Health Benefits Counseling By Michael Rust ABC for Rural Health, Inc.
ABC for Rural Health & HealthWatch 100 Polk County Plaza, Suite 180 Balsam Lake, WI 54810 (715) 485-8525 (715) 485-8501 (fax) firstname.lastname@example.org
North Dakota FamNet Health Benefits CounselingTraining April 12, 2011 Comfort Inn, Bismarck ABC for Health, Inc.
ABC FOR HEALTH, INC. A Wisconsin-based nonprofit public interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services. ABC for Health, Inc.
ABC for Health’s mission is to provide information, advocacy tools, legal services and expert support needed to obtain, maintain, and finance health care coverage and services. ABC FOR HEALTH’S MISSION ABC for Health, Inc.
What families face Losing coverage due to loss of a job or other circumstances. Employment that does not provide coverage Coverage that does not provide adequate benefits Common policy elements such as ‘pre-existing condition exclusions’. ABC for Health, Inc.
Extra obstacles Fragmented information on public health programs Patchwork network of providers; complex referrals/PAs to specialists Technology failures in assessing eligibility Intransigent or uninformed workers ABC for Health, Inc.
Family needs First priority is to provide counseling where and when it will be of greatest benefit to the family. Extra support during times of intensive involvement with the health system; i.e. the birth of a child or a hospitalization. Reduce stress caused by worry about how medical expenses will be paid for. ABC for Health, Inc.
Motivations for public and private health care denials From the public and private administrators’ perspective, the most important goal is to contain expense. Medical care is expensive—especially for medical equipment or treatment for long-term, chronic conditions. Private insurers want to maximize profit and public health administrators want to come in under-budget for the year. Seek to cut what they see as duplicative or redundant costs. ABC for Health, Inc.
Family stress Reassure families that they are not alone in trying to find answers to their questions about health care financing. Move quickly to connect families to coverage, both to make sure that they meet the strict deadlines for applying for public programs and to allay their fears early on. ABC for Health, Inc.
What is health benefits counseling? Advocacy for patients/clients without health coverage, with inadequate health coverage or who are in a dispute with their insurer. Also, advocacy for a better system of health care finance—broader benefits, more open eligibility, etc. ABC for Health, Inc.
Health Benefits Counselor A professional position! Training and education Professional judgments ABC for Health, Inc.
Client services in HBC Client services include: health benefits counseling to inform families of possible eligibility for programs or services; consultation about the patient’s rights and obligations under their managed care plan; assistance with filing grievances and appeals; legal assistance with filing hearings ABC for Health, Inc.
Appealing denials After discussing the case with the family, health benefits counselors should appeal any denials that seem incorrect. Types of denials: Medicaid under-assessment of coverage Denial of Medicaid coverage Denial of coverage by a private insurance plan Denial of a Prior Authorization for a procedure, therapy or for medical equipment ABC for Health, Inc.
Other tasks of the health benefits counselor In addition to working directly with families, benefits counselors should also consider: Conducting outreach Disseminating information regarding state and federal managed care and insurance laws (i.e. through brochures or press releases). Collecting information from HMOs; client demographics, special programs, etc. Collecting information from providers; demographics, charity care programs, etc. ABC for Health, Inc.
Outreach to families Families make extensive use of word-of-mouth information. Parent support groups and associations can rapidly distribute information. Health care providers, community agencies, other advocates for families and children with special health care needs are other good sources of information ABC for Health, Inc.
Common referral sources Agencies like these should be made aware of the existence of your counseling program and given your contact information: Health care providers County public health departments Disability rights organizations Community-based service agencies Disease-related organizations Information and referral agencies Schools and school nurses Public interest law firms ABC for Health, Inc.
Settings • Free-standing • Health Care Providers • Health Departments • Service Networks • Tribal Clinics • FQHC’s/CHC’s
Why should providers have health benefits counselors? Increased third party reimbursements (Up to $33/$1) Improve customer service Improve staff morale Improve community image ABC for Health, Inc.
Health Departments • Core/Essential Service • Clients (WIC/FP/PreNatal Care) • Federal Funding
Service Networks • Well-defined constituency • Common case patterns • Established partnerships
FQHC, etc. • Clients • Federal Funding
Tribes • Unique issues • Relationships • Preserve Contract Health Funds
WHY A LAW FIRM? Families have problems accessing and financing health care Complicated public benefits program Limited insurance coverage Lack of understanding and accessible information Lack of assistance and support in navigating the system, which is based on laws and regulation ABC for Health, Inc.
The role of lawyers Send letters of inquiry or demand letters Represent the family at hearings (grievance, appeal, medical review). Provide guidance, credibility and leverage for the health benefits counselor ABC for Health, Inc.
PARENTS AS ADVOCATES Parents are the child’s best advocate Identifying the local and statewide resources and supportive structures Advocacy organizations, e.g.. Family Voices, www.familyvoices.org ABC for Health, Inc.
Systems/ND Equivalents • Private Insurance • Managed Care • Medicaid/BadgerCare Plus • Social Security Disability • CYSHCN Programs (Children w Medically Fragile Needs • HIRSP (CHAND & PPACA • Medical Debt
Commissioner of Insurance What happens after I file the complaint form and how soon will I hear from the Department?Within a week after we receive your complaint, you will receive an acknowledgement letter from the investigator working on your complaint.If your complaint does not require us to contact the insurance company or agent, you will receive written answers to questions you may have raised or an explanation of why we cannot handle your complaint.What contact will be made with the insurance company?In most cases, the investigator will send the company a copy of your complaint, asking for an explanation of its position.After the company responds, we should determine within three weeks whether we must take any further actions.If the company agrees to resolve your problem, the investigator will send you a verification letter.
Insurance Basics • Types of policies/structure • ERISA • Managed Care • Consumer Rights & Responsibilities • Underwriting/discrimination • Prior Authorizations/Referrals/Notification • Terminations & cancellations • Grievances & appeals (internal & external) • COBRA continuation and conversion • ADA/FMLA/HIPAA/Parity/FMLA • Appeals
Health Insurance Law State v. Federal Regulation of Insurance ERISA COBRA Common Claim Denials & How to Fight Them ABC for Health, Inc.
APPLICABLE LAW Health Insurance Regulation State Statutes Regulations, Office of the Commissioner of Insurance Case Law Federal-ERISA State/Federal-ERISA ABC for Health, Inc.
ERISA Employee Retirement and Income Security Act of 1974 Federal Law designed to address the abuses in employee pension plans. Two major types of plans Insured and self funded plans Self funded plans are NOT regulated by state law What is the difference between insured and self funded plans? ABC for Health, Inc.
ERISA The Plan Document The legally binding contract that contains the detailed information on benefits NOT JUST A BROCHURE Employer is required to provide a summary plan document Reasonable copying costs may be charged Contact the plan administrator in writing. (30 day response time or a possible $110/day fine) ABC for Health, Inc.
ERISA Claims Claims should be resolved within 90 days Decisions must be in writing and must state the specific reason for the denial Every ERISA plan must have a review procedure for denied claims (generally 60 day review period) ABC for Health, Inc.
Choosing a policy Managed Care (HMO, PPO) Fee For Service Group or individual? ABC for Health, Inc.
Remember! North Dakota Law will not apply to self- funded insurance plans ABC for Health, Inc.
Consumer rights and responsibilities Know your policy – marketing materials, policy summary, and complete policy Follow the appeal process Document your work! ABC for Health, Inc.
Law of Insurance Contracts The insurance policy is a contract Confusing or ambiguous language is to be strictly interpreted in favor of the insured The reasonable expectations of the insured should be met Exclusions must be clear and understandable Get a specific reason for the denial Go up the management ladder ABC for Health, Inc.
Phantom clauses These may be inserted in a policy without a definition or without any accurate meaning. For example the phrase “services, care, or supplies that are not medically recognized by the American Medical Association” has no accurate meaning. ABC for Health, Inc.
Insurance Company Wrongdoing Failure to acknowledge communications about claims Failure to finish investigating a claim with reasonable speed Failure to promptly provide claim forms, instructions and reasonable assistance Failure to give a prompt and reasonable explanation of why a claim is denied ABC for Health, Inc.
Insurance Company Wrongdoing (cont’d) Knowingly misrepresenting facts and policy provisions Failure to respond to a claim soon after proof of loss ABC for Health, Inc.
Common Claim Denials Experimental treatments Obtain a written definition of experimental treatment from your policy or insurance company Obtain supporting literature from your physician (letters, articles etc.) ABC for Health, Inc.
Common Claim Denials: Medical Necessity “Not Medically Necessary” How is the term defined in the contract? Obtain documentation of the need for the service Is the denial contradicted elsewhere in the policy? ABC for Health, Inc.
Medical Necessity (cont’d) Medically Necessary This term can be very ambiguous and is often used as a “catch all” Other terms include medical necessity or medically indicated ABC for Health, Inc.
Usual, Reasonable and Customary Charges Waivers that bind you to payment obligations Illegal billing issues ABC for Health, Inc.
Pre-existing condition When is a condition a condition Misdiagnosis? Manifestation to the reasonable person, ABC for Health, Inc.
Educational verses medically related services Speech therapy Physical therapy Occupational therapy ABC for Health, Inc.