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Saturday, October 31, 2015

Appropriate Utilization of Healthcare Resources

Last week I shared information and resources you can use when faced with mounting medical bills. This week I would like to focus on processes that are in place today to ensure appropriate use of healthcare resources.

In the past physicians were not questions as to the care decisions they made.  This is because physicians had the power to write anything they felt the patient needed to treat their medical issues. Once written, the patient’s insurance company would pay the bill without much oversight. As a result of this practice, there was massive overutilization of services that caused healthcare cost to skyrocket. 

Today, there are utilization requirements in place by the payer that providers, physicians and hospital systems need to follow in order for payment to be provided by the payer. These rules may seem burdensome to providers and most consumers, but they have helped to control costs while ensuring the care provided is based on scientific evidence, is timely and in line with the patient condition. These practices have also been shown to have slowed healthcare spending and improved the quality care provided.

The first requirement from the payer is for providers, physicians and hospitals to supply evidence that supports their request for high costs treatments such as diagnostic tests, medications, home care, rehabilitation or other high costs services used to treat patients. The evidence should follow the National Guidelines that payers and providers all have access to.  

Having this system in place allows for a review process to take place by the managed care organization. The physician ordering the treatment must provide their rationale and evidence to support the care before moving forward. The hospital utilization review nurses or the office staff from a physician's office email the information via or send via a secure fax line to the managed care company to being the review process.

Once a request is received by the insurance company, a utilization review nurse will review the orders and documentation against the national guidelines. If  the information meets the criteria, the orders are approved. If the information does not meet the criteria, then the information is sent to a physician on staff at the insurance company who does their own review and makes a determination. Again, if the physician feels the information meets the guidelines, the care is approved. If not, the reviewing physician will issue a denial. It should be noted that nurses cannot issue denials. Only physicians can make these determinations to deny care.

Managed care organizations have to follow strict timelines to ensure these reviews are done on a timely basis and do not to hold up treatment. If the treatment is denied, the insurance company has to explain why and give the physician or hospital the rationale in writing as to why a denial was given.  

As you can image this is a difficult and controversial process. It is often argued that the ordering physician who knows his patient should be given the benefit of the doubt.  To assist, a process called peer-to-peer review is part of the utilization review process.  The theory behind this process is that the treating physician and the managed care physicians doing the review can take a minute to talk to each other about the patient, the rationale for the orders written, what the treating physician is  looking for and what the expectations are as a result of the treatment.  When this type of discussion occurs, most denials are overturned unless there is strong evidence against the proposed care. Most managed care physician wants to give the treating physician some leeway in treating their patients so the peer-to-peer review is an important part of the process. 

There may be some restrictions put on the treatment to allow for a trial period, but this would be spelled out in the approval letter.  Consumers and hospital case managers should encourage the peer-to-peer discussion as it will assist the process and is a way to advocate for the patient. This process also shows the importance of clear and supportive documentation that defends the plan of care.

If the denial is issued, then the treating physician, the hospital or the patient has the opportunity to appeal the decision. Again, there are strict rules around this concept that all have to follow.

If an appeal is requested, the insurance company has to have a physician who is an expert in the field of the patient's condition and has had no connection to the physician who did the initial review. This is so that the review process is independent and objective. 

Once the physician asked to do the appeal has an answer, a telephone call, and a letter is sent by the managed care company to the ordering physician. If a hospital or another type provider is involved they would also get notice of the decision as well as the patient. If the appeal overturns the denial decision, then generally the managed care company would abide by the decision. 

If the appeal upholds the denial, then generally, the physician would seek a new course of treatment or the patient has the option to pay for the service if they (and their doctor) feel the course of care is needed. Also, if there are additional avenues for the physician/patient to take that information would be detailed in the letter from the Insurance Company.

As a patient, you have a right and responsibility to participate and be involved in all of these discussions. You can and should encourage your doctor to send in detailed information on your case to prove an explanation as to why care is needed, take part in the peer-to-peer discussion, and appeal the decision if needed. As these processes take time, many physicians do not go through the process unless the patient request for them to advocate for them.

As mentioned previously these processes take time,  but they are in place to ensure that the care recommended is based on the most up to date scientific evidence to meet your needs. 

All of this information is included in your member handbook that your insurance company provides so take the time to familiarize yourself with these processes so you are aware of your rights. Physicians and providers are also well aware of the rules and the process as  part of their agreement when they become contracted to a managed care network.

Again, the utilization management process is in place to ensure the care you receive is:
1. safe  2. evidence-based  3. appropriate for your condition  4. based on your current condition 5. timely 6. cost-effective and 7 approved by the insurance company if there is an approval process required before treatment is rendered.

The role the patient plays in the utilization review process is important as your input can help your
doctor better understand your goals and help them plan your care to fit your needs. Patients should:
  • Understand the treatment recommended
  • If there is more than one treatment option, all options should be explained to the patient by the ordering physician so the patient is given the opportunity to choose the options that best meets their goals. This process is known as shared decision making.
  • Understand if the treatment being ordered and how it will make a difference in your care
  • Understand what the test show or treatment will show or do to improve your care?
  • If you don’t get the treatment, what are the consequences to your condition or life?
  • Are their complications associated with the treatment to be aware of?
  • What costs will the you be responsible if the treatment is approved? You may have a co-payment to make if/when the treatment is approved.
  • Your doctor should be able to answer all of these questions so you can be sure the treatment plan is understood by you. If your physician does not provide the answers to any of these questions, you should question the plan of care as having answers to these conditions are critical.  
With last week's post, Tackling Medical Bills and this week's post on Appropriate Utilization of Healthcare Resources, you can see how important it is for patients to understand all their options and to be an active member of the healthcare team.    

The more you understand your care and treatment options, the more likely you are to ask questions, learn, and receive care that meets your goals. When physicians and other members of the healthcare team work with their patients, it leads to improved health care outcomes as well as lower cost of care.

To assist you in better understanding these concepts, here are some articles that will explain the trends that are helping healthcare to be safe, effective, patient-centered, timely and cost effective.  

Shared Decision Making: Engaging Patients to Improve Healthcare: This article explains how being involved can improve your care.Here is the link to read the article.

Appropriate Use of Medical Resources:  TheAmerican Hospital Association provides information that will explain what Utilization Management is and why it is used today to improve care and control health care costs. Here is the link to access the information.

The Role of Utilization Management in Case Management: This article shows that a priority of every case management intervention is to support the patient to make sure that they are getting the best care and support over a continuum of time to achieve positive clinical outcomes.

I hope this information is helpful to you and a refresher to all members of the healthcare team. I look forward to your comments and recommendations for future posts. Please feel free to leave a  comment in the comment section or email me at Have a good week. 

Saturday, October 24, 2015

Tackling Medical Bills

In this week’s post, I would like to share my experience with paying the medical bills that accumulated during my illness. This is an important post especially for consumers as most have to pay a portion of their bills and the amounts can be staggering.  

Paying medical bills is not like paying your electric bill or your Macy’s bill.  Medical bills are complicated partly because most consumers are not familiar with medical billing and it is so different from the bills we pay on a routine basis.  

In doing research for this article, it was learned that bankruptcies resulting from unpaid medical bills will affect nearly 2 million people —making health care the No. 1 cause of such filings outpacing bankruptcies due to credit-card bills or unpaid mortgages is another serious issue, according to  Nerdwallet.  Paying medical bills is challenging as most of the services charged on the bill may not be recognizable, thus hard for the consumer to evaluate. I hope this post will help consumers of healthcare better understand how to tackle this challenging task. 

Like most of us, I am not sure I ever really appreciated the healthcare insurance benefit I received from my employer until recently. Many times when I saw the deduction taken from my paycheck for health care insurance, I  would say to myself: “I am healthy and I never use this insurance…why do I have to pay for this every two weeks when I don’t use it?  I wished so many times that I could just pay for health insurance when I need it.”  Today, most people realize that having healthcare insurance is an important way to protect ourselves and offset costs when a healthcare event impacts our lives. 

My healthcare event occurred on November 24, 2014, when I was diagnosed with a Central Nervous System Brain Tumor. I was never so glad to have health insurance as I was at that moment.  My insurance allowed me to see the physicians that were able to diagnosis me, treat me, and enable me begin to recuperate from what could have been a terminal event. Today, I am improving thanks to the treatment I received at Sylvester Cancer Center, a leading cancer center in Miami Fl as well as Health South Rehabilitation Hospital. I am not 100%, but I am alive and continue to work to overcome the deficits that I have as a result of the chemotherapy that eradicated the brain tumor.  

The cost of my care was in the hundreds of thousands of dollars and most of it was paid for through my healthcare insurance policy.  I consider myself very lucky and thankful to my former employer for taking the time to put together a comprehensive health insurance plan that covered most of the services needed to treat my condition.   

Paying the Bills

One of the responsibilities that comes with having health care insurance is making sure that the services provided were appropriate. As I was the only constant on my team, I was able to help by reviewing the bills to make sure what was charged was actually provided. I felt that this was a responsibility that I had as mistakes can and do happen as part of the billing process. Also, as we were responsible for a portion of the bills, we wanted to make sure that we did not pay for services that were not provided.  

So my husband and I took the time to review each bill as they came into our home and make sure (as far as we could tell) that what was billed was correct. This was easier said than done as reading medical bills is a skill that even I, an experienced healthcare professional, was not prepared for.  Some of the challenges we found were:

  • Many bills were not clear as to what had been done so reviewing them was a challange
  • Understanding who the providers were was difficult because many times we did not recognize the provider’s names or had never met them as they were behind the scenes.
  • Some bills had only the amount to pay with no explanation as to what services were provided.
  • Bills that did have explanations on them many times had multiple charges for what seemed to be the same service so deciding if  they were duplication was hard
  • It was sometimes hard to know when to pay a bill as we could not tell if the insurance company had paid or if we were responsible for the charge
  • In addition, as I was in a weakened state, having the stamina to review the number of bills coming in was  at times overwhelming
It is important to remember that bills should not be paid until they are reviewed and paid for by your insurance company. Many people think they have to pay a bill when it comes as you would with other bills, but this is not correct. You should wait for an explanation of benefits from the insurance company, so you know what they paid of the bill and inform you what portion of the bill you are responsible. 

Our strategy:

My husband took the time to sift through the mountain of bills that came in via the mail as well as through the two internet portals that Sylvester Cancer Center and our insurance carrier had in place. He put the bills into two piles. One pile was for bills that had all of the information we needed to do a review. The second pile contained bills that did not have all of the information or needed follow-up. 

The bills we had questions on required us to make calls to the providers to ask them to resend the bill with an explanation of all of the charges. This took time for them to resend so it could be reviewed. Once the full bill was received, we reviewed it to see that the services provided were accurate. Then we had to wait for the Insurance Company to send the explanation of benefits so we knew the amount they paid and what we had to pay.  

It was interesting to see what was billed, what was paid, and how the services were explained. Every bill format  was different and this made the process very tedious. 

In many cases, if there was a balance to be paid I made a call to the provider to see if they would accept what the insurance company paid. Many providers had programs that could help offset some of the cost, but it required more paperwork to be filled out to see if we qualified for the exemption.  If your life is impacted by your illness and money is tight, this is an import option to consider, although it does add extra work. 

I did have out-of-pocket costs in the beginning as I had not reached my out-of-pocket requirements specific to my insurance policy.  This meant that I did have payments for many of the bills that came in early. Once my deductibles and out of pocket requirements were met, we were not responsible to pay; as the insurance company paid their negotiated rates which was a relief. 

Matching up the bill with what the insurance statements showed what was paid which is an important part of managing the bills. Please remember not to pay anything till you get notice of what your insurance company paid. Doing so can result in duplicate payments which is a nightmare to resolve.
On occasion, we did have questions about payment of certain bills, so we made a call to the provider. Getting to the right person was not always easy and took persistence. Writing down the date, the time, who we talked to, and what they said was important so that we had a record of who said what. A few times, I was able to get items taken off the bill as they were not appropriate or mistakenly billed, but overall most of the bills were correct, especially after the detailed explanation of services was received. 
If there was a large payment expected I would call my case manager at the insurance company and he could check to see if the insurance company had paid their portion of the bill. This was helpful when it came to knowing what our responsibility was. Again, documenting the information received over the phone was very important. 

As an FYI, I was on a traditional commercial insurance plan but if I had been on Medicare, it would have been important to make sure that Medicare, as the primary payer, had received the bill and paid what they were responsible for. Once they paid their portion, the bill would be sent to the secondary insurance company. Secondary insurance will usually pay what Medicare does not pay, so again, keeping track of all of this is important. 

Communication is critical

Communication with providers and the insurance company is important when reviewing medical bills. Both organizations hold information that can help you understand the billing process and what your responsibility is.  Don’t be afraid to ask questions.  

Also, if you have a balance to pay and do not have the funds, ask the provider if they will accept what the insurance has paid.  Sometimes they will do this if you can prove paying is a hardship. If they will not, then you can ask if they will allow you to pay the amount due on a payment schedule which could be as low as $5.00 a month. Again, don’t be afraid to ask for these options.  If you find charges that you think were not appropriate on the bill, let your insurance company know. They can check this out for you.

Resources that Can Help

In this section, I wanted to include some resources that might help you better understand the medical billing process. Here are a few you can review:

Understanding your Medical Bills: This article will assist you in understanding your medical bills. Click here to read.

Professional Healthcare Billing Advocate Can Help: Patients who have complex or catistrophic health care issues care can rack up millions of dollars in medical bills which can cause financial hardship. If you are having trouble reviewing your bills, are too sick to handle this task, are getting called by bill collectors, have questions regarding how much you have to pay, or need financial aid there are professionals who can help you. They are known as Healthcare Billing Advocates.  Click here to read an article on how a billing advocate can assist you.

Insurance Handbook: Your insurance handbook has a lot of good information about your policy. Take time to read your insurance handbook so that you understand your policy, know what is covered and what your responsibilities are. Many insurance companies are not printing these books but place them online for your review. Take time to read your handbook and if you have questions, you can call the insurance company or talk to your human resource department

Understanding and Recognizing Healthcare Fraud: Health care fraud costs you, payers and providers, millions of dollars.  This article can help you to learn how recognize fraud and what to do if you suspect fraud. Click here to read.

Human Resource Department: If you have healthcare insurance through your employer, your Human Resource Department can assist you with questions you have or refer you to someone who can help you. Again, do not be afraid to ask for help. Paying medical bills is a complex task that most people find it distressing. Asking questions and getting clear information is important.

Individual Policies: If you have an individual policy that you pay for privately, you can call your insurance company and ask them questions.  Most have good customer service departments who have access to all of the policies and can find answers to your questions. If you have a clinical question, they may refer you to a Nurse Case Manager who can assist you. Usually, there is no charge for this as these people work for the insurance company.

Web Portals: Today many Hospitals or Health Systems have electronic portals that you can access once you register. The systems contain hospital and provider bills, hospital records, lab, and diagnostic tests. In addition, the Portals allow you to make appointments and even communicate with your healthcare team if you have questions. These systems are usually easy to navigate, but you have to register and have internet access. If you need help, the health care system will usually have technicians who can help you set up your portal and show you how it works. This allows all of your information to be kept in one place.

Your insurance company may also have a web portal that you can access to see what bills have been paid, and what bills need to be paid. This is where you will also find a copy of your Member Handbook. Again, you need to register and have internet service to access these portals. If you have questions they have technicians who can assist you.

Insurance Commissioner: Every State has an Insurance Commissioner who can be a resource for you if you have questions on health care bills or a complaint against your insurance carrier. Here is the link to find help in the Insurance Commissioner in your State

 I hope this information helps you better understand your role in paying your medical bills. As a last bit of advice try to keep up to date paying your medical bills as this will prevent them from accumulating and putting you into a deep hole.  If you have trouble keeping up with your medical bills due to your healthcare challenges the most important thing you can do is to let the various providers know that you are sick and will address the bills in due time and are not ignoring their request for payments. Also, do not be afraid to ask your family or freinds for help. 

Please email me if you have questions or comments.  You can reach me via email at

Wednesday, October 21, 2015

The Very Inspiring Blogger Award

I am excited to announce that Nurse Advocate was recently nominated for a Very Inspiring Blogger Award! This is an award given by bloggers to fellow bloggers who inspire them and who are motivated to make the blogosphere a beautiful place. The award asks us to honor and learn more about the person behind the blog. Nurse Advocate was nominated by a  fellow Blogger and nurse colleague Greg Mercer. His Blog is Big Red Carpet Nursing.

There are some rules that accompany this award: The first rule is that I am to share 7 facts about myself. Here they are:
1.      I am married to my best friend and soulmate and live in Fort Lauderdale FL
2.      I have two brothers and one sister who are my best friends
3.      I have been a nurse since 1978 and have had a wonderful career that I would not trade for the world!
4.      My favorite sport is swimming
5.      I love to watch all sports and have a great time keeping up and sharing scores and events with friends on Facebook
6.      In November 2014,  I was diagnosed with a Central Nervous System Brain Tumor that turned my life upside down. It has been a tough year, but I am still standing
7.      My Blog; Nurse Advocate, was created as a result of this experience to educate and empower others as to how to navigate the complex healthcare system

Next, I would like to nominate 15 of my fellow Bloggers for this award. These professionals are my mentors and colleagues. Please take the time to visit their Blogs and sign up for weekly updates. 

I would also like to thank my nephew Patrick Douville and his finance Kendal Spera who are my editors and collaborates for Nurse Advocate. They keep me on target and make me look good! Thank you both so much!

 It has been a true learning experience developing and keeping up with my Blog but when I read the comments that come from those who read and share Nurse Advocate I know I am making a difference.
Finally, I would like to thank Greg Mercer of the Big Red Carpet Nursing for offering me this opportunity to share information and to be part of the exciting community of Nurse Bloggers.

Monday, October 12, 2015

Celebrating the Practice of Case Management

Plans for the first National Case Management Week first started in 1998 as an effort to help move the Case Management industry forward.  The Case Management Society of America’s Board of Directors agreed to a Case Management Week celebration during the week of October 10, 1999, a date chosen in honor of the Association’s establishment on October 10, 1990. Later, it was decided to mark the second full week in October each year as National Case Management. Today, Case Management Week is celebrated by all of the major professional organizations, certification bodies, payers and provider organizations across the broad healthcare landscape. The week is a time for all involved in the advanced practice of case management to highlight and share what they do and the outcomes they have achieved in improving the health and healthcare of all who transition through the complex and diverse healthcare system.

As a leader in the practice of case management, I wanted to use my Blog to highlight the important role case mangers play throughout the system in assisting patients, their families and all healthcare providers deliver safe, quality cost effective care across the broad healthcare system. 

Today, case managers can be found at every entry point of the healthcare system. Each are charged with ensuring patients receive safe, quality cost effective care that is evidence based and delivered at the right time and in the least restrictive setting. When this is standard practice, barriers are decreased, fragmentation and duplication are reduced and the cost of care is lowered.  

Today, consumers are starting to ask for a case manager from the payer or the provider organization caring for them. They are leaning that by working with a case manager, they better understand their diagnosis and have a way to remove the barriers that impact their ability to address their health and healthcare as well as their quality of life. It has been proven that wellness even in spite of illness is achievable when patients and their caregivers are active participants in their care.  Today, it is exciting to see the good work going on throughout the system when everyone works together; lives are saved, costs are contained and patient and provider satisfaction is improved. 

Yet we still have gaps to close as many people who could benefit from a case manager don’t know one is available, or are not offered case management services in a timely manner causing them to fall through the cracks of the system.  Many issues cause this; restrictions put on case management services, confusion as to what case managers do. In addition, providers and consumers confuse case management services with utilization management. One way to remember the difference is that utilization management is a reactive process where case management is a proactive process. There is a need for both, but they are not the same. Today, professional case manager use their clinical expertise to anticipate and address problems before they occur.  As a result, patients are more prepared and adverse events can be avoided. These proactive activities reduce readmission's and save healthcare dollars.Experienced case managers take the time to break down barriers and when given the opportunity are able to find resources to meet the patient's needs in a creative manner.

Case managers who work with the patient and their families take the time to establish relationships enabling them to have better success. They take the time to understand their patient’s goals and communicate them to the rest of the team so the plan of care is in concert with what the patient feels is important to them. 

They also take time to educate and empower their patients which gives the patient the ability to understand their condition and the plan of care that can help them deal with the stress it takes to improve their health and healthcare. Case managers work with patients throughout the lifespan from pre-birth to death. They are there to support patients and families when life changes occur and they are forced to enter the complex world of healthcare. 

When patients are part of the process and have a say in their care they are more prone to adhere to the plan of care. Case managers also take the time to work with the team to ensure they are informed and educated on barriers that exist that can derail the plan. 

To have a successful case management program, the program must be led by someone who understands the role and function of what case management is and can communicate this to the leadership. The Director, managers and supervisors must stand up for what case management is and work to have the concept infiltrated throughout the organization if it is going to work.  All members of the team have a role to play to ensure successful outcomes. Today, with outcomes tied to reimbursement this is more important than ever.

Case management when utilized appropriately, can make a difference in your organizations overall operations, finance, risk management, quality management, public relations as well as improving the morale of your staff and the consumers who utilize your organizations services whether you are a payer or provider. 

Case management should be taken seriously by the leadership of your organization and given the resources needed to run a successful program. As mentioned, the concepts of case management need to explained to all members of the healthcare team as well as the consumers who utilize the services your organization provides. 
In closing, I wish everyone a Happy Case Management Week! Thank you for all you do! Please know that you work is appreciated. 

I hope you and your team takes the time to celebrate your success and share the important work you do each day to improve the patient experience. Feel free to share the link to this week’s issue of Nurse Advocate with your team as well as consumers. If you have questions on case management, please feel free to email me at 

Also please take a minute to share how your organization is celebrating Case Management Week! 

To assist professionals seeking to enter or better understand the practice of case management or for the veteran case management professionals wanting to improve their personal and/or professional practice take time to review my 2016 Reading List for Professionals engaged in case management and care coordination. You can access the list by clicking here.  

Thanks for reading Nurse Advocate and have a good week!