Getting the Most of Your Healthcare Dollar

Posted by Nurse Linda in Life After Paralysis on September 09, 2021 # Insurance

insurance formsOur healthcare system is always rapidly evolving and changing. Just when you think you have it figured out, something else pops up. Sometimes, we are so locked into the way we do things that we do not notice a change until it is upon us. Here are some ideas to think about, although not all ideas will be available in all areas. Still, this will be general information to use as a starting point. When I mention the payor, it includes both private and public insurers.

Often, people have an urgent health issue but are unsure about what to do. Choosing to phone your healthcare professional or deciding to call for emergency help can be difficult to discern. If you have an issue at home that you feel is an emergency, call 911. Emergencies cover a very wide variety of problems. Usually, we think of emergencies as being things that affect your ability to breathe, heart or cardiac function, or mental status. These issues are definite 911 calls.

But there are incredibly many more issues that are true emergencies. For instance, if you fall and cannot get up or into your wheelchair, call 911. If there is no injury, they might send the paramedics who know how to lift you, or they might send the fire engine crew who know basic maneuvers. If you fall and your leg is broken, definitely call 911 as they can stabilize your bone, so more damage does not occur.

If it is unclear if you should call 911, call and let them decide. They are great at assessments. The other important consideration is that it begins your healthcare coverage for this event. If the paramedics decide hospital transportation is needed, they have already begun emergency treatment in your home. When you arrive at the ER, your payor has less discussion as a healthcare professional, the EMT, determined the need for emergency assessment.

This determination is important as occasionally. ER visits might be rejected for payment if you were able to drive yourself or if someone else drove you. In other words, it must not have been an emergency if you could delay starting treatment during your ride to the hospital. Also, if you are in an emergency, you do not want to delay treatment as your condition could worsen. In your vehicle, there is no one to provide emergency care. Note: you can still take yourself to the emergency room for emergency/urgent care if you choose. 911 is for true emergencies.

Recently, a case occurred where an individual was very ill, so they called an ambulance company for help. However, ambulance companies now transport patients to medical appointments or move individuals from one location to another, like from hospital to home or to health office visits. Ambulance services provide several levels of care, including life support, but only for transport. Some are not emergency services, so payment was denied. That put the ER visit payment in jeopardy. It took several attempts over a year, but services were finally paid. This could have been eliminated by calling 911, which is appropriate today for emergency treatment.

Many have noticed a change in refilling prescriptions. Now the pharmacy does that for you if you ask for an auto-refill. But you must specify that. Depending on where you are in the country and what health system you are in, you might be referred to your pharmacy if you phone your health provider for a medication refill. Know and understand the process in your healthcare plan. You can expend a lot of energy by calling the wrong person for medication refills resulting in not having your refill in time. This process frequently changes, so do not be surprised if it is one way this month but another way the next month. Going through your pharmacy for refills is here to stay. If you have a question about a medication, be sure to discuss it with your healthcare professional or pharmacist.

Another money saver at the pharmacy is to ask if you can have long-term medications for three months. The cost of the medication will be the same, but you are charged one dispensing fee rather than three. Some payors allow this. Others do not. Some allow it but only through specified pharmacies. Check with your payor to be sure you are getting the best value by utilizing generic drug options if appropriate, three-month prescriptions, and use of the preferred pharmacy.

If you do not have a plan that includes prescription medication, look to reduced-price services such as GoodRX, Single care, or Blink Health. I have experience with the first two companies but none with the third. These companies have websites where you type in the drug and dosage you need. You do need a prescription. The app will tell you the prices of the drug at different pharmacies. If you have a couple of prescriptions to fill, you might need to go to different pharmacies for the best prices. This is a little extra step but can pay off greatly.

Getting medical equipment is one of the biggest challenges for everyone. There is a lot of equipment that we want, but payors provide what is needed. Be sure to check your individual policy for what is specifically paid. Your insurance policy is a contract you have made with that company. They are obligated to provide what is in your contract. Health policies are many in number. If you do not have a copy of your policy, and most people do not, call the consumer number on the back of your health payor card. The policy that is particular to you will be provided. Sometimes, they can tell you where to look to find your policy online. Every company sells many types and levels of policies. You need to review the specific policy that you have contracted with that company. Sometimes individuals make requests for equipment that is denied because they were looking at the wrong policy. This can leave you responsible for a big bill.

Almost daily, people will say, ‘I have insurance.’ That is good but realizing the policy you are paying for might not be the most deluxe. Having insurance does not mean everything will be paid. You may have a co-pay or limits called caps. Most policies have a cap which is the maximum that will be paid. Often, this is a million dollars. That seems like an astronomical figure but if you are in the ICU for an extended period, have multiple surgeries, lots of treatments, this money can be quickly spent. Once the cap is reached, that policy is complete.

Rehabilitation is one area that is often affected by caps or limitations within a policy. Many have a two-week rehabilitation cap. After a catastrophic illness or injury, that is not much time to become adjusted to a new normal and set up a transition to home. Get to know your insurance case manager. This person is assigned to individuals with catastrophic issues. There is a case manager in the hospital and rehabilitation setting that will help you within those systems, but the case manager from your insurance company is the one who can help manage your policy.

Some individuals have different elements in their healthcare plan. You might have two weeks of rehabilitation, but you may also have two weeks at other levels of care. Your insurance case manager may be able to shift funds to allow more time in rehab or may be able to move you to a catastrophic outlier plan. Not all payors have this type of structure but work closely with your insurance case manager to see what they can do to assist with major hospital and rehabilitation expenses.

Another reason to review your policy is to check benefits yourself. There might be some benefits hidden in your policy that can extend your rehabilitation, especially if out of the hospital or rehabilitation facility. Many policies have a yearly two weeks of rehabilitation therapy for mobility. Individuals let this slip by as they do not realize they have the benefit. Mobility can be defined in many ways, such as trying new therapies, learning to strengthen your arms for feeding or driving, all sorts of things. The two weeks will most likely be outpatient. The sessions can be stretched in different patterns. You might participate in therapy on varying days of the week with a home exercise plan in between therapy sessions to maximize your experience over a month.

Typically, available now is equipment such as a standing frame. You will need some therapy time to learn and tolerate this equipment. Standing has so many benefits to individuals with paralysis that many payors cover the item. If you are interested, check your policy. Not all payors cover a standing frame, but many do. More than likely, there will be a co-pay.

If there is equipment that you feel you need that is not covered by your payor, ask your healthcare professional for a letter of medical necessity. This is a document that your healthcare provider sends to your payor justifying why you need the item or therapy. Expect your first request to be rejected because if the item is not in your policy, it is rejected. This is the process. The payor needs the record of the first request followed by a denial so you can appeal. Keep working with your healthcare professional, who can send follow-up requests by responding to the response of the payor until your request is granted or the decision is final. If a decision is final, reapply when you are able.

Determination will pay off. A man who has a spinal cord injury was on the local news. He spent six years, an unfortunately long time, requesting a functional electrical bicycle. Finally, he got it. His message: do not give up. I wish everyone could see his news story.

That is the message. Do not give up. It can be frustrating but keep going. You will need to be considerate as you do not want to alienate anyone who can help you but do not give up. Nurse Linda

Pediatric Consideration:

Stretching your healthcare dollar can be a challenge in pediatrics because just as you get equipment or therapy, a growth spurt occurs, and adjustments are needed. Be sure to ask for equipment that can be adjusted to accommodate growth as well as for instructions as to how to adapt.

There is some good news. Most states have programs to assist children with specific needs. Be sure to look up pediatric healthcare assistance programs on your state’s web page. Keep digging. Talk with other parents who have this experience so you can benefit your child.

As with adults, it is exhausting but do not give up. There are options for everyone. Getting what your child needs to enhance their life can be a challenge but keep going. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.