What you don’t know about your insurance costs you…

Darn near every day I come across a situation where an insurance claim is denied by the insurance company in error.  Now a lot of hospitals just toss their hands in the air and go “Oh well, bill ‘em.” but at my office they have me to follow up.

Why is this important?  I also run across people whom we bill to get their attention who then either pay their bill or ignore it until we can no longer collect from their insurance company and they go to collections.  My mom and dad did that with many of their medical bills, not realizing they were screwing themselves out of money.  So here it is, the need to knows of your insurance and medical bills.

1) Don’t expect your doctor’s office or hospital to know if they are in your network. Every insurance company has many different plans.  Employers are able to pick and choose what is included in a plan, to a point.  Just because your buddy has United Health Care and sees Dr. Jones doesn’t mean your United Health Care covers the same doctor.

Doctors are also credentialed by where the services are covered.  So if you see Dr. Smith at 1234 Main St. Way and it’s covered doesn’t mean you can see him at 4321 Second Blvd. Ave.  He might not be credentialed there.

Most medical offices and hospitals do a verification of benefits but don’t count on them doing it or telling you if your out of network.  You have the right to see an out of network doctor, paying the full fees of course.  Call your insurance company before you make an appointment.  Make sure they know which doctor you are seeing and where.

2) Know your benefits. This is sort of like number 1 there but know if your insurance covers an epidural or that leg brace.  It may not.

3) Answer letters. A lot of insurance companies mail letters to their members on a regular basis.  Often times they are making sure you have no other insurance coverage or that you (or your child) is still in school if they are over the age of 18.  Answer them.  Call the customer service line and get a fax number then fax your response and keep that fax receipt showing it went though.  Until you answer them the hospital and doctor’s office can and will bill you the full amount of their service.  If you do not answer them in a timely manner they may deny the claim leaving you to foot the bill.

4) Get names and reference numbers. If you have to call your insurance to follow up on a claim get the person’s name and a reference number for your call.  If you need to follow up again you’ll have it.  Also, call the billing department and give them that information as well.

5) Ask the right questions. Ask when a claim was billed, what the CPT code was (that’s the code telling the insurance what the doctor is charging for).  Get the reasons for a denial.  Was an authorization missed?  Who was responsible to obtain that, you or the doctor’s office?  What information exactly are they missing?  Ask questions until you understand what they are telling you.

6) Don’t just take their word. The customer call center people are notorious for giving their members bad information like they don’t have a claim on file or that the doctor’s office or hospital messed up.  Call the billing department and find out why they were told a claim was denied.

7) Know how to read your EOB (Explanation of Benefits). Do you know what a contractual discount is?  What about a network discount?  What about a global code? If you don’t call your insurance company and have a rep go through an EOB with you.

8 ) It’s ok to take it to a higher power. Insurance company giving you the run around?  Or is it the billing office?  Don’t be afraid to enlist your doctor to help you.

9) You are the customer, to both parties. Your company (or your policy holder) and by extension you, is the insurance companies customer.  If you feel that you aren’t being helped by them call your HR rep and voice your opinion.  If enough people do this the company may shop elsewhere for better service.  Dirt cheap coverage isn’t any good if you still have to pay claims because they won’t when they should.

You are also the doctor’s customer.  While it can be daunting to argue or question  something with them don’t be afraid to ask them to clarify why you were charged for X, Y or Z.

10) Your doctor/hospital has a contract with your insurance company. This contract spells out what they can charge you for a service.  If you think your being charged for something they shouldn’t charge you for call your insurance company.  Honest mistakes are made by billing department/groups but if you don’t make a call or two to find out if you are supposed to pay something then the assumption is that you do if it goes to collections.

11) Keep your receipts. When you make a payment to an office, by check , credit card or cash, keep a receipt.  Payments can get lost but if the doctor’s office/hospital can’t find they payment it’s up to you to prove you’ve paid it.  If you can’t they will keep billing you.

12) Know about self-pay discounts. Sometimes a doctor isn’t in your plan, or something isn’t covered by your insurance (like a Chiropractor).  Ask them if they have a self-pay discount.  Generally it will be the average price of what an insurance company would pay for the service.

13 ) Know how to do a written appeal. Sometimes the doctor’s office/hospital just can’t help you fix a claim.  If that happens know how to do a written appeal.  Some things to keep in mind, know if your policy has a “reasonable person clause.”  Most policies have them.  What it means if is a reasonable person may think something could be an emergency (like having a headache of a 9 on the pain scale for 12 or more hours) then the quest for care or test was prudent.  If you appeal to that and have good showing to prove it then your claim will most likely be paid.  Remember let the billing people know you are appealing the claim.

When writing the appeal you should be to the point, not emotional and have names and dates.  If you called your insurance on the 14th and they told you Dr. Mike was in network, then your doctor’s office called and was also told that Dr. Mike was in network but it turns out that Dr. Mike isn’t in network but Dr. C. Mike is then you need to be able to show you put due diligence into avoiding an out of network claim.
Understand the appeal may still be denied but the doctor’s office/hospital will most likely give you a self-pay discount.  Ask them but keep in mind they are not under an obligation to not bill you until the issue is resolved, you will probably have to make payments until the insurance company pays.

My liver, the slut.

In the past month or so I’ve spend a good deal of time being sick.  Well since my gall badder in January.  The last month though, I’ve done the ungeekiest thing I could think of.  I’ve not wanted to sit at my computer and do anything.  Instead I find myself watching NCIS and House re-runs zoned out.  Why?  A lot of reasons.

Lately I’ve spent a lot of time wondering how my mother in law and my mother, who while my sister and  I were young was pretty much a single parent, did it.  How did they work full time and run a house.  Sure mom had dad but as Rosanne Connor once told Jackie “You want Dan.  You think he came outta the box that way?  I had to train him.”, meaning mom had to work for years getting dad to do basic stuff around the house.  How he kept his car was a better picture of how he’d have kept the house were it not for mom.  There is a story that is told from time to time about one of the times mom had dad’s car.  Carly and I had a friend along, Susan, so Carly and Susan were in the back seat and I was sitting in the back seat.  Carly opened a piece of Tupperware that was back there.  The smell that wafted from that tub that only moments before had been a harmless container to carry leftovers was so bad my mom pulled the car to the curb and demanded I throw it down a sewer drain.  My mom was neurotic about her Tupperware, it was never to be abused.  So the fact that whatever had been the remnants of dad’s lunch that fermented to a point where even my mother decided that it needed to be buried says a lot.

But I’ve spend time wondering how they did it.  Because by Thursday I’m pretty much held together by coffee and Diet Pepsi.  Once I stop with the caffeine I crash.  Not to mention my body hurts and I start to feel down and almost depressed when I look around and realize, if I don’t wash that dish or vacuum this floor no one else will.  There is no balance between spending time with your child, where years fly by, work and keeping a house clean enough you don’t feel the need to ask your guests to put on bio-hazard suits.  In every place something has to give.

Sometimes I just walk over the raisins and Cheerios’s that are now ground into the carpet.  A side note, when we moved here they were going to put new carpet it.  I requested they didn’t and put it into the lease that we were not responsible for damage.  In retrospect I think that was the smartest move I made.

Other times I let Kyle watch one more Backyardagains episode than I know in my heart he shouldn’t watch just so I can make dinner that is actually hot.

While sometimes at work I find myself making phone calls to my mother to make sure Kyle is no longer pukeing.

Everything gives somewhere.

In the last month Kyle has turned 1 year old.  I no longer have an infant.  The bucket car seat is retired and he watches the drive from the window where he can now see the other cars.  He walks, and babbles.  He’s begun to play a game where any ball he finds he gives to mommy.

He sleeps through the night and dances.  He shows his likes and dislikes and is learning how to manipulate mom and dad.  He’s still learning “no”.  To him it’s a game.  He finds joy in playing it too.  He’s had his first bout of a stomach bug, a few colds and his first cake.

In short, he’s him.  And I savor the cuddles he will give and the few kisses he’ll allow.  He’ll be 13 and won’t want me near him soon enough.

He was also sweet enough to give his stomach bug to mommy, who is done with vomiting until she’s 50 if she can help it.

Last Saturday I had an MRI called an MRCP done on my abdomen.  I’ve been having a lot of stomach pain and the END showed nothing so the GI doctor had me sent to have the MRI done and make sure a small stone wasn’t still lodged in my bile duct or that the bile duct wasn’t over producing and then putting too much bile into my stomach.  The good news was that they found nothing of that sort there.

It turns out, however; that my liver has been naughty.  I should have had them check that so much sooner, it is after all taken a lot of abuse over the years.  I thank O’Connor’s for that and the tequila.  The MRI showed a lesion of some kind on the slut of a liver.  Because the MRI wasn’t focused on that they have no real information other than something is there.  So April 17th I go in for another MRI, both with and without contrast and happy do not panic in the small tube drugs, of my liver to find out where it is and what it is.  Being the gal I am I did some Googling and found that in most cases these types of things are totally benign, so much so that doctors don’t even remove them if they are a tumor.  How, though, they will deal with the stabbing pain will be something that will need to be addressed.  In fact it could very well be a tumor caused by my birth control.  If that’s the case we’ll need to remove the IUD and see if there’s another option for us.  Aside from me charting again.  Or playing the “well you can’t get pregnant anyway game.”

Of course, my very Goth and gallows humor mind thinks, “Great all those years smoking and I die of   liver cancer not lung cancer, LIGHT ‘EM UP FOLKS!”

I realized yesterday that my birthday is hiding around the corner.  Honestly, I’m ambivalent about it.  I was last year too.  We’re broke, in fact everyone is.  It’s a Thursday and it’s only 31.  And most of my friends forget.  Last year, in a fit of pettiness, I remembered a friends birthday but refused to send him birthday greetings. In 3 years of friendship he’s never remembered mine once.  Of course I found out later from him that over all it was one of the shittiest birthday’s he’d had and my guilt gland kicked in and I apologized and then he apologized because he realized that, yeah in 3 years of me remembering he’d never even asked when I always remembered his.  So then it became an I’m sorry match.  I think it’s still going on.

So that’s life.  A little tired, a little pain, some I’m sorries and a few laughs.

Thanks again Sara for the post title.

There is proof

Got Shards?

Yeah, he’s got another one that says I cry because mommy plays WoW.  BTW, I’ve got an official level 80 now.  So I’m a real WoWer again.  Not just pretend.

Over all things are ok now.  Sadly Friday I have to go and have a tube shoved down my throat to check out my stomach.  Seems that chewing through Pepcid AC and Tums isn’t normal.  Who knew?  I have another test for next month too.

Kyle has found a new playmate!  Liam, Branden and Holly’s 3 year old.  Liam wasn’t really all that into other kids before.  But what can I say, the friendship is in the blood.  By day two Liam was handing Kyle his cars.  The ones that no one else touches to play with.  So Saturday they are going to come over for a play date.  And Holly is going to do some laundry.  Seems we moved from Quail at the right time.   By this point they hardly have heat at any time, the pool is always gross, they’ve been through 4 managers since me and in their building one washer and one dryer works.  Chris is now running for the hills too.  Good news for us ’cause we’re the hills and we get a rent credit for his lease.

Work is well.  I’m working with Sara more and most of my appeals get approved without too much issue.  At some time I may even get a raise.  Though from what I hear those things are hard to come by.

I’ve also impressed our tech support.  The clinic had to buy Sara a new computer so I called R up and told him we needed to point it to the server and get the key to the software.  Less than half way through the conversation he figured out while I may not always know an answer he didn’t have to spell things out to me.  Today he didn’t even think when I was setting up a shared printer when he asked if my PC had a static IP address.  And he didn’t blink when I told him yeah and what it was.

Problem is when I get him on the phone it ends up a long conversation.  He likes having someone to talk to on the other side of the phone who isn’t asking him “Ok what is an IP?”  And I freely admit to him my knowledge is limited and I’ll call him before I try and screw with it myself but now that he showed me that I can do it again on my own.

Of course today we got into the geek girls vs. the geek male ratio and he did accuse me of liking the attention.  My only response was to admit that, yeah, to some degree I did.  Why the hell else would I wear a tight pink tee shirt with the words “Talk Nerdy To Me” across my chest to a convention?  I didn’t tell him that part though.  I just agreed with him that it is rather nice for the ego.

I’m happy in my marriage, Jason is too.  But it is nice to know that you are still attractive to people who haven’t seen you vomit or with tissue stuffed up your nose.

That’s, sadly, about it for now.  Kyle will be one in less than a month.  Where did the last year go?

The photos please

The painful place

Well there you go.  Those are the war wounds.  It’s much easier to get around today but I have to admit I’m still easily tired out.  Jason went to work this morning and my wonderful mother in law picked Kyle up at 10am.  So between 8am and 10am I ran around after him.  I must say, you get creative when you have limitations.

I’m going to unplug and rotate the XBox because Kyle enjoys turning it on and opening the disk drive.  Then he likes to push on said disk drive.  This could be a bad, bad thing.  It won’t stop him forever but it should slow him down for a bit.

Ms. Lucky

So around 1:30 am on Tuesday morning I awoke in a crap ton of pain.  I got up walked around, tried to get into different positions and took some meds for my tummy.  By 4 am I told Jason we might want to call 911.

Long story short, I’m thankful for my grandmother, my parents, my mother in law and Karl and Stephanie because each one of them dropped what they were doing and helped get things in order for me to have my gall bladder removed on an emergency basis.

EMS took me to West Allis Memorial and when they called my regular doc who’s out of Waukesha Memorial she started laughing and told them if I was asking for morphine then I was in a ton of pain because she normally has a hard time making me take anything more than Tylenol.

West Allis was great but I opted to go to Waukesha to have the surgery for the continuity of my medical care and because Dr. Sukoway would be able to see me there if there had been complications while she couldn’t have at West Allis.

In both hospitals I had great staff from the nurses to the docs to the people who registered me.  If I can say it without sounding odd, it was actually a pleasant experience.  My grandma and I had a great visit, my mom and dad were extremely helpful getting me set up and ready to leave.

My surgon had told me before I went under to expect to stay the night given the time but then told the staff if I felt well enough I could opt to go home.  I actually felt pretty good, was able to get out of bed on my own, peed right away and sat well in a chair so I went home.

I’m still taking my pain meds and I can’t wait until 7 when I can shower.

And again, I’m lucky because I’ve got a whole group of people who are really going out of their ways to help me since I can’t pick Kyle up.  Or stand long.  Or drive.  I’m hoping to be off the pain meds by Friday and back to work but I’ll use my judgment.  I’ve already talked to Dr. Suk and she said if I felt I was ready to go back but the surgeon was nervous she’d release me.  But again, I’m going to take it day by day.  If I’m still having problems sitting up for long periods of time or still needing the narcotics I won’t push it.  But I think by now we all know me.  My idea of ok and another persons are two things.

In fact the surgeon did say the gall bladder was pretty bad by the time he got it out and was surprised I hadn’t been in more pain or had had it done sooner.

The Lord, He has placed wonderful people in my life.

The answer is fleece

I’m going to start this off and say there will be people who’ll read this and think very bad thoughts about me.  But the answer to Kyle and sleep is fleece.  As in a fleece blanket in his crib.  *gasp* *shock* /faint.

Friday as I tried to get him to sleep I sat next to his crib in my rocking chair in my robe, my fluffy robe.  After a bit of screaming he started to reach for the sleeve.  I thought he was reaching for my hand so I’d give that to him.  He’d play with it for a bit but then go back to my robe.

On Saturday morning when he woke at 4am I didn’t have my robe on.  And he didn’t sleep.

Saturday afternoon my mother tried to get him to nap and it was a fight.  But she got him down eventually.  No fleece.

Sunday evening Kat gave me a fleece blanket and as I sat next to his bed I put it over me.  He kept reaching for it over and over and mommy got a bright idea.  I put the corner of the blanket in between the bars of his crib.  Like I’d given him the most bestest thing in the world he rubbed his face against it and put his thumb in his mouth happily.  So I ran and grabbed one of his fleece receiving blankets and put that in there.

Like a moth to a flame he grabbed it and rubbed his face and sucked his thumb and was out in 10 minutes.  He never work up.  Ok, well he did but that was because he was stuck.  But after that not a peep until 8am.

Tonight I put him in his crib, he grabbed the blanket and found his sweet spot.  Not one cry, not one peep, not one moment of fussing.  15 minutes.

The moral of the story?  Saftey is so very important with our children.  I’m pretty vigilant about it with him but if a fleece blanket he wants to curl around and rub his cheek on will get him to sleep happily through the night I’m not going to argue.

Oh, as for my test today, the tech, of course, couldn’t tell me what she saw.  I should know tomorrow if it’s the gall bladder.  Until then I get to be on the happy cocktail of antibiotics again for the Colitis that reared it’s ugly head over the weekend.  My doctor did make it clear I had to go get the wonderful and way not uncomfortable scope up the butt test done and like, last week.

Told you

The day after Thanksgiving I got sick.  Now, those of you who know me outside of the computer world know that I am a very modest person who chooses not to discuss the intimate workings of her body with others.  Bear that in mind as you read this.

So, I got sick.  No stomach ache, no fever, no headaches but I had diarrhea.  The first couple of days I just dealt with it, it was a long holiday weekend, my niece Chye was here so she could lend me a hand with Kyle and it was just more gross than worry some.  By day 5 I started to worry.  A new twist had been added, periodically vomiting with no warning before hand.  It was like pregnancy all over again complete with getting up several times during the night to go to the bathroom except I wasn’t pregnant.

At day 7 I contacted my doctor who said it was the stomach flu, stay on liquids.  The back of my mind kept telling me that this wasn’t that simple but I stayed home from the Shewrin Christmas party and rested.  But my parents were starting to worry and my mom insisted I let my dad take me to urgent care who told me it wasn’t the flu but run of the mill diarrhea.  Gee, I didn’t know that but thanks for billing my insurance!

Saturday night I melted down and Jason got me a cheeseburger.  Oh it was so good.  I had been a week of living on Sprite, Gatroaid, Mrs. Grass noodle soup and other such bland offerings.  It was worth the pain, oh so worth it.

Yesterday at work I vomited again, only this time there was a tinge of blood in it.  Officially freaked out and in increasing amounts of pain I went to the ER.  Props to my nurse, Guy, who was able to get the IV started in one go and milked the vein for just enough blood for all the tests they had to run.  It wasn’t pretty but my hand isn’t bruised, the IV worked and it didn’t take 13 sticks to do it.  When I told him I was a hard stick he said he’d figured that because he had already been scoping out my veins as we were talking.  I really need to call the hospital and tell them what a great nurse he was.

The PA came in, ordered a cocktail of drugs for pain, nausea and to generally settle my stomach and ordered a CT scan of my stomach and pelvis.  He agreed that 13 days of this was probably something more than the run of the mill bug.  Come to think of it he was really good too.  Shook my hand, smiled, listened and looked me in the eye.  You know the way the run ER’s has changed a good deal.  Now they have separate rooms for each person, the ones at Waukesha have attached bathrooms for your privacy.  Instead of filling out tons of forms at check in they have a rolling cart that a person brings to you for your insurance and personal info.  And in this day of computers if you are already in their data base they can just confirm nothing has changed and move on.  I really need to call them.

4 hours, three blankets (one heated), and half a bag of fluids later the PA came back and told me I was right it was more than a bug.  Colitis.  A pretty nasty case of it too and he was surprised I’d not been in sooner.  Now I’m on a fun group of 4 drugs including 500mg of Cipro.  That means it’s another year of no Christmas wine for me.

All in all I’m lucky that I listened to that little voice in my head. When I got home I googled and found that bad cases often result in surgery or major infections.  I’m also lucky that Jason is the guy he is and that Kyle is the baby he is.  Little man slept until 8:30 this morning.  He’s never, ever done that.  Jason got up with him and has been letting me lay in bed and rest.  He’s at Target right now starting some of the grocery shopping and picking up more Dana friendly foods.

I’m going to go blow dry my hair and crawl under my electric blanket until it’s time to go see the Dr.