Friday, February 28, 2014

Be Your Own Medical Advocate: The Reference Number and the Diagnostic Code

The best movie of the year is Dallas Buyers Club. The Oscars are this Sunday and I hope it wins Best Picture and a wheelbarrow of golden men.
            Ron Woodroof, the main character, discovers that to survive he must become his own medical advocate, and the best way to do that is by being a medical advocate for other people at the same time. Ron is willing to break the law, skirt the law, and offend people in the process (which I don’t recommend) but in his mind he must do it survive.
            Growing up in San Francisco in the 1970s and 1980s, I saw how AIDS destroyed lives. As a budding wannabe journalist, I also met several Ron Woodroof-type medical advocates, and they impressed me with their patient persistence.
            I remember one man with HIV, Steven, who was working hard to get insurance companies to pay not just for Pentamidine to help combat the onset of pneumocystis pneumonia, but to get them to approve aerosolized Pentamidine, so AIDS patients could breathe it right into their lungs and fight the pneumonia that often killed them. Insurance companies had not yet approved this new method of treatment.
            Steven was a medical advocate for three men with AIDS who were too sick to fight for better care for themselves, and he took a living stipend so that he could work full time for them, and also for himself. He worked the phones all day, five days a week, on their behalf, and his own, and fought for service he could get for them. As he grew sicker, he knew he may need to then pay for his own medical advocate who would then fight on his behalf. I had a lot of respect for him working those phones.
              You may need to become a medical advocate yourself some day, and work to get great care for yourself, a parent, spouse, loved one, or a child. You may want to behave more like Steven than Ron Woodroof, but you’ll need to be patient and persistent.
            The American Health Care System works, if you have a challenge they know how to address. You may be having a baby, need to set a broken bone, or need surgery. The care, the cost, and the payments and the insurance are pretty straightforward. Problems start when you have a health challenge that doesn’t go away, doesn’t get better, and they don’t know what to do. Or, your doctor wants to try something new and different. Expenses rise for everyone, and a complicated game begins. 
            That’s when you’ll need, or need to become, a medical advocate.
            Here are some tips on how to become patient and persistent.

1)  Keep a phone log, and make sure they keep one too.
Keep a log book. Whenever you call a doctor’s office, a billing department, or an insurance company, write down the name of the person to whom you are talking, get their extension (if they can give it), and write down all the details you can about your conversation. Ask them if they are logging the conversation as well.  Before you hang up, go over your information to make sure it’s accurate, and ask the person if you should ask for them personally the next time you call. Finally, ask if there is a reference number for the call, so that you can refer to it the next time you call them.

2)  If you are talking to an Insurance Company, each call has a Reference Number
This is important. Insurance companies are run by people. The rules are so complicated and changing so quickly, the assurances that one person gives you may not backed up by the next person you call. This is a bad conversation to have:
            “I just got my doctor’s bill, and my new asthma breath test wasn’t covered by my insurance, but when I called last month, Debbie said it was.”
            “There’s no Debbie here.”
            “I called on the 21st, and 9:30 a.m. and talked to Debbie, and she said that my policy would cover that visit and that test at 90%.”
            “Sorry, whoever told you that was mistaken, or you heard it wrong.”
When you call and get information and assurances, make sure you get the reference number of the call, and write it in your log. This way, your conversation will go more like this:
            “I just got my doctor’s bill, and my new asthma breath test wasn’t covered by my insurance, but when I called last month before my visit, Debbie at extension 712 assured me that it was. May I give you the reference number of that call?”
            “Sure, give me the number and I’ll look it up for you.”
            You must track your costs, and who pays -- otherwise you will pay more. At the same time, listen to what the voices say while you are on hold. When you call Blue Shield, the recording does say that (I am paraphrasing) the conversation you are about to have is not a guarantee of services, coverage, or payment.  
            That’s an even better reason to get the reference number, since it allows you to keep the conversation going, even when they get their information wrong.

3) Doctors offices don’t really know what insurance covers.
If you call a doctor’s office and book an appointment, you may wonder if the visit, the procedure, the drug, or the diagnostic test you will have done is covered by your insurance. The hard-working staff may assure you that it is covered. They may even sound like experts, since they work with insurance companies every day.
            But your doctor’s office is NOT the insurance company!  Offices are run by busy people who write, enter, print, bill and mail information. What one person says on the phone isn’t always right. Someone in a doctor’s office can speak from experience, but they cannot guarantee anything about what an insurance company will do.
            A doctor’s office is sometimes guilty of saying what they think you want to hear, to get you to come in the door. A patient is a customer, after all.
            Therefore, if you are going to a doctor or a clinic for a new test or new procedure, or you’re being referred, you can call up and ask for the Diagnostic Code that the office will use for what is being done. Keep a log of the call.
            Then call the insurance company, and give them a description of what you are going to have done, and then give them the diagnostic code (numbers and letters) of that procedure/test/exam and see what they say.  Only they can tell you whether it is truly covered.
            And get a reference number for that call. Otherwise, you may get a surprise bill from your doctor’s office, for something you thought was covered, but isn’t.

4) The Surprise Bill -- Use the information you gathered to lower your costs.
            I had bad asthma that was keeping me awake at night.  I’ve had asthma intermittently since I was a child. It gets worse in spring and at the start of winter.
            I went to an allergist and asthma specialist who wanted me to exhale into a machine, which would test the inflammation damage in my lungs.
            My insurance pays for the test, if it is coded for “asthma.”
            My insurance does NOT pay for the test if it is coded for “seasonal asthma.”  My insurance company considers using that machine and that test for “seasonal asthma” as “experimental,” and is therefore not covered.
            I had my reference number of my call to the insurance company. I had the code for the test for asthma. I had my call logs to both the insurance company and the doctor’s office.
            I called my doctor’s office and my insurance company and asked that the bill be resubmitted, with the code for “asthma” instead of “seasonal asthma,” and the bill was resubmitted and I saved myself $285. My co-pay was $15.
            I did not have to debate anyone whether my asthma was seasonal or a life-long issue that came and went. Because I had phone records and reference numbers and diagnostic codes, they simply did it.
            But I did make sure I recorded that conversation in a log, with a reference number, and I got everyone’s name and extension as well.

5) Once you are dealing with the Billing Department, the medical office can’t help you, but they still want you to pay.
            Big hospitals and larger medical practices have billing departments that are separate from the doctor’s office, and you cannot visit them. If you object to a charge on one line of a bill, you cannot walk into the doctor’s office and ask to speak to the person who sent you the bill, because they are not there.
            The person behind the desk will take your information and help get you the service. They will take your credit card and receive payment from you, but once you object to the cost, they can’t help you. Here’s a typical conversation:
            “I’m here for my follow up with the doctor. I had my first procedure last month.”
            “You have an outstanding bill for that procedure that you haven’t paid.”
            “I know, there was a mistake. Can I talk to someone in billing? The insurance company told me something different.”
            “The billing department isn’t located here. All I know is that you have an outstanding bill, and we’d like to receive payment before you see the doctor. Is there some amount you can pay today?”
            “Can I visit the billing department? Can you give me their address?”
            “No I can’t. You can’t visit them.”
            “They don’t get back to me. Can I still see the doctor?”
Instead, you want the conversation to go this way:
            “I’m here for my follow up with the doctor. I had my first procedure last month.”
            “You have an outstanding bill for that procedure that you haven’t paid.”
            “I know, there was a mistake. I printed out this document for your files. I am disputing the bill because the first procedure was coded incorrectly, even after I called this office and the insurance company. Here is a record of my calls, their reference numbers, and their names. In fact, I’ve been in touch with Joan in your billing department. In the meantime, I have to keep my appointment, because the doctor said it was necessary for my medical care.”
            “I’ll put these in your file.”
            “Sorry to bother you with all this, but I wanted you to see that I’m organized and I’m on top of it, and I’m sure this will all be figured out soon.”

6) Do you research before you go to a new doctor or clinic.
            Name your Chronic Condition -- Arthritis, Asthma, Fibromyalgia, Irritable Bowel Syndrome, Diabetes, Pain, Back Problems, Insomnia, Chronic Fatigue --
            There’s a clinic that deals with nothing but your problem!
            However, check their reviews on and on and before you got to any appointment. If you read that their billing is wacky, or they overcharge, or they ding you with hidden costs, cancel the appointment. Go somewhere else, even if it’s more expensive.

7) If you keep a good log -- don’t be afraid of the Billing Department.
            Once you dispute a bill, scary things can start to happen. If you have a good log with names, dates and reference numbers, you don’t need to be afraid.
            Just be prepared to spend a long time on the phone, a lot of time on hold, and be ready to leave a lot of voice mail messages as you get the runaround.
            The bigger the medical provider, the scarier it can be. My family has had the biggest billing disputes with Cedars Sinai and UCLA.  Because they are huge they have huge billing departments, and the bigger the department the less compelled they are to deliver great customer service.
            My family had a medical bill that was coded incorrectly from the very beginning. It was truly an error, and we had reference numbers of calls and the correct diagnostic code. But for two years we kept receiving a bill for over $5,000.
            We called twice a week for over a year. We left messages. We asked to speak to supervisors. We got reference numbers and supervisors assured they would call us back. The bills kept coming, and eventually the even sent it to a collections agency. We then communicated with the collections agency with the same patient persistence that we treated the doctor’s office, the billing department, and the insurance company. Eventually, they backed down and we had our bill coded correctly.
            It can be scary and exhausting.  Your time is valuable and you may want to just pay the bill and be free of it. However, if you know you are right, and if you keep good logs, don’t stop fighting. Stay diligent with the collection agency, and explain your situation. Tell them your story, and that you have an entire file that you can send them.  Eventually, the supervisor will call you and work with you. People fight audits from the IRS, and people fight collection agencies over incorrect bills and they win. If you are right and you keep great records, you will win too.

8) Be Patient, Polite, Kind, Funny, and Insistent
            It's easy to dismiss someone who is just a voice on the phone. It's even easier to dismiss someone who has a rude voice.  When you make your first call and you start your log, be patient, kind, polite, and funny...but insistent.
            If you start having billing problems, there is a good chance you will call that same person again. They are doing their job. Part of their job may be to dodge you. Be friendly. Find out if they have kids. There’s a good chance you’ll end up trading stories. After many calls, that person will become an acquaintance, and even an ally.
            Then, the phone calls don’t seem so bad, either. After all, the person on the other end of the call has issues of his or her own, just like you.  It can even be pleasant, if you remember that we are all in this together.

            Good luck!


Friday, February 14, 2014

Valentine Notes

Friends and Family are telling me to lighten up.  Today’s blog post shouldn’t be about climate change, or California politics, education, or the health care system.  They want a blog post about love, for Valentine’s Day. 
And they’re right.
St. Valentine, imprisoned in Rome, would pass notes -- Valentine notes -- to other prisoners, to  give them hope.  These are my notes of hope, because where there is life, there is hope.
Candace Escobar helps me with this blog every week. She is my sounding board and my editor, and she keeps me honest. Candace helps Robin and me with our little company and she is kind and patient with our daughter Lily. Thank you Candace, this is for you.
Julie Murphy -- five years ago Robin and I went out on Valentine’s Night for a date, and you came to babysit. You and Lily made Valentine Hearts with love notes and stuck them all over our kitchen. We loved them so much that we left them there, and five years later they are still stuck to our cabinets, faded and curling, but such a part of the house that we don’t even see them. Now you’re having your baby, and Lily will babysit for you, and make you Valentine hearts.

David Trulli -- you have another art gallery opening tomorrow at Bergamot Station, which I can’t attend, but I want this blog post to promote it.  What I like about your artwork is that there is always a sliver of hope in it.  A woman on a swing, a man wanting more, a vine on a fence, a blade of grass pushing through the sidewalk. Break a leg tomorrow night.

To everyone, this is my Valentine note of hope that I pass to you. Be thankful for the problems in your life that never go away.  If you can say, “My life would be perfect, except for...” that means your life may already be perfect. The “except for” problem -- money, health, parents, children, wife, husband, home - contain the seed of awareness of how lucky we all are. It’s the dark that reveals the light, the yin to the yang, and we all share in it. Until it ends.
Thank you life, for the rock I push. I look over and see everyone else pushing their rocks, and our pain, toil, and joy unite us.
Here are lyrics to two great Valentine songs that capture everything I could ever want to say about the beautiful ache of life and love, and Jobim says it all in fewer words than I’ve already written here. 

Whenever I hear these songs, I think of Robin. My love. With you in my life, I am never alone. You are my blade of green grass that I keep in my pocket wherever I go. Together we can push up any sidewalk.
Most of all, this post is for you.  Happy Valentine’s Day!

The Waters of March
A stick, a stone, it's the end of the road
It's the rest of a stump, it's a little alone
It's a sliver of glass, it is life, it's the sun
It is night, it is death, it's a trap, it's a gun
The oak when it blooms, a fox in the brush
The knot in the wood, the song of a thrush
The will of the wind, a cliff, a fall
A scratch, a lump, it is nothing at all
It's the wind blowing free, it's the end of the slope
It's a beam, it's a void, it's a hunch, it's a hope
And the river bank talks of the waters of March
It's the end of the strain, it's the joy in your heart
The foot, the ground, the flesh and the bone
The beat of the road, a slingshot's stone
A fish, a flash, a silvery glow
A fight, a bet, the range of a bow
The bed of the well, the end of the line
The dismay in the face, it's a loss, it's a find
A spear, a spike, a point, a nail
A drip, a drop, the end of the tale
A truckload of bricks in the soft morning light
The sound of a shot in the dead of the night
A mile, a must, a thrust, a bump,
It's a girl, it's a rhyme, it's a cold, it's the mumps
The plan of the house, the body in bed
And the car that got stuck, it's the mud, it's the mud
A float, a drift, a flight, a wing
A hawk, a quail, the promise of spring
And the river bank talks of the waters of March
It's the promise of life, it's the joy in your heart
A snake, a stick, it is John, it is Joe
It's a thorn on your hand and a cut in your toe
A point, a grain, a bee, a bite
A blink, a buzzard, a sudden stroke of night
A pass in the mountains, a horse and a mule
In the distance the shelves rode three shadows of blue
And the river bank talks of the waters of March
It's the promise of life in your heart, in your heart
A stick, a stone, the end of the road
The rest of a stump, a lonesome road
A sliver of glass, a life, the sun
A knife, a death, the end of the run
And the river bank talks of the waters of March
It's the end of all strain, it's the joy in your heart

"Waters of March" is track #9 on the album Encanto. It was written by Antonio Carlos Jobim.


Quiet nights of quiet stars
Quiet chords from my guitar
Floating on the silence that surrounds us

Quiet thoughts and dreams
Quiet walks by quiet streams
And a window on the
Mountains and the sea, how lovely

This is where I want to be
Here with you so close to me
Until the final flicker of life's ember

I, who was lost and lonely
Believing life was only a bitter, tragic joke
Have found with you
The meaning of existence, oh, my love

"Corcovado" is track #6 on the album Elis & Tom. It was written by Antonio Carlos Jobim.

Exhibition: February 15 - March 22, 2014
Reception: Saturday, February 15, 5-8pm

Robert Berman Gallery
Bergamot Station Arts Center
2525 Michigan Avenue, B7
Santa Monica, CA 90404

Friday, February 7, 2014

I just got a fax----I'm paying too much for Health Care.

            The Health Care Industry  is ripping off my family.
            Over the last ten years, we have been misled, misinformed, and overcharged by doctors, hospitals, medical offices and insurance companies. All have been guilty, and it’s been going on long before the Affordable Care Act was passed.
            Like many American families with chronic health challenges, one quarter of my family’s time and money go to health care and health insurance. But after we pay good money for top-notch care, we spend time battling the rip-offs. They dodge our questions, and don’t return our calls.
            What pisses me off the most? The FAX MACHINE.
            You’ll have to fax that.
            We didn’t get the fax.
            Can I get your fax number? I’ll try to fax that to you later today.
            Are you near a fax machine?
            Our copier is down, so I can’t make a copy to send you that fax.
            Fax machines are 20th Century Technology. I have a cell phone, and I can take a high quality photo of any document and send it to you while waiting for coffee. I can keep my entire medical history, organized, in my pocket, and it’s backed up on my hard drive at home, on my computer, and in “the Cloud.” It’s even encrypted.
            For business, I am now expected to be digitally organized. I haven’t used a fax for business in ten years. If I told my boss or a client that he has to wait because I’m not near a fax machine, I wouldn’t keep my job for long.
            However, when I walk into a doctor’s office and see four rows of open horizontal filing cabinets jammed with thousands of manila folders, I feel like I just entered 1988 -- but they’re charging me like it’s 2018.
            Since the economic downturn of 2008, any business that has survived has been asked to do more work for less money. When I create a budget for a potential client, that client will always ask for a better deal, because someone wants a better deal from him. There has been a relentless drive for efficiency.
            I believe, however, that our health care system has been able to dodge that squeeze for six years now. As the Affordable Care Act kicks in, only now is the pinch beginning to happen in a major way. Doctors, hospitals and health care providers are all worried that they can’t deliver the same quality care for the same price, and still break even, much less make a profit.
            But when someone in a hospital, a billing center, or a doctor’s office asks me if I’m near a fax machine, I lose all sympathy. I’m happy to pay more in 2016, but I don’t think I should pay to help someone catch up to the second decade of the 21st Century. I feel like I’m paying for their tuition.
            Everyone in the American Health Care System should get used to a question we’ve all been hearing and asking for six years:
            What am I paying for? I want a better deal.
            Actually -- I would settle for a fair deal.
            Here’s an example, in which all facts are true. Someone in my family needs an MRI once a year, to track whether a chronic condition is stable, improving, or worsening. Getting the MRI is preventative and therefore cost-effective. If he waits and his condition worsens without him knowing, it can lead to an expensive emergency.
            His insurance pays for an MRI prescribed by a doctor.
            He called the Mark Taper Imaging Center, which is part of Cedars Sinai, to book his prescribed yearly MRI, and they told him there were no openings in the next month, even though it’s the facility his doctor recommended.
            They told him, however, that there were openings at another MRI facility associated with Cedars Sinai, the Mark Goodson Imaging Center, where they could take him right away. He asked if it was the same procedure. He was told yes, it’s the same MRI scan.
            He got the MRI procedure, and his co-pay was $1500, but he already had spent $500 out-of-pocket last year, so he only had to pay $1000, which made him feel like he’d saved money.
            Then his doctor told him that he should have waited and gone to the other facility, because that MRI machine has more current technology. The facility he went to had an older MRI machine, and the readings aren’t as thorough, which was not volunteered. It was also the same price.
            I don’t know what happened, but I will now speculate: the older MRI machine has been paid for several times over, and it’s now profitable. However, everyone wants the newer machine, so the older machines tend not to get used as much. I speculate that he was encouraged to use the facility with the older machine to maximize its use, get some profit, and reduce crowding at the other facility.
            He also has a friend with the same condition who also needs an MRI once a year. He feels nervous about the headaches he’s been getting, and he wants to be pro-active and get a second MRI, just to be sure.
            On a whim, his friend called an outside facility -- Tower Imaging, a private facility not associated with a hospital, and he asked how much it would cost if he paid cash. They told him $1000, and they could take him right away. He negotiated them down to $900.
            My family member feels misled and ripped off. He spent $1000 for the wrong test, and he’ll have to spend $1500 again to get the right one.
            No laws were broken. However, my family member is now a gadfly activist for his own health care, and he costs billing departments and office staff a lot of time and money with all his phone calls, as he checks every prescription, every procedure, and every line on every bill, as he calculates how to get the best deal.
            And guess what? He bought a fax machine and got a second phone line, just to deal with antiquated medical offices and billing departments who dodge him.
            Here’s his typical telephone banter, while standing up in the kitchen:
            So, can I get that price in writing?
            Yes, I have a fax machine. I’m standing next to it now.
            Can you fax that to me now?
            I was on hold for 30 minutes to reach you, do you mind staying on the line
            until I get the fax? I’m standing next to it, I will see it come through.
            I signed the document and sent it back. My fax machine said it went through. I don’t mind waiting, can you go see if you got it? Yes, I’ll hold.
            It sounds like he’s talking to the lady who books rooms for the Sochi Olympics, but he’s talking with the best medical service providers in Los Angeles, at Cedars Sinai and UCLA.
            Most patients just accept the status quo, however. They are so worried about their health care, they’re afraid to question its speed, price or quality.
            But you should ask questions. You’ll get better care, and you will help an industry join the 21st Century.
            Over the next few blog posts, I will share more medical stories. Consider them rants, consider them advice, consider them guidance. They may help you.
            I am the son of a doctor, the grandson of a doctor, the brother of two doctors, and the nephew of a doctor. Although I am not a doctor, I run a business that provides health care coverage to employees who work for more than six months, and my family has typical chronic health care problems that require me to know insurance policies and the health care system. I have some good stories to share.
            Here’s my first piece of advice about ALL health care providers. Embrace this, and it will give you strength as you ask your questions:
            Most doctors are merely adequate, and not great.
            Remember that, no matter what they charge, or how they treat you.
            That is not disrespectful to doctors. The truth is, most people are adequate. Most people fall into the middle of the bell curve on everything in life -- which is the definition of average. A few people are exceptional, and a few people are terrible. This same statistical truth applies to doctors of all kinds, even in the top specialties. If there are 2,000 brain surgeons in the country, only 200 can call themselves great. The mere fact that you are a brain surgeon doesn’t mean you’re a great one. The Peter Principle may be in play here, as well; a doctor may have been a terrific general surgeon, in the top 10%. However, by choosing the more challenging speciality, that doctor may actually have ended up being merely an adequate brain surgeon.
            This is true of lawyers, architects, teachers, and movie directors. It is a fact of all professions. Most people are average at what they do, and only a few are fantastic.
            There is nothing wrong with being adequate. I love paying an average price for adequate service. I also don’t mind paying for an adequate procedure on an older machine, if it does the job I need. I never want to pay top price for the best when adequate will do just fine, thank you.
            However, I don’t want to be misled, or overcharged, or to endure disorganization and inefficiency. The same applies for the office staff. A bad office staff can sully the health care experience that a fantastic doctor delivers.
            Therefore, be your own advocate. They are people, mostly average, just like you.
Ask questions about your service and your bill. And please...tell them to get rid of the fax machine.
            Next week:
            The Cost of Your Medical Records!
            The Medical Reference Number!
            Stay tuned!