Archive for the ‘Blog’ Category

THE HEALTHCARE PATIENT VERSUS THE HEALTHCARE CONSUMER

Today, we define a healthcare patient as receiving healthcare services; we define a healthcare consumer as making healthcare choices.  Undoubtedly a very big difference that requires a shift in focus.  The healthcare consumer is responsible for the overall management of their health needs and out of pocket costs. Out of pockets costs are defined as deductibles, co-pays, co-insurance, premiums, and other related costs. The typical consumer does not plan for healthcare.  Consumers, annually, select a health insurance plan based on premium cost and hope they are healthy enough to avoid large out of pocket costs.  A Personal/Family Health Plan should be the first step to proactively managing healthcare options and costs. The Plan should be all inclusive from selecting a health insurance plan to creating a budget.  Radical? Yes…but by not planning for healthcare the result could be disastrous with health and financial consequences.

The average healthcare consumer has limited experience navigating the healthcare system, including those who work in the healthcare industry.  Many of us have heard friends and relatives express their frustration managing options, care, and costs, resulting in incorrect billing, high costs, out of network charges and denied services. One example is a recent survey that shows the consumer lacks understanding of basic health care terms. The following are the results:

  • 45.3% Co-Insurance
  • 35.2% Max out of pocket
  • 30.8% Covered Services
  • 27.2% Premium
  • 25.6% Deductible
  • 23.5% Co-pay

The degree of misunderstanding is astonishing.

The healthcare system is a maze that healthcare consumers cannot navigate easily. Healthcare consumers are afraid, frustrated, confused and angry.  All healthcare sectors, including Doctors, Hospitals and Insurance Companies, have contributed to the growing confusion.

Many talk about consumerism in healthcare but don’t understand healthcare consumer needs and wants. Clearly, the healthcare consumer has not been prepared to manage their healthcare finances as the above survey demonstrates.  The healthcare system has failed the healthcare consumer.

Our responsibility is to educate and guide the healthcare consumer through the maze.  With that said, the following company and web site has been established:

HEALTHCARE CONSUMER NAVIGATOR CENTER, LLC

Our Vision…The Need….The Mission Statement

Our company has a vision that all healthcare consumers have easy access to reliable and timely healthcare information, education, and tools required to plan and manage their healthcare needs.

Consumers need understandable healthcare information to make informed decisions regarding their medical and financial future.

Healthcare Consumer Navigator Center is a national company with a business mission to guide consumers through the complex healthcare system.  Healthcare Consumers will be provided tools, guides, information and education to navigate the complexities of the healthcare systems.

WEB SITE:   www.healthcareconsumernavigatorcenter.com

Take a look and lets us know your comments and thoughts.

 

 

 

Did Your Health Insurance Company Deny Your Bill?

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I have experienced denied claims and they can be very frightening and frustrating. My first reaction was how is this possible when I pay for health insurance.  Most of us do not really know what our health insurance covers and what are the procedures to secure payment.  Hopefully, the following can help.

Health insurance companies deny healthcare bills for a variety of different reasons. Normally there is a legitimate reason for the denial.  The healthcare consumer should be prepared for such an event.  They occur more than you may think.  Healthcare providers receive the denials from the insurance company and automatically bill the consumer.  The consumer is now responsible financially for  the bill.  The following are common reasons bills are denied.

  1. Medically Unnecessary Services

The medically unnecessary denial is a denial that insurance companies use when a claim does not meet their medical criteria for payment. This can occur when your healthcare provider has improperly or did not fully document your medical service.

  1. Medical Service was not Pre-Authorized

Many healthcare services require the healthcare provider to obtain an authorization from the insurance company, prior to service, to obtain payment.  Healthcare providers sometimes miss obtaining a pre authorization.  If this occurs, the healthcare consumer can call the ordering doctor and healthcare provider to appeal the denied claim.  Most insurance companies will grant a retro pre authorization which means they approve the service after the service was rendered. .  If not, the healthcare provider should not bill you.

  1. Non-Covered Charges or Services

Some healthcare services can be excluded for payment as defined in your health insurance policy.  These excluded services are generally those not frequently used by the healthcare consumer or are very expensive procedures.  Before receiving or scheduling services, contact your insurance company to insure they are covered.

  1. Wrong Information on the Claim

Healthcare providers and insurance companies can make errors that will result in a denied claim.  Examples for these types of errors are:

  • Wrong Insurance Information
  • Wrong Patient Information
  • Transposed Information on the Claim
  • Wrong Information in the Insurances Companies Computer System

Anything can go wrong.  Be prepared to deal with these situations.

Insurance companies will send the healthcare consumer an Explanation Of Benefits (EOB) that will have specific codes explaining why a claim has been denied.  Take the time to understand the reason for the denial.  The reasons will lead you to the next steps in appealing the denials

The Healthcare Consumer Navigator Center has a step by step process  as to how to appeal denied claims.


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