When the insurance company received the entire bill for the hospital stay, they denied payment for all of the psychiatrist’s visits, saying that they had not been pre-authorized by the insurance company, so they would not be covered.  The hospital then billed my client for the psychiatrist’s services.

My client called me, saying, “My doctor said I needed this; how could I possibly have known it needed to be pre-authorized?  I was sick; he recommended a treatment and I agreed.  How can they charge me for it?”

I could see immediately what had happened; this is a very common event when someone is in the hospital, and it frequently leads to an INITIAL denial by the insurance company.  When I called the insurer, I said “you have this happen all the time: how can we get this reconsidered?”  The insurer requested medical records to review.  Once they were provided, the claim was paid.

Points to remember:

• Review all medical bills carefully; make sure you understand the charges.
• Team with the hospital billing department; they can assist with sending medical records.
• The first review of a claim frequently is a denial.
• Appeals are the rule of thumb:  be prepared for two or more.
• Work patiently with everyone:  you will get a better response if you are respectful but determined.
• If your bill is very complex, you might want to hire a medical coder to review it and make sure the coding was done correctly.

In the “old world” of medicine, people seeking care were patients.  The origin of “patients” is from the Latin for  “to suffer or endure”.  Is that a relevant description for today?  Only partially.  Yes, people who are ill do suffer and endure, but they are also taking steps to learn about their options, talk with others in a similar situation and research centers of excellence and specialists.  They approach their providers with this information, and are collegial in their approach to their care:  they don’t ask a healthcare provider to tell them what to do:  they discuss options, risks and benefits and outcome data and then decide with their provider what options to take.  This is a very different way to approach healthcare.

So language needs to follow the shift:  rather than a “patient”, which conveys a static, “waiting-for-someone-to-tell-me-what-to-do” position, I think the title now is “consumer”. People look at healthcare as a product they can research and purchase.  These consumers have shifted away from the old model to the empowered healthcare model.  Patients no more, they are driving some of the most significant changes in healthcare delivery today.

What is particularly interesting is that  people are curious, and are willing to sped upwards of $399 to find out this information.

This is the world of new medicine: the information can be out there, for a price,and people are curious and would like the information.  So, if you were to appear at your doctor’s office with a genotype of your DNA, he or she might ask:  what can I do with this?  How will it currently help me keep you in good health? And that is the dilemma of healthcare today:  we can access very sophisticated information, but knowing how to apply it and where to go with it remain a challenge.

It’s one of the reasons healthcare advocates are so critical today:  helping the consumer know what to do with the information they acquire!

Ann Tardy, Founder, LifeMoxie; Keynote Presenter: “The New World of Healthcare Advocacy — Creating It Together!”

Jeff Belkora, PhD, Director of Decision Services and Assistant Professor of Surgery in the Institute for Health Policy Studies, U.C.S.F.: “Making Good Decisions in a Family Health Crisis”

Linda Garrett, Partner, Risk Management Services: “Confidentiality and Privacy Law for Healthcare Advocates”

Gail Gazelle, MD, Assistant Clinical Professor of Medicine, Harvard Medical School: “Inside the Doctor’s Mind: What Every Advocate Needs to Know”

Maggie Radany, RN, Founder, Radany & Associates: “How to Solve Health Insurance Problems and Be a Hero to Your Clients!”

Dianne Savastano, Founder & President, Healthassist: “Bringing Bob Home: A Case Study in Patient Advocacy”

Elisabeth Schuler Russell, Founder & President, Patient Navigator LLC: “Inside the World of Pediatric Healthcare Advocacy”

Judith Stark, Principal, Judith Stark Consulting: “Harnessing the Power of Technology Solutions for Healthcare Warriors”.

To register, go to www.nahac.com.  Early registration (at the reduced rate of $150 for NAHAC members and $200 for non-members) ends October 15th.  After Oct. 15th the rates will be $200 for NAHAC members and $250 for non-members.

Are you trying to navigate the Medicare maze for yourself or a
loved one? Become an empowered Medicare consumer by
attending an expert workshop led by one of the nation’s leading
professional advocates.

At the workshop you will:
Learn about eligibility, cost, and coverage options for Medicare
Parts A, B, C (Advantage), D (Prescription Drug) and
Supplemental (Medigap)
Discover how to find and use trustworthy resources in your
community and online
Master tips and tricks for making informed plan choices that are
right for you
When:  Saturday, September 12, 2009
8:30 am to 12:00 pm
Where: Portland State University
(Downtown Portland Campus)
Cost: ! $35
The workshop will be led by Joanna Smith, LCSW, MPH. Joanna is a
nationally recognized expert in Medicare and other patient advocacy
issues. She is the founder and CEO of Healthcare Liaison in California,
and has more than 30 years of experience helping patients and families
navigate the healthcare system.
The workshop is sponsored by Health Advocacy Solutions, a Portland-based nonprofit
dedicated to helping patients, families, and communities get the best care possible.

To register,  visit

http://www.hasolutions.org/upcoming or call 503-828-1078.
Space is limited, so please register soon!

Consumers continue to be overwhelmed by healthcare.  Decisions about treatments, choosing and understanding specialists, coordinating care, addressing billing and insurance issues–all of these areas can be overwhelming to someone in the middle of a complex medical situation.  While many people are alert to the difficulties that seniors encounter in navigating the healthcare system, people who have very ill babies and children, young adults with new diagnoses of diseases or people of all ages facing surgery or treatment decisions need people to help them navigate through.

But who is doing healthcare advocacy and what are their skills?  What are the “best practices” for the profession?  how can consumers find someone near where they live?  These are the questions a National Association can begin addressing.

Who can join?  Everyone with an interest in healthcare advocacy:  medical professionals, consumers, academicians, policy makers.  But the data base of members is open to the public, who can search without charge for an advocate in their geographic area and read about their particular qualifications to help them decide if the advocate is a good match for what they need.  There is only one credentialing program right now in the U.S, and that is run by Healthcare Liaison and is for medical professionals.  Will there be one for consumers?  What are the skills a heatlhcare advocate needs to have?  What about licensing?  Join the Association and join the dialogue!