CarePartner: Patient Advocates Help Consumers Solve the Mysteries of Healthcare, Obamacare

COLUMBUS, Ohio, Sept. 14, 2015 /PRNewswire/ -- One of the unforeseen results of the Patient Protection and Affordable Care Act – more commonly known as Obamacare – is that consumers may suffer from insufficient coverage and frustrating customer service as small companies rush to add or switch to health plans that are more cost-effective. Small companies that have never provided health insurance are now required to do so, and new administrative costs and coverage mandates have forced many small employers to seek cheaper, less comprehensive coverage.

This, in turn, is spurring a new industry of professional patient advocates who can help unravel the complications and advocate for patients, especially when the bills start arriving.  One such service, called CarePartner, claims to have saved patients more than $255,000 in out-of-pocket costs over the past six months, simply by "fighting through the system on behalf of patients," according to Melody Bogan, one of the company's patient advocates.

An Indiana couple recently turned to CarePartner, when they were hit with a $3,989 bill following the hospitalization of their three-year-old for respiratory problems. The anxiety of nursing their child back to health was accompanied by a stream of documents from the insurance company, called Explanations of Benefits, and hospital bills that said this portion of the treatment cost wasn't covered by insurance.

The mother, an attorney, said her first instinct was to "call every administrator in the hospital and start preparing my lawsuit." But instead, she asked CarePartner to resolve the issue.

"I was just confused and tired of dealing with this mess," the mother said, "I just want to focus my energy on our baby."

Bogan, the Care Coordinator handling the case, said the charge was a penalty for not "pre-certifying" the admission, but that was ultimately the hospital's responsibility. Initially, however, the hospital's billing department didn't want to acknowledge this.

"We started making calls and it took even us, as experienced professionals, several calls and quite a bit of time to unravel the mystery and start working toward a solution."

"We had to get to supervisors and push pretty hard," she said. "But eventually the hospital agreed it was their mistake and cancelled the charge."

Bogan cited another case in which the pharmacy was refusing to fill a prescription for a new drug prescribed to help delay progression of a chronic disease.  The pharmacy told the Maryland patient the drug was subject to "prior authorization" that required documentation from his physician, but after three weeks the matter had not been resolved.

After calls to the pharmacy, the "pharmacy benefit manager" that pays the claims, and the prescribing physician, the Care Coordinators determined that the physician had neglected to submit the documentation, then did so on an outdated form.  The Care Coordinators instructed the office on what to do and then confirmed that the proper documents had been approved and the prescription would go through.

Even then, Bogan said, the patient was hesitant because this was a $30,000 course of medication and the patient believed he would be responsible for a 50% co-pay. Bogan studied his policy and discovered that he had a $1,800 out-of-pocket annual maximum liability, which had already been met, so she guided the patient to filling the prescription at no out-of-pocket cost.

"This was not a drug that he should be avoiding," Bogan said, or he could have serious health issues later.

"I spent months trying to comprehend and resolve insurance issues when I stumbled upon CarePartner," the patient said. "They took charge and alleviated the stress of working and trying to manage insurance, doctors and pharmacy to play nice together."

In another example of patients unsuccessfully fighting the system, a Georgia man purchased individual coverage through the state's public health exchange. Toward the end of 2014, the insurance company he selected applied his last payment for 2014 to the 2015 plan year. As a result, his coverage was terminated for November and December 2014, just as he was admitted to the hospital. When his claims arrived, they were denied by the insurance coverage for lack of coverage, when in fact his 2014 payment had been misapplied.

After lengthy discussion with customer service, he was told that his payment was being corrected and his coverage would be reinstated. However, when the hospital re-submitted his claims, they were once again denied for lack of coverage. That's when he engaged the care coordinators from CarePartner to advocate on his behalf.

"We have seen a dramatic increase in consumers who have bought an individual insurance product through the exchange having trouble getting their enrollment correct and claims to be paid correctly," said Linda Butti, RN, one of the care coordinators who tackled the Georgia situation.

"In this case, we had to make numerous calls to both the exchange and the insurance carrier, and frankly be pretty aggressive, to get someone to make things right for this consumer. At one point they reinstated him, but at the level of a Bronze plan rather than the Silver Plan had paid, leaving him with an additional $3,000 in deductible to cover."

Butti said she was eventually able to get to a high-level manager at the insurance carrier to do a manual override to reinstate the man back to November 2014, with the correct level of coverage, and get his claims reprocessed and paid correctly.

She said the insurance companies, exchanges, physicians offices and hospitals all respond better to another industry professional who can speak to them as a peer.

"I won't say that there are magic words to use, but you really need to know the industry and how it works. Sometimes you need to push through what might be a smokescreen or an administrative roadblock. The average patient or family is simply not able to do that."

Pushing hard through the roadblocks allowed CarePartner to help another consumer, also in Florida, save more than $10,000 in out-of-pocket cost.  When he bought an individual policy through the public exchange, the website showed that he owed no premium because subsidies had been applied. Although he didn't feel this was accurate, the website's payment "Submit" button was inactive -- because the computer showed him as paid in full -- so he couldn't make a payment even when he tried.

When he was hospitalized and incurred nearly $100,000 in cost, his claims were denied because the insurance company said he had never paid his premiums.

He had learned about CarePartner through a friend, so he hired them to help resolve the situation. Initial calls to the large insurance company were unsuccessful, as they said the consumer should have known he owed payments and made them aware. By "fighting through the smokescreens," as Butti said, the Care Coordinators finally obtained the go-ahead for the consumer to be reinstated.

But the administrative errors didn't end there. The insurance companies then claimed the hospital he utilized was out-of-network, when it clearly showed as "in-network" on the company's website. This made him subject to an out-of-network deductible of $10,000, compared to the in-network deductible of $150.

Even as the insurance company's claim processors argued that the hospital was out-of-network, their website continued to list it as an in-network facility. The patient advocates took screenshots of this erroneous information and sent it to managers at the insurance company, who finally relented and processed the claim as in-network. Between getting his coverage reinstated and claims processed as in-network, the patient avoided some $60,000 in potential personal cost.

The need for patient advocates and care coordinators is growing, according to CarePartner's Bogan.

"We've been helping people get their healthcare problems sorted out for 15 years," Bogan said, "but with the increasing number of insured patients, and decreasing availability of doctors, and more individual policies being sold through the exchanges, this need is greater than ever.  We're seeing a wide range of administrative and service issues that patients are falling victim to."

Butti, the nurse, added that while you are sorting out a patient's administrative or billing issues, you often find that their healthcare is suffering as well.

A Maryland man had purchased an inexpensive individual policy on the public exchange instead of the plans offered through his employer, but when his wife became pregnant, he asked CarePartner to help him decide which option was best for him. They analyzed the coverage trade-offs and concluded his family was best served by staying with the individual policy.

In the process, however, Butti discovered that he had not been filling an important prescription. She probed this issue and learned that the pharmacy was trying to charge co-pays amounting to $900 per year, so the man just didn't take the medication. She counseled him on the medical importance of this drug, but said she would check with the pharmacy on the cost. As it turns out, the pharmacy had the wrong drug plan identification code, and when this was corrected the drug was dispensed for a $5 co-pay per month – saving more than $800 per year on just this one drug.

"We got him the medication at a price they could afford," Butti said, "and most importantly he started getting the treatment that he needed so his health didn't deteriorate. So that's a lot of avoided suffering and cost in the future." 

Note: Names and contact information of specific patients who have similar experiences can be provided upon request to allow for direct interviews. Other patient stories can also be found at https://www.carepartner.com/about/media-kit-2/.

ABOUT CAREPARTNER

CarePartner.com is a membership-based patient advocacy and care coordination service operated by Quantum Health, Inc., one of the national leading providers of third-party care coordination services. For more than 15 years, Quantum Health has served employers and the employees covered under the health benefits plan, reducing frustration and cost while helping physicians support their patients. CarePartner.com was created in order to offer this patient advocacy directly to consumers, including those covered by Medicare and individual insurance policies. 

SOURCE CarePartner

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