deemed experimental. Insurance company denied claim because the claim was not

clean. Insurance company failed to pay 100% of the out-of-network

provider’s claim. Always contact the medical provider’s office and explain

that they need to look to the insurance company for payment as they are prohibited, by Texas Administrative Code and provider contract to bill the patient for covered services. They should exhaust their appeal rights before billing the patient.