7 steps to an appeals request in healthcare

The Affordable Care Act, the health care reform law passed in 2010, requires many health plans to meet basic standards regarding internal appeals and external review processes. An internal appeal is when you ask your insurance company to determine if its first decision to deny coverage was a correct one. An external review happens if your insurance company determines that its decision to deny coverage was correct and you believe that decision was in error.

Listen to my podcast for more information. Should you require any further assistance, pls call me at 315 333 0756, to consult further.

Appeal Process podcast

Julia Kohutiak, RN, LNC

Newest Timelines for Obama Healthcare

The Department of Health and Human Services (HHS) has issued three proposed rules implementing provisions in the Affordable Care Act.  The rules are set to become effective in 2014.  The rules outline the following:

  1. Health insurance companies are prohibited from discriminating against individuals because of a pre-existing or chronic condition. Under this rule, insurance companies would be allowed to vary premiums within limits, only based on age, tobacco use, family size, and geography. Health insurance companies would be prohibited from denying coverage to any American because of a pre-existing condition or from charging higher premiums to certain enrollees because of their current or past health problems, gender, occupation, and small employer size or industry.
  2. The second proposed rule outlines policies and standards for coverage of essential health benefits, while giving states more flexibility to implement the Affordable Care Act.  This would give consumers a consistent way to compare health plans in the individual and small group markets.
  3. The third proposed rule implements and expands employment-based wellness programs to promote health and help control health care spending, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status.

The Cloud, the STORM has arrived!

Of all of our overused buzz words, this one seems to be the most ubiquitous in consumer advertising these days (possibly tied with mobile).  What does the Cloud really mean and what are the implications for healthcare?  Cloud computing involves giant banks of connected computers that can handle multiple software applications and data storage at once.  In the past, sharing software applications or storing data was inefficient and had several downsides. Then voila, a genius came along and developed software that would enable you to spread your application and storage across many networked devices.  This led to much more efficient computing.  The good thing is, if one computer breaks no one really notices because the load is balanced by others.

How does this effect healthcare? The power of mobile and the power of Big Data could not be achieved without the added innovation of cloud computing.  As of now, storage of  Big Data is in the Cloud.  These three innovations rely on one another for success.

It is revolutionary, and here to stay  They truly are the epitome of how technology and healthcare have become brothers and sisters.    

Oh That phone thing

Well, I will not repeat my self, and ask for that phone thing again! You ask me why, well, for one thing, do you not spend hours on the phone with claims of finding out what the benefits are, and then get be stuck in a maze of transferred calls, and no one knows what you are asking for? The first thing that needs to be done, is that training inside a managed care company needs to be improved, otherwise you would not be transferred 7-8 times, then when you finally reach your destination, to be told no authorizations are required! Did you say 45 minutes on the phone, waiting to be told this!!! Yes, I believe you.

Technology can do better, and so can the company. So, back to that phone thing!

A thought

Ok, after giving much thought into this new maze of what a healthcare benefit entails, I must say, you really do have to be a rocket scientist. Most policies are not written in the English language, and most claims are done out of the country to save costs. So what does that mean for you, the member? Heartache, gastro intestitnal reflux and some side effects to crohne’s disease, meaning diarrhea.

Honestly, most big insurance companies are making about a 30% profit for their shareholders, so how does that impact you? More deductibles, more cash out of your pocket and more headaches. Very simple, right!  Oy vay, so what can we do? My opinion, we need to do it right, so why not run our own company, and put the profit back into our own company. That is how you will save money.

Now your turn, go ahead and ask me how!

Where does America rank in the world?

With all the hullabaloo that is going on in healthcare, we are a nation that has a lot to answer for. America is currently ranked # 37. WOW!! With all the monies being spent on politics, we need to reshift our focus on the people and for the people!

So what country has the best health care? We took these statistics from the World Health Organization, which measure spending and medical infrastructure in nearly 200 countries across the globe the data shows that:

• The US has the highest health spending in the world – equivalent to 17.9% of its gross domestic product (GDP), or $8,362 per person. And it’s not all private – government spending is at $4,437 per person, only behind Luxembourg, Monaco and Norway.

I say, what a disaster and what a shame for Americans!

Happy blogging!