TO INSURANCE COACHING!!!

Transcription

1 TO INSURANCE COACHING!!! 1

2 COMPASSION*WORKS MEDICAL/NPKUA INSURANCE COVERAGE 2 FOR MEDICAL FOODS YOUR RESCUE FOR COVERAGE!!

3 INTRODUCTION Raenette Franco, CEO, CBCS Certified Medical Biller Coder Specialist and Patient Advocate Founder of Compassion*Works Medical, LLC 3 Disclosure: This presentation is presented for the NPKUA insurance coaching program and created by Compassion Works Medical, LLC. The information provided is not related and/or currently in any conflict of interests bounded by outside business breaching.

4 THE GOAL! Covered Benefit? Medically Necessary? Processed Correctly? COVERED! 4

5 STEPS TO INSURANCE COVERAGE FOR MEDICAL FOODS Understanding your insurance coverage and policy. Gap exceptions/out of network referrals. Assigned case manager from your insurance carrier. Following State mandates for fully insured policies. Medical food exclusion removals from employers. Tools and Resources. Insurance terminology. Medicare and Medicaid advice. Understanding EOB s. Difference between Medical Food benefits and Pharmacy benefits. 5

6 UNDERSTANDING YOUR INSURANCE COVERAGE AND POLICY (PART 1) What is Creditable Coverage? Creditable Coverage provides policy guidance and benefit information from any public or private health insurance or health benefits plan, whether insured or self-insured. Read through your Creditable Coverage policy for an accurate description of medical food/formula benefits before calling your insurance carrier for questions. Key words: ENTERAL, MEDICAL FOODS, NUTRITION, METABOLIC HCPCS Codes: B4155, B4157, B4162, B9998, S9435 6

7 UNDERSTANDING YOUR INSURANCE COVERAGE AND POLICY (PART 2) In-network: Providers that participate with your plan. Out-of-network: Providers that do not participate with your plan. Tip: Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered. 7

8 UNDERSTANDING YOUR INSURANCE COVERAGE AND POLICY (PART 3) Deductible: Amount that you must pay before the insurance kicks in. Out-of-Pocket: A predetermined amount of money for a chance to increase your insurance to 100%. It can be a bit confusing with the deductible. The good news is that you don t have to meet any amount before your coverage kicks in. Sometimes confused with deductible. 8

9 UNDERSTANDING YOUR INSURANCE COVERAGE AND POLICY (PART 4) What is a Pre-certification also known as Prior authorization? 9 Pre-certification serves as a utilization management tool, allowing payment for services and procedures that are medically necessary, appropriate and cost-effective without compromising the quality of care to you. Pre-certification for medical foods must be approved before your insurance will cover.

10 UNDERSTANDING YOUR INSURANCE COVERAGE AND POLICY (FINAL PART) Questions and support? Compassion*Works Medical together with the National PKU Alliance can support you through our insurance coaching and patient advocacy program. 10

11 HOLDING HANDS TO THE NEXT STEPS GAP EXCEPTIONS AND ASSIGNED CASE MANGERS 11

12 GAP EXCEPTIONS/OUT OF NETWORK REFERRALS What is a Gap Exception? It is asking permission from your insurance carrier to use a particular provider that is out-of-network and getting the same benefits as the in-network level. How can I request for a Gap Exception? Usually your out-of-network provider will make the request. It is based on no other comparable providers that can provide the requested service within 30 miles of your residence proximity. 12

13 ASSIGNED CASE MANAGER FROM YOUR INSURANCE CARRIER A system of coordinating medical services to *treat a patient, *improve care and *reduce cost. A case manager coordinates health care delivery for patients. How do I request for an assigned case manager from my insurance carrier for my medical foods? Answer: Contact member services then ask for the utilization management department. Once you re connected, ask for an assigned case manager and explain that you have an inborn error of metabolism disease and need long term assistance. 13

14 HOLDING HANDS TO THE NEXT STEPS FOLLOWING STATE MANDATES & MEDICAL FOOD EXCLUSION REMOVAL 14

15 FOLLOWING STATE MANDATES FOR FULLY INSURED POLICIES (PART 1) How do I know if my State has a mandate? Answer: You can check the NPKUA website to determine if your state has a mandate. aspx. Every state has their own laws. Few have deductible and co-pay waivers that helps a great deal without paying out of pocket to get coverage before insurance kick in! Some have an annual maximum (i.e. $2,500, etc.). 15

16 FOLLOWING STATE MANDATES FOR FULLY INSURED POLICIES (PART 2) If I am in a state with a deductible waiver, how can I get my insurance carrier to ride-off the deductible? Answer: The good news is that some insurance carriers already follows their mandate After verification of benefits they will make a note on your policy and create a rider. What is a Rider? Answer: A rider is an amendment to an insurance policy. 16

17 FOLLOWING STATE MANDATES FOR FULLY INSURED POLICIES (FINAL PART ) If a policy is unaware of your state mandate, you should send them a copy of the law to create any riders. (i.e. deductibles, medical exclusions, etc.). Advice: Print out a copy of your state mandate from the NPKUA website and keep for insurance assistance. 17

18 HOLDING HANDS TO THE NEXT STEPS INSURANCE TERMINOLOGY AND MEDICAL FOOD EXCLUSION REMOVAL 18

19 WHAT IS THE PROPER INSURANCE TERMINOLOGY? Without knowing the proper insurance terminology, understanding your insurance coverage for Medical Foods/Enteral Formula can be confusing and frustrating. Let s learn a few simple questions to ask and words. 19

20 HOW DO I COMMUNICATE WITH MY INSURANCE CARRIER? What is my coverage for Medical Foods and Enteral Formula? I have service codes that I will like to check? (B4157, B4162 (pediatric), S9434, S9435). A service code also known as HCPCS/CPT code is the description of the medical food service. 20

21 HOW DO I COMMUNICATE WITH MY INSURANCE CARRIER? What is my deductible (if any)? Has my deducible been met? What is the allowed amount on my plan? 21

22 HOW DO I COMMUNICATE WITH MY INSURANCE CARRIER? Is my plan fully insured or self funded? This could help to determine when to use your state mandated law (fully insured plans). What is my out-of-pocket? This could help to increase your benefit coverage to 100%. Is there any Exclusion to the service codes or service? If any, this is a good time to use your state mandated law. 22

23 HOW DO I COMMUNICATE WITH MY INSURANCE CARRIER? May I have a reference number for this call? IMPORTANT **** WHAT IS THE BENEFIT CUSTOMER SERVICE NAME? WHAT IS THE REFERENCE NUMBER FOR THE CALL? You may get different answers from your providers verification. Always contact your provider to compare answers. 23

24 INSURANCE WORDS Medical Foods and Enteral Formula: Are the same description with different words. Service Codes: A description of service in a numerical/alphabetical format. Pre-certification also know as prior authorization: An approval from your insurance company that service are medically necessary and covered (i.e. # ). Deductible: An amount of money that needs to be met before your insurance pays. 24

25 INSURANCE WORDS Fully Insured Plan: When you may your own premium or a percentage from your employer. Self-funded Plan: When your employer pays for your benefits or if you have Medicaid/Medicare (state/federal funded plan). Out-of-Pocket: Sometimes confused with deductible. It s when you pay for medical expenses until you reach your insurance dollar amount. It increases your co-insurance to 100% (if any). Does not have to be met before insurance pays their part. 25

26 INSURANCE WORDS Exclusions: Items or conditions that are not covered by the general insurance contract. Allowed Amount: Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. Lets talk a little more about allowed amount 26

27 MORE ON ALLOWED AMOUNT WITH HEALTH INSURANCE PLANS.. Example of an allowed amount: All of us with health insurance think that 100% is covered in full, or even 80%, 70%, 60%, 50% we think they pay the full percentages. Right?? The answer is NOT Typically, this is how it works with out us knowing. Example: The Allowable Charge is typically a discounted rate rather than the actual charge and considered payment in full from your insurance company and the provider. 27

28 MORE ON ALLOWED AMOUNT WITH HEALTH INSURANCE PLANS.. It may be helpful to consider an example: You have just purchased your medical food. The total charge for the medical food comes to $100. If the provider is a member of your health insurance company's network of providers (in-network), they may be required to accept $80 as payment in full for the medical food - this is the Allowable Charge. In-network providers: Your health insurance company will pay all or a portion of the remaining $80, minus any co-payment or deductible that you may owe. The remaining $20 is considered provider write-off. You cannot be billed for this provider writeoff. 28

29 MORE ON ALLOWED AMOUNT WITH HEALTH INSURANCE PLANS.. Out of network providers: If, however, the provider you purchased your medical foods from is not a network provider then you may be held responsible for everything that your health insurance company will not pay, up to the full charge of $100. This is your responsibility! You can check the charges, allowed amount and your patient responsibility from your EOB (Explanation of Benefits). A statement, not a bill provided by your insurance company. Or you can ask for a copy from your provider. 29

30 HOW TO READ AN EXPANATION OF BENEFITS (EOB)? 30

31 EOB PROCESSING CIRCLE 31

32 THIS BRINGS US TO OUR NEXT STEP MEDICAL EXCLUSION REMOVALS AND THE DIFFERENCE BETWEEN MEDICAL VS. PHARMACY BENEFITS 32

33 MEDICAL FOOD EXCLUSION REMOVALS FROM EMPLOYERS My insurance is not covering my formula because there is an exclusion. How do I get my exclusion removed? Answer: Usually your exclusions come from your employers contracted plan with your insurance company. You will have to present a letter of medical necessity (LOMN) and a medical food exclusion removal request letter to your Human Resource Department for assistance. For Federal and State plans, exclusion removals are a bit complex. You should seek assistance from a certified insurance advocate. 33

34 MEDICAL FOOD EXCLUSION REMOVALS TOOLS LOOKING FOR HELP AND TOOLS??? Please find template letters for medical food exclusion removal request letters and letter of medical necessities on the NPKUA website. 34

35 DIFFERENCE BETWEEN MEDICAL BENEFIT VS. PHARMACY BENEFIT Medical benefits for Enteral Formula/Medical Foods use a HCPCS code (i.e. B4157, S9435). Pharmacy benefits uses NDC codes to identify a particular product not a medical service such as a HCPCS code. Depending on the patient s insurance plan, some may have enteral formula/medical foods covered only under medical, some only under pharmacy or both. Some pharmacies bill both DME & Pharmacy covered items. Some just cover pharmacy benefits. Nothing here ostracizes a medical benefit or pharmacy benefit. 35

36 DIFFERENCE BETWEEN MEDICAL BENEFIT VS. PHARMACY BENEFIT It s important to understand the difference. It can be a bit confusing to patients and some clinical professionals. This is one of the reasons why it is good to verify both benefits to choose the most affordable benefit choice! 36

37 INSURANCE ADVOCATE SUPPORT For certified insurance advocate support: Compassion*Works Medical and the NPKUA INSURANCE COACHES PROGRAM. The NPKUA has a new resource to help guide you through the difficult process of obtaining medical foods coverage. The NPKUA Insurance Coaches Program, led by Raenette Franco, CEO, CBCS of Compassion*Works, is a place that can help! 37

38 GOT MEDICARE OR MEDICAID? 38

39 DO YOU HAVE MEDICAID OR MEDICARE? HERE ARE SOME TIPS! My Medicaid and/or Medicare plan does not cover my formula? Answer: First do you have a straight plan from the state? If so, the best way to get covered under your plans would be to enroll into a Managed Medicaid or Medicare plan. A supplement plan is not the same as a managed plan. Supplement plans follow the same rules with the straight plans. 39

40 WHAT IS A MANAGED MEDICAID/MEDICARE PLAN? The term managed care or managed health care is used in the United States to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care. A managed Medicaid or Medicare plan is the middle man between your straight care plan and the managed care plan (i.e. Aetna, Humana, United Health Care, Blue Cross Blue Shield, etc.). It offers special needs and leniency towards medical food coverage than a straight state plan. Most state Medicaid plans pushes to a managed care plan. Medicare is your choice. However, best choice! 40

41 HOW DO I FIND A MANAGED CARE PLAN FOR MY STATE? Managed Medicare plans; use Medicare Plan Finder at Or simply call member services listed on the back of your Medicare card. Managed Medicaid plans; call member services listed on the back of your Medicaid card. 41

42 HOW TO GET HELP. Simple Steps of how to get help provided by Compassion Works/NPKUA. Trained and managing the NPKUA volunteer insurance coaching program. 1. For one on one coverage support and more coverage information, please contact the NPKUA Reimbursement Coaches. Call NPKUA to see if there is a Coach in your state. 2. Please visit the NPKUA website 3. Contact Compassion*Works Medical, LLC at (973) or raenettef@compassionworksmrs.com We want to help you get there! 42

43 HOLDING HANDS FOR PATIENT ADVOCACY SUPPORT Compassion*Works Medical mission is to provide Medical Food Coverage/Reimbursement and true patient advocacy support to clinics and people with rare genetic diseases. We are the first responders for coverage support! Together with the National PKU Alliance and other supporters we can go a long way! You are not alone. We are here to hold your hand all the way through the difficult tasks of medical food coverage! Contact: Raenette Franco, CEO, CBCS raenettef@compassionworksmrs.com 43

44 The first habit of the heart: We re all in this together! 44