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Posts Tagged ‘age’

Kaiser News – Health insurance claim denied? Appeal, appeal, appeal

Posted by 4love2love on June 25, 2011

By Michelle Andrews, Kaiser News Service7:47 p.m. EDT, June 23, 2011

Nobody wants to get into a fight with a health insurer, but it may be worth your while. A recent Government Accountability Office report found that more claims problems stemmed from annoying but often straightforward billing and eligibility issues than from disagreements over whether care was medically appropriate. What’s more, the odds are about 50/50 that if you appeal an insurer’s decision, you’ll win.

When Natasha Friedus’s son, Nofi, was born almost two years ago, her insurer refused to pay $1,500 of Friedus’s $7,500 hospital bill because she hadn’t gotten prior authorization for the hospital stay near her home in Seattle. The plan also sent a $600 bill to Nofi, because he’d neglected to inform the insurer that he’d be in the hospital for a few days. “Apparently he was supposed to call before being born,” Friedus says.

The new mother spent hours on the phone trying to sort out the problem, but she got nowhere. Finally, someone suggested appealing the decision to the insurer and asking for retroactive approval for her hospital stay. That did the trick, says Friedus, even though the insurer had never informed her that she could appeal the bills.

Under the 2010 health law, the situation should improve. Health plans will be required to inform members that they can appeal disputed claims internally within the health plan as well as to an independent review organization not affiliated with the health plan.

Coding is everything

As anyone who has tried to decipher a health plan’s “Explanation of Benefits” knows, coding is everything. That’s where many errors occur, experts agree. If the CPT (Current Procedural Terminology) code that describes the medical service or test you received doesn’t correspond to the ICD (International Statistical Classifications of Diseases) code that describes your diagnosis, your claim may well be denied, a decision that will probably be communicated via a “reason code” on your EOB.

Medical services aren’t the only thing that must be in sync with the diagnosis: “The CPT code needs to correlate with age and sex and place of service as well,” says Candice Butcher, head of Medical Billing Advocates of America, which helps consumers resolve medical billing problems. In other words, if the CPT code is for a routine physical for an adult, but the patient is a 10-year-old child, the claim will be denied, says Butcher.

Sometimes claims that appear to be denied because the treatment isn’t appropriate — a particular service isn’t considered “medically necessary,” for example, or is deemed “experimental or investigational” — are actually coding errors, say experts, because the diagnosis code is wrong, for example.

You can’t prevent providers from miscoding your care or insurers from misinterpreting your plan or eligibility, but you can ask your doctor or insurer to cross-reference the treatment with the diagnosis and make sure the two are in sync, says Nancy Davenport-Ennis, chief executive of the Patient Advocate Foundation, which works to resolve these and other problems with health insurance claims.

Phone calls didn’t work

Sometimes even seemingly straightforward billing problems take months to resolve. When Janet Wolfe was hospitalized in central Georgia following a diagnosis of lymphoma a few years ago, she received a $1,600 bill from the insurer because she had stayed in a private room, which their insurer would pay for only if there were no other options. The hospital had only private rooms, but despite numerous phone calls by her husband, Andrew, to try to sort out the problem, the insurer eventually sent the bill to a collection agency.

When the letter from the collection agency arrived, Andrew took it and drove to the hospital. He demanded to see someone who could address the issue. Eventually, with the help of the hospital’s chief financial officer, the insurer removed the charges. “No one was taking responsibility for fixing the problem,” he says.

Getting assistance

Such experiences illustrate the difficulty that people with serious illnesses may face when trying to manage their medical bills, says Stephen Finan, senior director of policy at the American Cancer Society’s Cancer Action Network. Having a family member or someone else to backstop the process is essential. “If [patients] get lost or overwhelmed, there’s someone else who can help them with this critical process,” he says.

Organizations such as the Patient Advocate Foundation are not the only sources of assistance: The new health law provided $30 million for state-based consumer assistance programs to help people appeal health plan decisions.

Claim denial rates vary significantly by insurer, according to the GAO report. In California, for example, the denial rate for six managed care insurers ranged from 6 percent to 40 percent in 2009. Whether you’re insured by a plan that kicks out many claims or only a few, it may pay to appeal. The study found that consumers were successful in appeals filed with insurers in 39 percent to 59 percent of cases. When they appealed to an independent reviewer, consumers prevailed roughly 40 percent of the time.

Before you file an appeal, talk with your insurer to understand why your claim was denied, says Cheryl Fish-Parcham, deputy director of health policy at Families USA, a patient advocacy organization. “The biggest mistake people make is that they write an appeal that doesn’t really address the reason for the denial,” she says.

Have questions for Michelle Andrews? Write to her at khnquestions@kff.org.

Andrews writes for Kaiser Health News an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan healthcare policy research organization. Neither Kaiser Health News nor the foundation is affiliated with Kaiser Permanente.

Copyright © 2011, Los Angeles Times

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Reuters – Heart risks lower in men who get enough vitamin D

Posted by 4love2love on June 24, 2011

Amy Norton Reuters3:22 p.m. EDT, June 24, 2011

NEW YORK (Reuters Health) – Men who consume the recommended amount of vitamin D are somewhat less likely to suffer a heart attack or stroke than those who get little of the vitamin in their diets, a large U.S. study suggests.

Following nearly 119,000 adults for two decades, researchers found that men who got at least 600 international units (IU) of vitamin D each day — the current recommended amount — were 16 percent less likely to develop heart problems or a stroke, versus men who got less than 100 IU per day.

There was no such pattern among women, however, the researchers report in the American Journal of Clinical Nutrition.

The authors say the findings do not prove that vitamin D, itself, deserves the credit for the lower risks seen in men. So they should not start downing supplements for the sake of their hearts.

“The evidence is not strong enough yet to make solid recommendations,” said lead researcher Dr. Qi Sun, a research associate at the Harvard School of Public Health.

On the other hand, the apparent benefits were linked to vitamin D intakes near what’s already recommended: Last year, the Institute of Medicine (IOM), a scientific advisory panel to the U.S. government, bumped up the recommended dose to 600 IU for most people. Adults older than 70 were told to get 800 IU.

So these latest findings may encourage more people to meet those guidelines, Sun said.

But as far as whether vitamin D cuts heart disease and stroke risk, the jury is still out.

Sun said that more answers should come from an ongoing clinical trial that is looking at whether a high dose of vitamin D (2,000 IU per day) can cut the risk of heart disease, stroke and other chronic diseases.

Clinical trials, wherein people are randomly assigned to a treatment or a placebo, are considered the “gold standard” of medical evidence.

So far, there have been few such randomized clinical trials testing vitamin D’s health effects.

A flurry of studies in recent years has linked higher vitamin D intake to lower risks of everything from diabetes, to severe asthma, heart disease, certain cancers and depression.

The problem with those studies is that were “observational” — researchers looked at people’s vitamin D intake, or their blood levels of the vitamin, and whether they developed a given health condition. Those kinds of studies cannot prove cause-and-effect.

The current study was also observational, based on data from two long-term projects that have followed two large groups of U.S. health professionals since the 1980s.

Out of 45,000 men, there were about 5,000 new cases of cardiovascular disease over the study period. These were defined by an incident of heart attack, stroke, or death attributed to cardiovascular disease.

After accounting for a range of factors — like age, weight, exercise levels and other diet habits, such as fat intake – Sun’s team found that men who got at least 600 IU of vitamin D from food and supplements had a 16 percent lower risk of heart attack and stroke compared to men who got less than 100 IU of vitamin D per day.

For women, though, there was no correlation between vitamin D intake and cardiovascular health.

It’s not clear why that is, Sun said. One possibility is that women may have less active vitamin D circulating in the blood; vitamin D is stored in fat, and women typically have a higher percentage of body fat than men do.

But more research is needed, Sun said, to know whether real biological differences underlie the current findings.

In theory, vitamin D could help ward off heart disease and stroke; lab research suggests that it may help maintain healthy blood vessel function and blood pressure levels, reduce inflammation in the blood vessels, and aid blood sugar control.

But until clinical trials help show whether vitamin D works, Sun advised people to stick with the tried-and-true ways of protecting their hearts: maintaining a healthy weight, getting regular exercise, eating a well-balanced diet and not smoking.

“There are many established ways to lower your cardiovascular disease risk,” Sun said. “People can focus on those measures.”

As for vitamin D, the sun is the major natural source, since sunlight triggers vitamin D synthesis in the body. Food sources are relatively few and include fatty fish like salmon and mackerel, and fortified dairy products and cereals.

SOURCE: http://bit.ly/irO9Xe American Journal of Clinical Nutrition, online June 8, 2011.

Copyright © 2011, Reuters

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