Tag Archives: insurance

Diabetes Blog Week Day 4- Healthcare Experience

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Diabetes Blog Week

Today’s topic: Most people who live with a chronic illness end up with a lot of experience when it comes to dealing with healthcare. How would you improve or change your healthcare experience? What would you like to see happening during medical visits with your healthcare team? How about when dealing with your health insurance companies? What’s your Healthcare Wish List or Biggest Frustration? 

Oh man, I don’t even know where to begin. I’ve had so many awful experiences with doctors, offices, insurance companies and pharmacies. I can’t forget about the Epic Letter of Complaint that I wrote and sent to a former endocrinology office. Or the more recent Insurance Frustrations I’ve dealt with that are all too common.

Unfortunately I have yet to have a doctor and office where I felt like I consistently received competent, respectful, helpful care. Some visits and doctors have been better than others, but on the whole, there is much room for improvement. In fact, at my last appointment, the doctor forgot to check my A1c! We’re talking lack of basic diabetes care here.

So I’d like to invite you to my imaginary endocrinology appointment, an idealistic appointment where I get the exact care and consideration that that I as a patient and person deserve (and you know, a few extra perks since this is my fantasy appointment after all).

Receptionist: Good morning Reva, you’re here to see Dr. Rainbow?  Please have a seat in the massage waiting chairs, the doctor will be with you in a just couple minutes. She is actually running ahead of schedule this morning.

Nurse: Hello Reva, come on back with me. I can take your pump, dexcom, and meters from you. We’re going to download all your numbers and information and use a software that graphs them together. Do you use any additional apps that we can also incorporate the information? Any fitness or food tracking apps? With this integration, we can get a better idea of how exercise is affecting your blood sugars and if your carb and insulin ratios are adjusted for the foods you eat and when you eat them.

Now we’re going to check your A1c right here in the office with a simple finger poke. We know how annoying it can be for you to have to go to a separate lab early in the morning before work and before your appointment to get your blood drawn to check your A1c. And then have the lab forget to send it to your doctor so it isn’t there when you arrive for your appointment. We wouldn’t want that to happen to you.

You’ll be in exam room 2. It looks like the doctor is ready for you now.

Doctor: Hi Reva. I wanted to let you know that all your prescriptions are up to date. We were contacted by your pharmacy that your insulin prescription needed a refill. So we took care of that and it should be all set when you’re ready to order more.

So, how do you feel things are going? I have your graphs up on the screen and I can see some places that we can make some small adjustments. But before we go into that, do you have any specific questions or concerns  you’d like to talk about?

Our nutritionist is in the office today if you’d like to meet with her after we finish. Now let’s take a look at your graphs. Your A1c is looking good, good work on improving it since our last visit.

I also wanted to see if you’d be open to talking about or trying different brands of insulin or other medications that have been approved for use with type 1 diabetics to see if we can get your numbers under tighter control. What I would hate to have happen is to not talk about other options that exist, since treatment of type 1 diabetes has progressed over the years. We pride ourselves at this office with keeping up to date with the latest research, technologies, and treatment options. You deserve the best care that we can provide and we will work together to make sure you get it and reach the goals that we’ve worked together to set.

Is there anything else that you’d like to cover that I may have missed today? I want to make sure that you feel like you got the most out of this appointment and feel comfortable with your changes and next steps. Great.

Well, I look forward to seeing you in 3 months. If you have any questions over the next few months, please don’t hesitate to call, email me, or use the patient portal to communicate and I will personally respond within 24 hours. I would hate for you to have to make multiple calls and wait days to get a simple answer from me.

Have a good rest of your day and keep up the good work!

And scene.

Insurance frustrations

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bubbleDuring the time that I was on my parent’s insurance, I was pretty much removed from the entire billing and insurance process. I was lucky in that my dad took care of the paperwork and the phone calls. I lived in my nice little naive bubble where all I worried about was going to my appointments, ordering my supplies, and taking care of my health. I didn’t worry if a certain device or procedure was covered by my insurance, everything just magically worked out. Oh what wonderful times those were.

Then I got a job and my beautiful bubble popped.

I know that I’m very fortunate that my job even offers insurance and that it has pretty good coverage. However, if you ever want to simultaneously raise your blood pressure while feeling like you want to bang your head against the wall, try calling your insurance company to argue a claim.

Take a few weeks ago as an example:

It all started with an email notification that I got that a new claim was available to view online. It was about my most recent routine appointment with my endocrinologist. I followed the link to an EOB. I feel like I should be able to say that I speak “Insurance” since it often feels like I’m reading a foreign language while trying to decipher what is being said. I noticed that the entire bill was higher than the past 2 appointments. Scanning the paper, I found a tiny number leading to the appendix with the following text:

Our payment policy limits the number of times this procedure is allowed and that limit has been met.

Ummm huh??? I went back up to see what billing code this was referring to, thinking perhaps it was some unnecessary test or blood work that I may have unintentionally duplicated.

GLUC MONITOR, CONT,  PHYS I&R 95251

Like I said, a foreign language. But whatever it was, I was being charged the entire amount of $120. But if it has to do with glucose monitoring, it probably is necessary. I called my insurance company. The woman explained that the billing code that the limit was referring to was 95251 (side note: I did some googling and this particular billing code can range from $35-$350!). With some simple googling I determined this billing code was referring to the following:

95251: Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; interpretation and report.

Essentially it’s downloading my CGM and interpreting the numbers. At this point I was starting to get both confused and angry. I checked the EOB. I was also charged for an Office Visit so it’s not like it was the only thing they were billing for. But the part I was getting angry about was that downloading and interpreting my numbers is really all my appointments are since checking my a1c and blood work happens at an entirely different time and facility.

I called back the insurance company, asking what the limit of visits are for that code: 2. I attempted to calmly explain that the standard of care for a type 1 diabetic is seeing their endo every 3 months, so 4 visits a year. How could they only be covering half of them?!?!

The insurance woman explained that I’m going to need my doctor to call the patient management team at the insurance company and get the additional visits pre-certified ahead of time for them to be covered and additionally to appeal the charges from the last visit.

Ugh. Really??

At this point I’m just annoyed. But I’m more annoyed at the idea of having to pay so I call the health system starting with their billing department. After explaining the issue, I was told that the doctor will have to call and that it’s something that the billing department can’t take care of. Okay fine.

I call the doctor, the receptionists says I should talk to billing. No, billing said to talk to the doctor. At this point I’m ready to hit my head against the wall. My doctor is not available so I leave a message explaining the entire issue. The receptionists assures me she will deliver the message.

A week goes by. No response.

I call back. The person on the phone looks at my file. He tells me that it looks like it was seen and sent to billing. The person on the phone offers to have someone from billing follow up with me. Yes please.

I wait.

A few days pass and I finally get a message from someone from Billing. “I see the message in your file,” she says. “It looks like they’re talking with someone at the insurance company. I can call you back when I know more.”

Ughhhh.

A few more days. “It looks like they are taking off the charge for your most recent appointment.” “That’s great,” I respond “but what about the future appointments? I have one coming up in a few weeks. Are they going to charge me again? The whole point was to get them pre-certified.” “Oh ummm, well I can tell them to look at the September appointment. You’ll have to call ahead of time for each appointment and tell them to contact the insurance company.”

Are you frickin kidding me?!?! Why is this so circular?!?! I thanked her, not sure exactly what was accomplished besides not being charged for the most recent visit. However, the fact that it took almost 2 weeks does not give me much hope if this is the process I’m going to have to go through twice a year, every year!

The funny thing is, I would consider this a successful encounter compared to some of the other arguments and conversations I’ve had with the insurance company. But it’s amazing to me the number of phone calls it takes to accomplish even the simplest task. Working in the health care field and having a masters in public health, I consider myself to be more knowledgeable than perhaps the average person in navigating the health care system. And if I found this process to be arduous, I can’t imagine that many people with much less knowledge are being successful in their efforts.

If anything, I’ve become a much more assertive person through this process, but really I just wish that the whole system was fairer and simpler for everyone.

 

 

 

 

 

The Patient Experience

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I work for a global healthcare leader. A couple weeks ago we had our company conference. While listening to the various speakers within the different business segments of the company, one theme became very prevalent. Leaders in pharmaceuticals, medical devices, and consumer healthcare, all kept emphasizing the same topic: the patient experience. Speeches were littered with phrases like, “patient-centered”, the “patient journey”, “putting the patient first”. As a public health professional and as a chronic disease patient myself, I was happy to see the clear focus shifting towards the patient.

But then I stopped to think about what this really means. As a type 1 diabetes patient, what does patient-centered care really look like?

To start, I can tell you what it does not look like. A few days ago, I received this letter from my health insurance company. At the top of the letter it read, “Talk to your doctor about this important issue. It may improve your health.” Intrigued, I kept reading. The letter explained that they had basically reviewed my health records and wanted to bring a potential health problem to my attention so that I may speak to my doctor about it. The health topic was on the back of the letter. Since my various doctors have already tested and reviewed my blood work, I was curious what health issue they may have missed. I turned over the letter.

The first line on the back said, “Our data shows that you may have diabetes.” The paragraph went on to explain the importance of checking for protein in the urine as a sign of kidney damage if you have diabetes. It’s not the letter itself that annoys me. I actually think it’s great that the health insurance company is sending reminders or health information to patients to bring up with their doctor. It’s the fact that the first line says, that I may have diabetes. Guess what? I do. And I have for the past 14 years. Honestly I find this letter off-putting and probably has the opposite effect than intended. I expect that my health insurance would know that I have diabetes, they see the diagnosis codes for all my doctor’s appointments, they aren’t making a leap to say that I have it. Telling me that I may have diabetes basically says that you don’t know me at all. It’s the opposite of patient-centered. It’s communicating that I’m just another medical record that a computer scanned and looked for key words or results to send a form letter.

If they had just changed the top line, I would have reacted completely different to the letter. They should have instead said, “Reva, since you have type 1 diabetes, here is some information that you may want to bring up with your doctor at your next visit.” This would have instilled confidence that my health insurance company actually knows my health condition, it would have felt more personal, and I would have reacted overall more positively to the actual information rather than getting caught up in the first line.

My “patient experience” doesn’t just happen in my endocrinologist’s office 4 times a year, it’s tied up in everything that is communicated to me and that I do day-to-day. It’s in letters like this one. It’s in all the moments between doctor’s appointments. It’s in the way that the doctor speaks to me and even in their particular word choices when talking about my diabetes. It’s in the waiting room or exam room when I’m waiting 30 minutes to talk to the doctor for less than 15. It’s in my conversations with customer service about my pump or CGM. It’s in my multiple phone calls with my mail order pharmacy when they screw up my insulin prescription or the countless inconveniences of getting my a1c test done. My patient experience involves the lack of integration and communication between doctors and health care systems and even medical devices.

I applaud the shift and emphasis on the patient experience. It’s about time. When a patient truly feels at the center of their care, that their time and efforts are acknowledged and respected, when their obstacles are recognized and addressed, I think there is huge potential for helping patients live longer and healthier lives. I’m glad to see that we’ve taken the first steps of a long, but necessary journey.