Become a Better Healthcare Consumer

1. Become a Better Healthcare
Consumer
PRESENTED BY: LAYTON LANG

2. What is Healthcare Consumerism?
 To empower individuals with information and
financial responsibility to support a position of
ownership.
 Most employers are well aware of cost containment
tools such as risk assessments, disease management
and wellness programs.
 What about a strategy to engage in the purchase
decisions regarding medical products and services to
reduce employee out-of-pocket expenses?

3. Learn your plan’s rules
Learn how to access a primary care or specialtist
physician; referals and authorizations
Fully-Insured or Self Funded Plan.
Understand your plan’s pharmacy formulary.
Promptly respond to any claim questions your health
plan may send you.
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Request for medical records
Subrogation Request
Pre-existing Medical condition
Coordination of Benefits

4. Network vs. Out-of-Network providers
Verify provider and facility are in your network plan.
Learn which facilities are in-network when
preparing for emergencies.
Know how your plan will pay an out-of-network
provider: Usual and Customary or a Proprietary
Formula. Emergency Care or Network Inadequacy
Remedy for hospital-based providers billing you for
out of network charges: Texas House Bill 2256

5. Out-of-Network Scenario
Hospital Provider Bills $2500
Your plan benefit is 80%/20%
Billed Amount
Allowed
Blue Plan
$ 2,500.00
$ 1,500.00
Red Plan
$ 2,500.00
$ 2,500.00
Deduct
$
-
Coins
Amount paid
$ 300.00
$ 1,200.00
$ 500.00
$ 2,000.00

6. Prescription Drugs
Use “Preferred’ Brand Name Medicines
Purchase Generic Drugs
Buy in bulk
Ask for Samples or Drug Savings Cards
If you don’t have a pharmacy benefit then shop
around.

7. Medical Services
Inquire about Cost-Effective Medical Options
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Cutting-edge devices or procedures may not be the most
worthwhile .
Ask whether provider has a financial interest in preferred
facility or equipment.
Global Periods
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In- office procedures allow for 10 days free follow up care.
In -hospital procedures allow for 90 days free follow up care.

8. Facility Costs
Diagnostic Studies
Over the past 5 years, the price variance between studies
performed at a hospital owned facility vs. an independent is 2
to 3 times greater.
Procedures and Surgery
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Physician office
Free-standing surgery center; not affiliated with a hospital
Hospital facility

9. Hospital vs. Medical Office
Cardiac Stress Test Study

10. Hospital vs. Medical Office
Cardiac Nuclear Study

11. The Medical Bill
Ask for the cost of the procedure/service along with the
CPT codes.
Example: Patient decides she wants a nevus mole
removed from her neck. The general dermatologist
agrees to perform the surgery and bill 11401 and 12032
CPT codes which pay $415.58. The patient requests a
second opinion and visits a dermatologist specializing in
MOHs surgery, who states he will remove the mole and
bill a 14041 which pays $765.34. Both dermatologists
agree to perform the procedure but each receives a
different payment amount from the same carrier under
the same benefit plan.

12. Medical Bill Audit
U.S. Government Accountability Office states 9 in 10
hospital bills contain overcharges.

13. Medical Bill Audit
As hospitals and medical groups consolidate medical
billing operations, staff and service become less
sophisticated.
Example: Employee was balanced billed $1309.00 by the
emergency room physician because the carrier denied the claim
for diagnosis not substantiating the care. Employee contacted the
emergency physician’s third party billing company and
discovered they had failed to pull the correct diagnosis and never
appealed the claim. He contacted the provider’s office and
advised them to pull the emergency room records to locate the
other diagnosis. They complied by correcting and refilling the
claim which was subsequently paid.

14. Medical Bill Audit- What to look for
Compare services rendered to what was claimed
Verify provider filed with all insurance plans and
exhausted appeal rights

15. Examples that Merit Medical Bill Review
 Insurance company did not apply the correct benefits: fee schedule,
edit logic, co-insurance, deductible.
 Insurance company has never responded or paid claim.
 Insurance company denied claim because it was not medically
necessary or deemed experimental.
 Insurance company denied claim because the claim was not clean.
 Insurance company failed to pay 100% of the out-of-network
provider’s claim.
Always contact the medical provider’s office and explain that they
need to look to the insurance company for payment as they are
prohibited, by Texas Administrative Code and provider contract to
bill the patient for covered services. They should exhaust their
appeal rights before billing the patient.