Health Insurance and Patient Advocacy
Jimmy is a married 75-year-old, who is in the hospital. Lucy, his wife, is 73 and in relatively good health. Unfortunately, Jimmy has been in the hospital a lot this year. Jimmy is a “dually eligible individual” as defined by the Centers for Medicare and Medicaid Services (CMS), which means he is eligible for two types of government-offered insurance. In Jimmy’s case, it is Medicare and Medicaid. Jimmy receives a bill from the hospital that has been denied. Jimmy will benefit from patient advocacy.
Click Dually Eligible Individuals for more information on CMS’ Dual eligibility.
Introduction
This case study is common, and BRPS Consulting has received a few questions about individuals in this situation. As such, I decided this would be a great scenario to bring several BRPS services into one case study. Please feel free to use BRPS Consulting’s tools to get your financial and legal lives in order, or you can contact BRPS Consulting for assistance with some or all of the services described.
Jimmy and his wife should be considering the following:
Important Document Location and Organization
Jimmy is still cognitively healthy, so now is a great time to ensure that Jimmy and Lucy are prepared. Jimmy and Lucy could utilize my tool “What You Need to Organize” to inventory important information. This tool helps you inventory your professional contacts, personal contacts, online account information, and important document existence and their location. Some of those important documents include the documents described in my post Advance Directives.
Jimmy and Lucy should have a will, a living will, a health care proxy, a do-not-resuscitate order (DNR), if they want one, and a power of attorney (POA). Of these documents, a POA is the most urgent for Jimmy. If Jimmy’s cognitive ability becomes impaired, Lucy will not have the ability to sign on his behalf without a POA. BRPS recommends to its clients that they have a primary and a contingent POA.
BRPS’ Estate Planning / Review of Estate Planning Services helps clients document their wishes to populate these documents.
Release of Health Information
One document that I did not write about in the Advance Directive post is a release of health care information. Unfortunately, each insurance company has its own release of information. BRPS encourages everyone to give at least one trusted individual access to the insurance company’s information, as, without this consent, the insurance company is legally constrained from speaking with anyone other than the patient. I personally have a release of information with the insurance companies for my mother, mother-in-law, adult child, and husband. My husband and adult child have a release from me to see my records.
If I have not listed your insurance carrier, an online search of your insurance carrier’s webpage for “release of health information”, should show results for their form.
Jimmy and Lucy should download and fill out their respective insurance company releases of information. BRPS recommends that Lucy have access to Jimmy’s information and that Jimmy have access to Lucy’s information. In addition, BRPS recommends that a third trusted individual be appointed to have access to both Jimmy and Lucy’s information.
Health/Patient Advocacy
In my post on Are Your Medical Bills Keeping You Up At Night, I provide a link to. The Patient Advocate website provides assistance with understanding your rights as a patient, your diagnosis, procedures being recommended, alternatives, and helping with an appeal to your insurance carrier. In addition, it contains a myriad of resources that anyone can explore. As Jimmy has received a denial from his insurance company, BRPS would walk Jimmy and Lucy through the resource “Insurance Denials – How to Construct your Appealing.”
Patient Advocate free resources are limited, so if you are interested call 1-800-532-5274 to find out the available resources in your location. BRPS Consulting can assist with talking to your insurance company. Having worked in the health insurance industry, I bring a unique understanding of the U.S. Health Care System, to assist with an insurance denial. BRPS’ recommendation to anyone, including Jimmy, when they receive a denial is to call the insurance company to understand why the claim was denied. With this understanding, a solution often presents itself.
A patient advocate and/or BRPS Consulting can only talk to your insurance carrier if the insurance carrier has a valid release of information form on file.
Estate Planning / Review of Existing Estate Planning Documents
Estate planning is more than just drafting your advance directives. BRPS’ estate planning services help its clients detail their assets and liabilities and their income and expenses. After understanding its client’s financial position, BRPS will discuss the client’s wishes. Through a thorough understanding of its client’s wishes and financial position, BRPS can assist the client with at least the following:
- Assist with reconciling your wishes, goals, and needs by identifying the barriers and challenges that exist.
- Identify risks associated with your current financial and estate plans and offer solutions for mitigating those risks.
- Accessing available public services, some of which are detailed in the post “Do You Need Assistance.”
- Reviewing the client’s insurance coverages for adequacy, including property insurance, health insurance, life insurance, etc., and beneficiary designations for each.
- Review the client’s investment statements for age-appropriate investments, expense loads, and beneficiary designations, and assist in conversations with the client’s investment advisor(s).
- Reducing probate complexity and a client’s and/or their heir’s tax burden.
- Recommendations for asset distribution to heirs.
- Identifying updates to the client’s existing will and/or living will.
- Assisting in conversations with loved ones about your end-of-life choices.
- Helping to identify an appropriate health care proxy.
- Assisting with planning and pre-paying for funeral arrangements. I recently learned that there is now an advanced directive called a Disposition of Remains Appointment (DORA), where a client details their burial or cremation wishes.
Bill Paying Services
Finally, if a client finds that taking care of their loved one, themselves, their home, and the household expenses is too much, BRPS can pay your bills for you. Unlike many bill-paying services currently available, BRPS’ service includes a full reconciliation of each medical bill to the explanation of benefits provided by your insurance company. You should never pay a medical bill until you have verified that the amount billed agrees with the amount the insurance company indicates you owe. Errors are frequently made by both providers and the insurer; therefore, the recommendation is to reconcile the two sources.
CMS has a Social Security Payee Representative program where you can appoint anyone to manage your money. You do not need to appoint BRPS as your payee representative, but the rules behind this program are a gold standard. As such, BRPS bill-paying services are consistent with the CMS rules to ensure transparency.
Miscellaneous
Every time I talk to a client, a new service presents itself. Some services I cannot perform, such as drafting your will, care management, in-home care, helping locate housing, providing investment advice, etc., and in those situations, I have a qualified network to refer my clients to.
BRPS is confident that it can help all clients get their financial and legal lives in order through direct help or through referral.
Let’s find out how BRPS can help you!