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How often do people think of making room for their insurance in their overall budget for themselves and their families? Surprisingly, most people forget to add it to their household budgets, because for most people, a co-pay for a doctor’s visit just doesn’t come up all that often. So most people don’t even think to include it in their budgets at all. For all I’ve seen over my many years of being a medical coder, I highly recommend people start looking at adding the insurance co-pay into their family budgets, if for no other reason as calling it the “don’t get burned by co-pays” column.

If you have an elderly family member who is thinking of switching insurance coverage, please look at what it would truly cost  your senior citizen members of your family if it’s a high amount, because many older family members go far more often to the doctor than most people. And if they live on a fixed income, not looking at how the insurance co-pay fits into their budget can completely implode that fixed income budget with sad repercussions for your family members….case in point below:

I’ve seen too many heartbreaking stories in my almost 20 year career in the medical field, with most of years as a medical coder when a well meaning family member convinces them to go with a higher co-pay amount.

I looked at the older parent and middle aged son seated across from me, he was sure his high copay amount would convince his mom to switch to another insurance. She of course wanted nothing to do with the plan. The copay amount in question? $90.00

So I asked them to do an experiment I came up with years ago while working with many elderly patients over the years in doctor’s offices

“Ok, so $90.00 is an acceptable co-pay for your mom?”

“Yes!” He replied confidently

“So you think it’s a one time and done type of thing?”

“Well, isn’t it? ” Her son wasn’t quite so sure now….

“I wish I could say in a perfect world, yes, one time would be enough. However, we just don’t live in a perfect world. A perfect world only exists in peoples minds, it’s not realistic sadly enough.”

“Ok, humor me for a minute….your mom has to have a procedure for 5 days straight. How many times will she have to pay the copay?”

“Once?” The son asked hopefully.

I shook my head. “It’s a $90.00 co-pay every day she goes for the procedure, so that’s five days at $90.00 a day copay, how much will that cost your mom in that 5 day period?”

The son went deathly pale and he started to sweat. “$450.00” he whispered.

“Exactly, so how will you mom eat or pay the rest of her bills on a fixed income?”

“I see what you mean of having your copay fit the budget, and on mom’s fixed income, the $450.00 for a 5 day procedure or cancer treatment, it’ll obliterate her budget if I insist on the $90.00 for everything covered, but at what expense will that mean to my mom’s care, to my mom?”

” I don’t know.” I answered him honestly “Something to think about, isn’t it?”

He nodded. Two very sobered people walked out of my small home office that day, however, they returned a couple weeks later for me to help them figure out what would be best for his mom’s budget and still get the kind of care he thought his mom deserved.

Out of pocket maximum is the set amount of money you will have to pay in a year on covered medical costs. In most plans, there is no copayment for covered medical services after you have met your out of pocket maximum. All plans are different though, so make sure to pay close attention to plan details when buying a plan.

A deductible is the amount you pay for healthcare before your plan benefits take effect. … Your plan may have an office visit copay and a separate, urgent care copay, and sometimes a separate emergency room co-pay among others. Coinsurance is the percentage of covered healthcare costs you pay after your deductible has been met. Co-insurance IS NOT the same thing as a co-pay. many people get those two terms mixed up all the time and then I have to explain the difference between the two.

A co-payment, or co-pay, is the flat amount you pay at the time of a medical service or to receive a medication. Each health insurance plan establishes these fees up front — they are often printed on your health insurance card. Insurance companies use these co-pays in part to share expenses with you. In addition to cutting a small portion of the costs, the co-pay is also used to prevent people from seeking care for every trivial medical condition they might encounter. In this way, co-pays can save an insurance company a substantial amount of money. However, while the co-pay has been found to lower costs by making people think twice before running to the doctor over a case of the sniffles, they might also prevent people from seeking necessary medical attention. For example, a person with a chronic condition may need to see four doctors over the course of a month, all of which require a $25 co-pay. However, if that patient cannot afford $100 each month, he or she will most likely skip one, if not all, of those appointments. Co-pays can often total hundreds of dollars each month if you have several health ailments. In these cases, many patients begin to pick and choose which medications they deem necessary, making for a potentially dangerous situation. But most would say that the alternative — no health insurance — would be worse.

Is copay included in deductible? In most cases, copays do not count toward the deductible. When you have low to medium healthcare expenses, you’ll want to consider this because you could spend thousands of dollars on doctor visits and prescriptions and not be any closer to meeting your deductible.

Some common questions I get when it comes to co-pays……

Do you still pay a copay if you have 2 insurances? Honestly speaking from my point of view as a medical coder in the back office? It depends on what insurance you have. Not all insurances think of co-pays between insurances in the same way. The other plan can pick up the tab for anything not covered, but it won’t pay anything toward the primary plan’s deductible. If both plans have deductibles, you‘ll have to pay both before coverage kicks in. You don’t get to choose which health plan is primary, meaning the one that pays first. Does secondary insurance pay for copays? Yes, you can use secondary insurance to pay your deductibles. Plans that offer cash benefits can be used to pay for out-of-pocket costs such as deductibles and copays. So that’s cop-pays in a nut shell….your call to action tis time is to go check and see if your co-pay is compatible with your present budget. No sense getting burned if it can be avoided. and keep checking on how co-pays will affect your budget anytime open enrollment comes around.

With Open enrollment just around the corner for many insurances and companies, I thought that sharing the mistakes I see being made day in and day out, and what mistakes I see over and over and over again every year will save some people some heartache and major headaches later on.

This is the time to switch plans if you don’t like what you’ve had for the year. And believe me, people do switch if they aren’t happy with the plan they have that year. A few years ago I had the privilege of helping during the open enrollment period one year for Medicare and it was a truly eye opening experience. It was fast, it was busy and it was crazy. I worked 7 days a week during that entire open enrollment period for Medicare’s open enrollment dates of October 15th thru December 7th. Here’s some things I learned that will help others during open enrollment as a housekeeping type thing:

Write legibly. I saw some of the worst handwriting I have ever seen that could rival a doctor’s. And I read doctor’s writing a lot while I’m coding off the notes from the visit. If the person processing the paperwork can’t read it, it’s heading back to you along with fresh forms to fill out again simply because nobody could read your handwriting! You’ve now lost precious time getting the new paperwork in before the deadline. Is the headache of all that worth nobody being able to read your handwriting the first time??

If you need to, type the information. In this day and age of computers, sometimes it’s easier to type it out instead of filling it out by hand. If your family can’t read your handwriting, this is a good option to do so people will be able to read the forms you filled out for coverage.

Use black ink- It even says on the paperwork write in black ink...I’ve seen purple ink, red ink, green ink, neon orange and a hot pink ink color. If you name a bright color ink not usually seen on paperwork, I have probably seen different bright colored inks on insurance paperwork at least once over the years of my educating people on open enrollment periods. All that does it get you your paperwork sent back with fresh forms and a post it note stating you have to do black ink before it can be processed. While I was doing the open enrollment for Medicare, I had one lady argue with my supervisor that her paper work said to use blue ink, technically, she had used a blue ink which showed she had indeed followed the instructions…… we just couldn’t get it through her head that electric blue ink wasn’t an acceptable blue ink color. My supervisor walked away from that confrontation shaking her head all the way down the hall back to her office.

If you aren’t happy with that year’s plan….speak up. Insurances want to know why your leaving. If mass people are exiting a particular plan, believe me, the insurance is gonna sit up and take notice. The plan won’t improve if you don’t alert the insurance on why that particular plan didn’t work for you. Insurance agencies hate being kept in the dark on things that aren’t working, just like the rest of us. Seriously, if there is a problem you had with a particular plan, speak up so the insurance people can fix the problem with that particular policy if they can!

If your using a gel pen, wait til it dries before folding up the paperwork to mail it in. It smears like crazy if you don’t let it dry first. If you have to wave your hand or blow it dry, that’s perfectly alright. It just looks terrible when it smears all over, making your writing become illegible and you have to fill out the paperwork and have to send it back in again for it to be processed in time by the end of open enrollment.

When it comes to talking to people on the phone during the open enrollment period, it pays to be kind. Nobody wants to be yelled or screamed at. The people processing your paperwork talk to you to make sure everything is in order for a smooth transition to January 1st when the new plan starts, they deserve to have some kindness. Being nasty to people who are working 7 days a week to get your paperwork processed in time for a January start date is not going to win you any brownie points!

1. Check on if your insurance policy will even still be around for the coming year.
2. Check on what policies are available if yours isn’t
3. If the company goes with a different insurance plan for the coming year, make sure the one they pick can still cover what YOU need to have covered.

DON’T BLOW IT OFF!!! I see this so many times, and it still makes me shake my head when I see another patient has blown off the open enrollment….again. It creates a headache not only for me in the back office, it’s a bigger headache for the patient. Don’t believe me? Here’s one of the  examples from my time in the back office…I’ll call him the Scotsman. The Scotsman was a patient who had been coming for years and years. Well, one year, he quickly discovered the doctor’s office no longer took his insurance and since he hadn’t signed up for new insurance, I couldn’t even offer what doctors did take his insurance in the town we were in. So he stayed with our doctors. That was a LOOOOONG year for the Scotsman. He ended up paying out of pocket something like $120,000+ out of his own pocket if memory serves me correctly, because there were a couple surgeries that year, and he had to pay the ENTIRE cost. It wasn’t pretty. The Scotsman kept swearing A LOT in that lovely Scottish brogue of his for that entire year, I just quietly remind him he’d created the situation because he blew it off. When open enrollment finally came around again in October, he asked if I could tag along so he knew what questions to ask. One bitten twice shy. He never blew off another open enrollment period again. He’d learned his lesson. Open enrollment is only for a short amount of time between October and November with the starting date for January 1st. This is your only chance to look over your insurance options. The only exceptions to that rule are if you left the company, had a child join the family, or got divorced or a spouse died. That’s it, end of story.

Check your prescription coverage! Check for price changes and tiers. Different tiers affect pricing on the drugs. Some drugs lose their FDA approved status and check if preferred drugs are covered. You’d hate to find out on down the line your prescription is no longer covered by insurance. That’s a nasty surprise I wouldn’t wish on anybody! Of all the changes I see during open enrollment, this is the biggest change I see every year. I’ve seen so many people cry over the years because they have to switch medicines because insurance no longer covers the old prescriptions, and sometimes they develop allergic reactions to the new medicines. A definite must check on!

Ignorance is NOT bliss! Learn as much as you can about what your employer offers for insurance. It’s much more than medical with a side of dental!

Ask about flex-spending, and dependent benefits( which aren’t just for children, it can be for an elderly relative you care for) These help pay for what insurance covers, and isn’t your family worth that?

Think about the big picture. Think about the insurance you have, and just how much did you use the insurance this year? Make a big list of the care you require or required, and then write down how much insurance you’re going to use the next year ( if you are planning on expanding your family, include those people too, even if you don’t have them here yet. It will save a lot of grief later if you plan ahead, trust me) Most places have online tools to compare plans and costs.

If you decide to switch plans because of a lower cost, your deductible goes much higher and the out of pocket costs are much higher, and it’ll take longer before insurance starts paying. Carefully debate if going with a lesser cost being deducted from the paycheck is worth the higher co-pay costs and higher deductibles you’ll be presented with. And sometimes, the coverage you were planning on, sometimes it’s not going to be covered in most cases. I’ve seen more tears just from this alone over the years being in the back office when most new medical insurance plans start in January of the coming year.

It began when I saw the bag a patient was holding a few years ago. It was HUGE.

It had 27 pill bottles in it, I kid you not. The only reason I know that is because I helped pick them up after they spilled out of the bag when the patient was asked to show what pills she took..

The receptionist had asked her what medications she had, and the next thing I witnessed was pill bottles going all over the place, on the counter, some bounced on the floor, and one actually rolled over to the front door. The patient was just a wee bit embarrassed to say the least. I quickly went over to help pick everything up. We got the patient settled in the exam room and I took the bag to quickly write down what everything was for, so the doctor could look it over. I’m still surprised to this very day that I could still read my writing 20 minutes later because I was jotting everything down so fast so I could get this HUGE bag back to the patient to take back home with her.

Unfortunately, many people do that. Not only is it kinda dangerous, sometimes the pill bottles had expired and the doctor notices it first. Not a good idea, unless you want an earful from the doctor…..

After working as a float coder for many offices, I came up with an idea. I have used this one idea for several years now.

I simply call it “the list” and those whom have seen it, think it’s brilliant because you have all the information in one place. Another plus is with everything going electronic for medical records now, you can actually scan the page in at the doctor’s office and they have all the information at their fingertips when they bring up your chart on the computer.

While everybody is different, I have a few things that help doctors out the most being on a list

ALLERGIES– List all of them, also include if it runs in the family or not. Include Food, Medicines, Nuts-EVERYTHING- and put what happens when the allergy happens, like hives, rash, blisters, shortness of breath, etc. It helps the doctors. I remember working in a small office when the pharmacy called and asked if the doctor had a death wish for this one particular patient. It turned out the patient was allergic to sulfates, and that medicines the doctor had prescribed were all sulfate based. There was nothing in the patient’s chart that clued the office that there was a sulfate allergy. Nothing! I shudder to think what would have happened to that patient if the pharmacy hadn’t called asking a serious question. It saved a life.

CHRONIC CONDITIONS- what chronic conditions you have and how bad it gets, also put if the chronic conditions run in the family. Both sides of the family if it applies. Some chronic conditions are hereditary. It can clue the doctor in to how long it’s been affecting the entire family.

MEDICATIONS– Put down dosage, what time you take it or how many times a day you take it, and how long you have been on it.

SUPPLEMENTS– this is the place you put vitamins, etc. Believe it or not, sometimes vitamins counteract with some medicines. It helps the doctor know what your taking

SURGERIES– put what surgery, what age you were at surgery, etc.

CANCERS– if you’ve had cancer put it down. put age at time of diagnosis, if a family member had had cancer, put it down. Breast cancer is one that is hereditary. Prostate cancer is another one that runs in families. Having that will help the doctor assess your risk, especially when cancer runs in your family. The risk goes higher with every generation.

FOR WOMEN– date of 1st period, last mammogram and pap smear done.

SMOKING– put age started, how many packs a day smoked, also include when you quit if that applies.

BLOOD WORK– Write down when it was done, what the blood draw was for, etc. I had a childhood friend tell me one day that she got so tired of having to repeat information because nobody shared it. If you have the actual blood draw record, so much the better. Also put down if you have problems getting blood drawn– veins collapse, you bruise horribly after a blood draw, etc. I personally feel faint at the sight of blood (one reason I became a medical coder instead of a nurse) so they have to do blood draws with the smallest needle possible for me or else they’re picking me up off the floor because I fainted. I will be the first to admit I close my eyes when I have my blood drawn, I find it helps me immensely when I do that

IMMUNIZATIONS-put everything down. most doctors’ offices don’t always have updated records of immunizations.

While this isn’t a complete list by any means, it does give people a chance to get all the information in one place. Make a list for every member of the family.

Believe me, the Doctor will thank you when you hand the list to the front desk for them to scan into your record.  Having that list at their fingertips will help you get the best care possible.

Advocating for a loved one is always scary, however, it’s necessary.

A dear friend of mine took her husband to the ER three years ago and it had a nightmarish quality and it became a complete and utter circus I’m afraid.

In the ER my friend’s husband was diagnosed with kidney stones. It was ONLY AFTER he was admitted did they find out that there were no resources in order to treat him. And they were informed that the only way her husband could be taken to a different hospital was if it was life threatening. I was floored when I heard that update. Their nightmare had begun. The hospital kept promising my friend that things would work out, and then nothing would happen, and her husband was getting sicker and weaker by the day.

I told my friend through DM (we’re Instagram buddies and we live in the same city right now) that she needed to call the number on the back of her insurance card and ask for some help from the insurance. Since she hadn’t had good insurance previously, this was something she hadn’t known about until I mentioned it. For a person who normally avoids talking on the phone, this friend of mine became an absolute warrior. She was telling the insurance what was going on and one of the customer service agents went above and beyond to get my friend some answers and see what to do. My friend called her an angel. She had a caseworker for her husband by the end of Monday. When my friend started making some noise to get attention to her husband’s dilemma, other people started doing stuff too. She recruited her father-in-law, a retired doctor to help her advocate for her husband since she was running on empty. She hadn’t slept much and it was showing. I’m so glad she recruited her father-in-law to help because things started to push forward. I smile every time I think of her father in law doing the best freaking ballsy move I have ever seen before or since by a retired physician. Her father-in-law called the hospital every single time he had a new question and got updates when his daughter in law was stonewalled, told the wrong thing and basically lied to. Not the best way to treat the wife, ya know?

Once a case manager from the insurance was on board, they were working on trying to move her husband to a new facility. Well, the CEO and the head nurse came to visit her husband to see what the heck was going on. He personally called a doctor and surgery was scheduled for Tuesday morning. While they had a brand-new urology department, it hadn’t been used because there were no staff to man it.

Tuesday morning everybody was eagerly awaiting news that they had gotten the kidney stones out. NOPE! One of the kidney stones was deeply embedded and there was now an infection. The urologist that had been brought in to do the procedure was at his wits end and frustrated with the administration. My friend learned he’d been in the ER department all day the day before, and not once was my friend’s husband’s case brought up to the urologist. Not once! In fact, by the time the call came for him to come do the procedure, the doctor was home for the night and in bed already! To say that physician was beyond livid when he learned of this case is putting it rather mildly.. My friend’s husband had another procedure done and he was able to go home and be with his family as he recovers from this nightmare of a hospital stay.

If you think that was the complete end of the story, you’d be wrong. When all the bills came due, it totaled a whopping amount. You ready for this? The hospital charges totaled $84,000.00 and no, they never sent anything into the the insurance. I told my friend to call the case manager immediately. Like now. I’d told my friend the news would not be taken very well. I was right. The news went over like a lead balloon and it got the hospital investigated by not only my friend’s insurance, the hospital is being investigated by 4 of the biggest insurance companies in the country right now. Insurance takes stuff like this quite seriously. The insurance really saw red when the hospital sent the bill to collections. There is a law (The Medical Debt Collections Act) that collectors must wait 180 days after the initial billing before they can contact the debtor

So if you want to advocate for a loved one here’s some tips:

1. Call the customer service number on the back of your insurance card. insurance is there to help. Besides, the insurance keeps track of what’s going on and if there’s a huge problem brewing, they can get some headway and get a case manager for you
2. Recruit family to help make phone calls and make some noise if nothing is being done
3. Keep at it. You may be tired, however, you may be the only one advocating for your loved one.
4. If necessary, bring in the newspaper and the nightly news. Sometimes shedding light on the bad stuff gets stuff changed so it won’t happen to another person like it did to your family.

So here’s 8 tips on how you can get started to advocate for yourself and a loved one.

Believe in Yourself!!!! I can’t stress this one enough. If you don’t believe in yourself, nobody else will believe in you either. Take this chance to shine and get our voice out there for what you want(within reason of course)

Know Your Rights-You are entitled to equality under the law. Some who have had mental health challenges erroneously believe that they do not have the same rights as others.

Decide What You Want Clarify for yourself exactly what you need, be it a procedure or surgery. This will help you set your own goals and help you be clear to others about what it is that you want and need for yourself.

Get the Facts When you advocate for yourself, you need to know what you are talking about or asking for. The internet is an excellent source of information. However, you will need to check its accuracy by looking at several different references to see if they agree. I myself, use at least 5 different vantage points when doing research of what I need to ask for to advocate for myself. Check with people who have expertise in what you are considering. Ask others who have issues similar to yours. Check references in the library. Contact mental health agencies and organizations for information and support.

Planning Strategy Using the information you have gathered, plan a strategy that you feel will work to get what you need and want for yourself. Think of several ways to address the problem. Ask supporters for suggestions. Get feedback on your ideas. Then choose to take action using the one that you feel has the most chance of being successful. Gather Support In advocating for what you need and want for yourself, it is helpful to have support from family members, friends and other people who have similar issues. This one is HUGE. The more support you have, the better things can get worked out to getting what you need or have changed. Target Efforts Who is the person, persons, or organization you need to deal with to get action on this matter? Talk directly with the person who can best assist you. It may take a few phone calls to discover which organization or person can help, or who is in charge, but it is worth the effort. Keep trying until you find the right person. Sometimes this will take longer than you think it will, plan your time with a buffer around it to make sure you don’t run out of time trying to find the right person to talk with.

Express Yourself Clearly When you are asking for what you need and want for yourself, be brief. Stick to the point. Don’t allow yourself to be diverted or to ramble on with unimportant details. State your concern and how you want things changed. If the other person tries to tell you reasons why you cannot achieve what it is you want for yourself, repeat again what it is you want and expect until they either give it to you, help you get it, or refer you to someone else who may be able to give you what you need. If you feel this may be difficult for you, you may want to role-play different scenarios with a supporter or a counselor. Assert Yourself Clearly Don’t lose your temper and lash out at the other person, their character or the organization. Losing your temper over something is never a good thing. Speak out, asking for what you need and want and then listen. Respect the rights of others, but don’t let them “put you down” or “walk all over you.”

Be Firm and Persistent Don’t give up! Keep after what you want. Always follow through on what you say. Dedicate yourself to getting whatever it is you need for yourself. Also keep a running written log for proof of your tries and the results or non-results of those tries to get something moved forward.