advocate

Where do we go from here? Discharge planning after your senior parent’s ER visit

After all of the tests and waiting and treatments are completed, it is time to decide what the next steps are for your Mom or Dad. Here are some possible scenarios.

Scenario 1: The doctor wants your father to stay in the hospital

Ø The first question is … Why?

If it is for a blood test or x-ray that is needed tomorrow, can it be arranged and completed on an outpatient basis?
If it is because he should not be alone for the first 24 hours, can your dad go home with you or can you stay with him?
Does he live in an assisted living facility where you can arrange some nursing care and monitoring?
Can he be sent home with in-home supports you can arrange, such as private home health aides?

Ø The second question is … Will he be admitted or placed in an observation bed?

Keeping your father in the hospital does not necessarily mean that he is going to be admitted!
If the doctor is planning to place your father in an observation bed that means that:

– MEDICARE WILL NOT PAY FOR ANY OF THE HOSPITAL BILLS INCURRED ONCE THE ER TREATMENT IS COMPLETED, AND

– IF YOUR FATHER HAS TO BE TRANSFERRED TO A SKILLED NURSING FACILITY FROM THE HOSPITAL FOR REHABILITATION WITHOUT BEING ADMITTED, MEDICARE WILL NOT PAY FOR ANY OF THE BILLS FROM THE REHAB FACILITY.

If the doctor is planning to admit your father to the hospital, that means that Medicare will most likely pay for his hospital bills, as long as it is a medically necessary admission.

Scenario 2: The doctor wants to discharge your mother

Ø Where will your mother go?

If she lives alone in an apartment or house

– Does she need someone to be with her for a day, a week, or longer?

– Does she have stairs to get to her bedroom or bathroom that are now an obstacle?

If she lives in an assisted living facility, do you need to contact them for added services and supports to be in place before she returns home?

– Can they have these supports available to her immediately upon her return, or does it take some time for them to arrange theses?

Before your parent leaves the ER

Regardless of where your parent will be going, there are several issues you need to discuss with the doctor before your parent leaves the ER.

Need assistance? Wondering what the right thing to do is? Give us a call!

In good health,

The Health Champion Team

Medicare – Enrollment

“Now What” Series

At Health Champion, we hear the phrase “Now What?” from our clients so often, we have decided to create a series of “Now What” blogs.

We hope that these posts will provide you the insight and advice you need to become a successful health care consumer.

Our first “Now What” blog pertains to the following scenario:

You are turning 65, still working and plan on continuing to work. Now what should you do about Medicare, if anything?

If you have health benefits from your employer and you are continuing to work, you should sign up for Medicare Part A. You should also speak to your human resources department to determine whether or not to sign up for Medicare Part B. If you decide to enroll in Medicare Part B, then the question is, which of your insurances is the primary payer of your health care? In general, the size of the employer group determines who is primary payer for “the working aged”. (Could we please replace that phrase with something like “HIP Older Person?). Ask your human resources department who your primary payer is.

If you have worked 40 or more quarters you are eligible for Medicare Part A when you turn 65. Medicare Part A covers inpatient hospitalizations, skilled nursing, home health and hospice care and some selected outpatient services. If you have worked the 40 or more quarters there is no cost for Medicare Part A. Most individuals who are receiving Social Security will be automatically be enrolled in Medicare Part A – on the first day of the month you turn 65. If you are not receiving Social Security at age 65, you are still eligible for Medicare, but you will have to enroll yourself by contacting Social Security.

Medicare Part B, which covers physician costs among other types of services, is an option that you must elect. You should enroll in Part B 3 months before the month you turn 65, but can also enroll the month you turn 65 and 3 months after your 65 birthday. You do that by contacting your local Social Security office or on the Social Security website.

If you chose to continue to work past your 65^th birthday, and you are receiving employer sponsored health insurance, you can defer your enrollment into both Parts A and Part B. When your employer coverage ends, you can elect Part A and enroll in Part B. This is called a “special enrollment period.” The 8-month “special enrollment period” begins the month after the employment ends or the group health plan coverage ends, whichever happens first.

A word of caution, if you fail to take advantage of the special enrollment period, you risk paying a penalty later. www.medicare.gov is good resource for general overview of enrollment periods.

For more information go to:

Medicare: www.medicare.gov

Social Security Administration: 1-800-772-1213 or www.ssa.gov.

Your friend at Health Champion,

Ida

Choosing Your Health Care Advocate

Going it alone is NEVER the best choice when it comes to health care. Especially if you have time-sensitive treatments, a complicated diagnosis, or insurance issues to consider. When you need someone on your side — supporting your well-being, getting medical appointments, managing treatments plans or fighting for your benefit rights — you need a health advocate.

A relatively new response to today’s complicated health care system, health advocacy is considered a critical service by CNN and other news sources. Knowing when to hire an advocate, and how to choose one that’s right for you, is key to a successful outcome.

What’s the Problem?

Define your needs before looking for someone to help resolve issues. For example:

Do you need someone to oversee care being provided to yourself or a loved one?
Are your needs related to developing a plan of care for a particular diagnosis?
Is it an insurance issue? Are your benefits being denied?
Do you need help researching the latest technologies and treatments for a disease?
Are you worried about mom and dad living alone?
Will you need the advocate to be onsite at a hospital or facility?

Locating a Private Advocate

An internet search, using the key words “health care advocate” will direct you to advocate websites. Review their areas of expertise; narrow your choices and examine how their services meet your defined needs. Ask for referrals from friends, family members and physicians (use the terminology “case manager”).

Consider the Fit

Like physicians and health problems, advocates come in all shapes and sizes. Some have a “take charge” style” others are more laid back. Finding the right fit is critical. Things to consider:

Have they helped clients with similar issues?
If so, what do they consider a successful outcome?
How many client cases do they work on at the same time?
Do they have a resource network?
How easily can you reach them during the week? Off hours? Holidays?
How do they keep clients apprised of progress?
How does the advocate charge for services: hourly or set rate?

Health advocacy is typically private pay, with fees ranging from $100 – $200/hour. The right advocate will guide you through the health care maze and so that you get the benefits and treatments you need when you need them. And that’s priceless.

Is this an Emergency?

There are times when you know it’s an emergency and you’re off to the ER. You don’t fool around with chest pains, for instance (no taking chances that it’s just indigestion). Ditto for broken bones and deep cuts.

But what about those other times? You know them: the sense that something’s wrong, but you’re not sure how bad it really is. it always seems to happen over a weekend or during the evening, when the doctor’s office is closed. Waiting doesn’t feel right, but neither does rushing to the emergency room.

Call your doctor. Most physicians have an answering service for this purpose. Offer the following:

Your full name; that you’re a current patient, in active treatment.
The best way to reach you (provide both cell number and land line).
The reason for your call, emphasizing that, while it doesn’t seem like an emergency, it’s a matter of serious concern that can’t wait for office hours. Don’t be too explicit, as most folks who take messages have little clinical experience. Use phrases, such as:
- My new medication is making me ill
- I am experiencing several new symptoms
- My pain has increased over the last (number of) hours and I need to discuss a different approach

Find out who’s on call. Ask the service to contact the doctor on your behalf rather than waiting for him/her to call in for messages. Note the time of your call and ask to be called back after the service relays your concerns. This will give you a time frame and help relieve anxiety.

Don’t ever hesitate to seek help. Even over a weekend. Even when you’re not sure whether or not it’s an emergency.

Renewing Your Individual Health Plan Policy

Do you carry your own health insurance policy?

Is it time to renew?

If so, don’t do it blindly. And don’t take anything for granted.

Before signing on the dotted line or sending in that premium, you need to know what, if any, policy changes will take place in the coming year. Specifically, check for the following:

Provider networks & physicians: have hospitals been removed from the list of participating facilities; is your doctor still in the network?
Co-pays: will you have higher coinsurance or deductibles?
Benefits: check for benefits that are important to you, whether it’s mental health coverage, physical therapy or visits to specialists. What’s changed? Can you live with the changes?
Pharmacy Benefits: what drugs have been added or changed tiers? Will you be paying more for your meds?
Lifetime maximums: If you’ve been in the plan for awhile, are you hitting up against lifetime maximums? Often your expenses against lifetime maximums are not easily discerned from the Explanation of Benefits you receive when a claim is paid. Find out how much you have used and what’s left for specific services. Better to know upfront than find out too late you’ve had treatments that are no longer covered.

Buyer be aware. You may be glad just to have the coverage and assume that year after year changes will be minimal. Caveat Emptor – that isn’t always the case.

And if you’re having trouble figuring out your coverage, call your plan’s representative; be persistent or turn to a specialist who can help you understand your benefits.

Where’s Common Sense When You Need It?

We’re offering a friendly challenge to the CEO’s of all health plans: leave your corner office and walk a mile in the shoes of people covered by your plan. What do you see? What touches your heart? What are you doing right? And what needs fixing? Notice a common theme in your walkabout: a lack of plain old common sense.

Here’s a case-in-point from an experience with Oxford, as we attempted to help our client through the health care maze. She engaged our services, signed a HIPAA form, as well as a form authorizing Health Champion as her representative. Because many health plans have their own authorization forms (wouldn’t standardization be in everyone’s best interests?), we immediately contacted Oxford. Here’s what ensued in our dealings with customer service:

O: Reading from the computer screen (no thinking necessary!): the completed form must be mailed to Oxford at their Bridgeport, CT address.

HC: Our client needs immediate help. Can we scan the signed form and email it?

O: No.

HC: Can we fax it?

O: No.

HC: If we overnight it, how long before the information becomes available to customer service reps?

O: About a month.

HC: Is there someway to move this along?

O: Nope.

HC: Our client needs help now. Isn’t there something we can do?

O: Well, you could get her on the phone with you, call in together so that she gives permission for the rep to answer your questions.

And you didn’t tell us that upfront?

We did just that. Our list of questions was long and the customer service rep was ill prepared to answer them, frequently placing us on hold to check with someone or something (a manual?). We reached the end of a long business day and our client was fading (remember, she’s dealing with health issues).

HC: Let’s finish this tomorrow. Can you note in the system that we received permission to speak to Oxford; can we continue the call in the morning without having to get our client back on the phone?

O: No.

HC: Why not?

O: We can’t do that. We are only allowed to get verbal approval for one call.

HC: But the call isn’t finished.

O: Sorry we can’t do that. The federal law, HIPAA, prevents us from doing that.

Since when? (When in doubt, quote the federal law, even if you’re wrong!) Now, there’s common sense in play!

CEO’s: are you paying attention? While health and clinical services are critical to accreditation from the National Committee on Quality Assurance, we suggest that, a common sense standard is just as critical.

Your thoughts? Post your experiences, comments and insights.

Read Your Plan Documents

How was I to know that my health plan didn’t cover this?…

With over 25 years each working within the health care system, you can only imagine how many times we at Health Champion have heard this question. Whether receiving a unique or experimental treatment, seeking care from a state-of-the art facility, or simply seeing a doctor who happens to be outside of your health plan’s network, you can easily find yourself in a frustrating and expensive situation if you don’t know what your health plan covers.

Health insurance is a valuable benefit especially in today’s times. Unfortunately, too many people really don’t know much about their plan and don’t seek to learn about their coverage until they are in the midst of a crisis.

Fortunately, there are numerous resources available to health plan members. Health plans go to great length to provide information to their members. Benefit summaries, membership agreements and other coverage documents are typically available in hard copy or on-line. Members can contact their health plan’s customer service line or refer to the plan web site to learn how to access this information.

Health plan members should review their coverage and make certain they understand how their health plan works. And most importantly, Health Champion strongly encourages members to review their health plan before seeking care and whenever they have a question about whether a service is covered.

Prior to seeking treatment ask yourself, “Am I 100% certain these services are covered by my health plan?” If not, reach for your membership documents or call customer service! Many employer plan years begin in January. Now is a great time to review your health coverage!

We’re New And We’re Here to Stay

“You’re a WHAT? And you do WHAT?”

It’s a typical a response from physicians who haven’t scanned the forest of health care lately to see there’s a new animal in their midst. That animal goes by the general name of “health care advocate” and the specific name of Health Champion. Our general nature is to help, guide and support individuals lost in the maze of decisions, diagnosis and insurance benefits.

Here’s an example —

The Call: We were recently retained by a family to help navigate their sister’s s journey through multiple myeloma. They called as she was recovering from surgery, having experienced the disease’s wrath in the form of bony metastases.

The Need: On a very basic level, they were seeking clarity about their sister’s condition, needing a greater understanding from the surgeon and oncologist regarding prognosis and overall treatment plan.

The Approach: We quickly established contact with their sister’s medical providers, providing each office with signed HIPAA and Representative forms, so that physicians could speak freely with us. The goal was to collect information from the various sources and then connect the dots for our client, explaining complicated information in a clear, accessible manner.

The Result: Our client and her family felt fully informed and, thereby, empowered to make smart decisions regarding the recommended treatment plan.

The Response: Because we’re newcomers, medical colleagues are often surprised by our presence. Who are we . . .where did we come from . . . what’s our intention? But, seeing that we come in peace, they’re collaborative, professional and open to the concept of advocacy. And then there are those few defensive physicians, wary of our intentions, certain our goal is to undermine and undercut, to add an unneeded layer to an already complex system. That is so not so!

They’re right about one thing: The health care system is definitely layered and complex. It’s fragmented, confusing and overwhelming. It isn’t easy being a physician in today’s insurance-based model. And it’s not easy being a patient or consumer. That’s exactly why we exist.

Our role is to support our clients and their health care team by closing gaps in communication and planning, by explaining and reinforcing the difficult messages they have may have been told, but didn’t understand, and were too embarrassed to ask for clarification.

While health care reform may be upon us, it isn’t going to fix the very things that health care advocates are hired to do. We’re on the scene, and we’re here to stay.

If you have your health….

A co-worker recently shared this story: “My mother is 84 and incredibly robust. Ever since I can remember, she’s had this one refrain: ‘If you have your health you have everything.’ Growing up, I figured this was merely a sentiment, designed to distract me from wanting all the material things they couldn’t afford. In fact, I couldn’t really internalize the value of that statement until I hit my 40’s (ah, the joys of middle age!). Now I get it.”

Listen closely to people edging toward the other side of middle age, or those challenged by illness or disability, and you’ll see a shift in values; they’re talking more about the state of their health than the status of their portfolio. They understand that things are just things. But if you have your health, you have everything.

As health care advocates, we’re reminded daily of how important our health truly is. In fact, it’s our greatest asset. Take care of it like you would your life savings: Invest in it. Manage it. Pay attention to it. Like your nest egg, once it’s gone, it’s not easily replaced.

As we look ahead to 2010, we hope the year brings you the blessings of good health. Happy New Year.

Advocating For Your Needs

Whether you’re trying to get through the health care maze on your own, or need to engage the services of a health advocacy group, such as Health Champion, one thing is certain: you need unbiased, credible, up-to-date information. That’s what you’ll find here.

Through this blog, our goal is to help you become an empowered health-care consumer. And, because we’re a private advocacy company — without ties to government or insurance companies — beholden to no one — you can count on us to be in your corner. We commit ourselves to honesty and integrity. We’ll share what we know, offer our opinions, help you find answers, and give you information you won’t easily find elsewhere.

Over the past few years, there has been a growing need for health advocacy, giving people somewhere to turn . . . someone who will support and promote their rights within the health care system. Health Champion is answering that call.

We’re a young company with passion and experience; all of our established health care professionals are dedicated to helping people navigate today’s complex system, finding the answers they need when they need them. We work with individuals and families on a variety of levels, privately or through their employer.

We’re excited about starting this blog, a natural extension of our commitment and outreach to health care consumers. Look for a new post every Wednesday, where we’ll write about everything from health care reform to making wise medical choices to getting the most from your benefit plan. Be prepared for topics such as Ten Stupid Things in Health Care Today, Shopping for Colonoscopies, and What Reform Will Mean to You.

We welcome your comments and look forward to a lively exchange in the months ahead

Health Champion Blog

"In Your Corner"

Where do we go from here? Discharge planning after your senior parent’s ER visit

Medicare – Enrollment

Choosing Your Health Care Advocate

Is this an Emergency?

Renewing Your Individual Health Plan Policy

Where’s Common Sense When You Need It?

Read Your Plan Documents

We’re New And We’re Here to Stay

If you have your health….

Advocating For Your Needs

Welcome to the Health Champion Blog

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