When Claims don't get paid

I'm getting ready to send out another cycle of billing statements, which means I'm going to get a few phone calls from patients who are anxious to know why their insurance didn't pay for something that they think it should've. Let me tell you what we do when a claim is denied:

• If it's denied because the service is supposedly not covered under the patient's policy, and I see that they've had similar services covered previously, I always call the insurance company. Often this straightens things out, and the claim is "reconsidered." This can take up to 6 weeks, believe it or not. If it turns out that whatever it is isn't covered, the patient gets billed.
• If the service is denied because the patient has received the service within a period too short to be covered (ie, a complete physical within 2 years when the policy only covers one every 3 years), we have to bill the patient for the service. It's the patient's responsibility to know what their insurance plan covers.
• Sometimes a claim is denied because the patient is no longer covered by that insurer. I always check this online - almost every insurer has a website where providers can at least check eligibility. If I get the information that the patient's insurance has been terminated before the "date of service," I attempt to call the patient to get their new insurance information. If they don't have any coverage, or they never return my call, we bill the patient for the visit.
• Insurers are very wary about whether an office visit covered a "Pre-existing condition." This refers to a health condition that existed before you started coverage with them. Often we are required to send your medical records to the insurer so they can investigate it further. This can hold up your claim for literally months, and then, it can be denied. We have no choice but to bill you for this visit.
• Sometimes a claim is denied because we made a mistake. Read this article (which prompted this post, by the way) and you'll see some of the coding errors that can happen. In our office, Dr. Nelson and Dr. Hahn code their own office visits in what we call an "encounter". In order for an encounter to be sent as a claim to your insurance company, they translate their visit notes into CPT (Current Procedural Technology) codes describing what they did during the visit that are linked to ICD (International Statistical Classifications of Diseases) codes that indicate what conditions they were treating. If these don't make sense when they're linked on a claim, it's rejected. Sometimes a CPT code hat's not appropriate for a patient might be used by mistake-- maybe they used a CPT for a preventive visit for a 12-17 year old when they were actually seeing an 18-year old. Usually this is a simple mistake on the provider's part. We fix it, send it back, and it's paid. This, too, can take 6 weeks for the insurer to correct.

There are other things that can happen, too. It comes down to this. It's the patient's responsibility to know whether or not they have insurance, and what is covered. When you check in at our office, you are asked "Has your insurance changed? Have you received a new card?" Before coming in to any doctor's office, you should make sure you're covered for what you're going in for, especially if it's a new office, or something you haven't had done before. It's also your responsibility to review the Explanation of Benefits that the insurance company sends you following any visit where you used your insurance. If there's something on there that you don't understand, you can call them and they should explain it to you. And it's our responsibility to send in correct claims, and to follow up with those that don't make it through for whatever reason. 

If you get a bill from us that you don't understand, we will always discuss it with you. We keep copies of the Explanation of Benefits that we receive when your claim gets paid, and we can help explain those to you as well if you're having trouble understanding why an insurer didn't cover something. We know how confusing it can all be.

Hot Fun in the Summertime

Ah Summer! Look at the jewel-like rows of gorgeous fruits and vegetables at the Farmers Market. Even the produce in the grocery store looks better than ever. But what happens if you just don't feel like cooking? It's too hot. You're too busy having fun. Unexpected company drops by and you'd rather chat than be stuck in the kitchen. It's too hot to eat! I know all the excuses! Well, here are some ideas to get you out of the kitchen while maintaining a healthy diet.
Look in your garden and pick the biggest, juiciest tomatoes you can find. Surely you've planted some basil along-side? Cook some couscous, and then while it's cooling a bit, cut the tomatoes into cubes and slice the basil very thinly. You can mince some garlic too. If you have some fresh mozzarella, cut it into small cubes and let it join the party you have when you toss it all together. Here's a recipe if you're feeling unsure.  You could also use orzo or even regular pasta if you didn't have couscous.

Or, take those same tomatoes, garlic and basil and chop them all together. Slice your fresh mozzarella, and then slice some french bread very thinly. Toast the slices until just golden brown, and then heap the tomato mixture and fresh mozzarella on top. Instant bruschetta! You can also broil it for a moment to melt the mozzarella if you like. I could personally live on bruschetta all summer if I had to. Unless, of course, gazpacho were an option.

Gazpacho is a family favorite.  In case you've never had this chilled soup, it's basically a tomato broth with lots of finely chopped vegetables. I usually take 2 cups or so of tomato juice, blend in a handful of cucumber, red pepper, small amount of onion and garlic, a teaspoon or so of balsamic vinegar, some olive oil, and whirl it in the blender until I've created a delicious broth. Then, I add chopped cucumbers, any kind of peppers, tomatoes, oregano, until it looks and tastes good. If I'm short on time, I stick in the freezer for 30 or so minutes; better still is letting it sit in the refrigerator for a few hours so the flavors can all blend. If you're new to making gazpacho, or feel like you need a recipe, either google "Gazpacho" or look at Cooking Light's offerings. The fact that you'll get practically all your daily requirements from this wonderful soup is just a bonus to the wonderful taste.

What's your favorite hot weather recipe?

This Just In: US Life Expectancy Lags Far Behind

I wasn't surprised to read this article on WebMD last week about a study that shows that life expectancies in most U.S. counties are lagging far behind other countries. I understand the four reasons given that we're behind Spain, Norway, France, and Canada to name just 4 of the 36 countries that have a higher life expectancy than men and women in the United States: Income and education, access to healthcare, quality of healthcare, and preventable risk factors.


After I finished obsessing over the amazing animated map that shows, among other things, that in 2007, Morgan County WV men on average can expect to live to 74.1, and that Slovenia and Oman have better life expectancies than that, I decided to read the PDF of the study for more detail. I browsed through, reading that the geographic disparities in life expectancies vary more in the US than in Canada (which has a lot more wilderness than the US), more than 85% of US counties have fallen behind instead of catching up or doing better than other countries between 2000 and 2007, and despite all this, we outspend every country on healthcare. I finally reached the end where I read the sobering words "Given the poor performance of the US on health outcomes, a performance that is worsening each year, it is time for new thinking targeted to where the biggest impact can be made on health outcomes." Well, duh!


Preventable risk factors, according to the study summarized in the article, is the number one reason we are so behind. Smoking and obesity are the biggest risk factors that could prevent chronic illnesses such as diabetes, cancer, and heart disease. Other countries are doing much more than we are to encourage their citizens to give up bad habits, sometimes to the point of enforcing good health habits. For example, when obesity rates in France started to climb, the French passed laws that prohibited the sale of junk food in their schools, levied a tax on food companies that didn't  encourage healthy eating, and banned misleading food advertising. French politicians considered the obesity rate to be so critical that they got local communities to govern their overweight and obesity levels in a program called Epode (this is a translated page, so excuse some of the awkward language!). Epode, from what I can gather, made everyone in a community a stakeholder in their fight against obesity. Leaders were held responsible for their community's progress. Allowing communities to direct their own program also allowed for cultural differences, so there was no directed format from the national government. Obesity was lowered by 25% in some communities in the 6 years the program's been running, and is considered a success.


The fact that we are finally putting really scary warnings on cigarettes makes me hopeful that perhaps our health leaders are paying attention. I hope states will go further and jack up the tax on these cancer sticks. And the next time I see one of those ads decrying possible taxes levied on soda, I just might write a letter to Congress encouraging them to do so. The woman in this ad insinuates that the government is telling us how to eat and drink with taxes. Americans Against Food Taxes, the organization that paid for the ad, is made up of all my love-to-hates: Burger King, Coca-Cola, Domino's Pizza, Wendy's.... who of course don't want you to spend your dollars on healthy food! Why these companies don't start offering more healthy food, with the unhealthy stuff as a minority of the menu, only makes me think they really are the devil that's trying to fatten us up so we can sizzle better in Hell in the name of "the gov'munt can't tell me what to eat!"


Realizing that most citizens are against government intervention makes me realize, sadly, that we have become a country that really does not care about each other. Being healthy doesn't just benefit the individual. Being a healthy individual has a profound ripple effect. Remember that elementary school teacher that missed more than half a year because she was sick all the time? Remember how miserable your kid was when substitute after substitute was marched in to  babysit the kids? And what about the cost of taking care those patients chronically ill with a preventable illness? According to the study, the US outspends every single country in healthcare. I'm sure we can all think of someone in our community who smoked themselves into the lung cancer ward, or lives on oxygen. Or needs a scooter because they're too obese to manage the supermarket aisles. Who do you think is paying for that? It's us, folks. Us. Our tax dollars pay for Medicare and Medicaid; our health insurance premiums go up with the cost of healthcare. I'm not saying we should begrudge these victims their healthcare. I'm saying let's have fewer victims. We should be throwing some of that money into prevention, and enacting some real regulations that prevent poor health.


Healthcare providers can only do so much. You can lead a horse to water, but you can't make it drink water instead of soda pop. And, believe it or not, there isn't a pill that can fix everything. Until people start taking their health seriously, we will continue to outspend every country on the globe and die earlier from preventable diseases before most of them.

Rankins wants to get you ready for summer!

It's easy to let your workout schedule get off-track in the summer with so much going on. Some of us have less structured schedules once school is out, relatives come and visit, and then there are your own vacations! Making a commitment to your exercise routine is sometimes easier when you join a class. Now Rankins is offering a great range of classes for you to participate in:
Bootcamp 1

Entry level cass to build endurance
This class is for someone who is new to exercise , has had an extended break from exercise (child birth, lack of fitness, etc), or does not exercise regularly.

•  Mon & Wed 7:00-7:45AM with Rachel (starts 6/20) 
• Tue & Thu 6:15-7:00AM with Morgan (starts 6/7)

 Bootcamp 2

 Build Strength & Lose Inches

 This class is for someone who exercises regularly, but would like to improve their metabolism, strength, and fitness level.

 

• Mon & Wed 6:15-7:00PM with Morgan (starts 6/6)
• Tue & Thu 9:00-9:45AM with Tracy (starts 6/7)

 Bootcamp 3

 Final level class burn fat and tone muscle

 This class is for someone who exercises regularly, is used to prolonged physical exertion and is ready to step up their workout!

 

• Mon & Wed 5:30-6:15PM w/ Rachel (starts 6/20)

 Cardio 1

 Fitness Walking-suggested to be taken in conjunction with Bootcamp 1

 This class is for someone who is new to cardiovascular exercise and would like to begin a regimen that will strengthen their heart and raise their fitness level

•  Tue & Thu 7:15-8:00AM w/ Rachel (starts 6/21) 
• Tue & Thu 4:15-5:00PM w/ Rachel (starts 6/21)

 Cardio 2

 Fitness walking/jogging-suggested to be taken in conjunction with Bootcamp 2

 This class is for someone who regularly exercises, but is looking for a new regimen that will aid in fat loss and overall heart health.

•  Tue & Thu 8:00-8:45AM w/ Rachel (starts 6/21)

 Ladies Circuit Training

 New kind of workout 30 seconds on/off machines

 This class is designed for all ladies regardless of experience in the gym. The circuit is always set up but the following times are when an instructor will be there to aid you through your workout.

•  Monday through Friday 8:00-8:45AM w/ Morgan
• Mon, Wed, & Fri 1:00-1:45PM w/ Tracy

 ***This class is FREE for our members $6 drop in rate for Non-members

  

Speed & Agility

 Designed & Trained by Andre McDonald

 Andre McDonald is a professional football player who has come to Rankin fitness Center to personal train you! He has taken his football experience and designed a speed and agility class that is suitable for all sports! Get in shape/stay in shape before sports camps! 

• Monday & Wednesday 4:00-5:00PM w/ Andre

Healthcare in the Age of Zombies

After two years of working in a medical practice, I'm still shocked when a patient is unwilling to try a diet and/or exercise plan to deal with their health issue before going on a prescription drug. I can sympathize with the patient who, despite a healthy lifestyle, has to go on medicine, as well as the patient who has a condition that can't be treated without medicine. They have no choice. But patients with chronic issues like diabetes, high blood pressure, and obesity owe it to themselves to try natural, self-driven methods of controlling their health problems. For one thing, it's less expensive, both for the patient, as well as the population at large. When patients have to get expensive medicine,  insurers pay the price, and guess who they pass that price onto? Yep. All of us.

And while we're talking about money, do people really like taking money out of their pockets to make the pharmaceutical companies even wealthier than they already are?  Sales of pharmaceuticals in the US amounted to $289 billion dollars in 2009, accounting for more than half of all international sales. How about taking care of yourself, and if  you want to give your money away, fund the skatepark or your local Arts Council instead of those pharmaceutical companies :)

Also, why would anyone want  to depend on something if they didn't have to? "Being healthy" might mean just 300  fewer calories a day, and 30 minutes of exercise. Wouldn't that be better, and healthier, than relying on medicines?  Do people go on welfare before trying their best to get a job and take care of their families themselves? Because that's what drugs are like if you haven't tried a healthy lifestyle first: welfare for your body.

Enough of the sobering realism. What if we have a Zombie invasion? The CDC has even prepared a document to prepare us for this event! And sure, it just makes sense to stock up on your medications, but they can't last forever. What do you think will happen when your meds run out? By then, the pharmaceutical companies have probably shut down, and all the workers have been eaten. Are you going to be fit enough to run from a Zombie? Or are you going to be getting sicker and sicker, unable to run from the Zombies because you can't have your pills and you've ignored your fitness?

I'm just sayin'.