PHA Case Study – Coverage denied for an experimental treatment

May 27, 2011


Mike had a Metatarsophalangeal Joint (MPJ) replacement surgery that his insurance company consideredexperimental and therefore did not cover. He appealed, but coverage was denied. Working on his behalf, his Personal Health Advocate gathered research documentation about the surgery and drafted a letter to submit to an Internal Review Office for review. The denial was subsequently overturned based on the research supporting the benefits of the procedure. This saved Mike over $11,000 in hospital fees. Soon after, the insurance company updated their medical policy to cover surgery for certain procedures they did not previously cover.

What The Healthcare Survival Guide Says:

Talk with both your doctor and insurance company about your treatments before services are rendered to make sure you are covered. Watch out for condition exclusions relating to certain conditions – some plans may specifically exclude coverage for heart disease, cancer, or pregnancy, for example (pg. 26). If you do have a pre-existing condition and were previously covered before job termination, you can’t be discriminated against for healthcare coverage (pg. 24). If you have a chronic, life-threatening, and/or debilitating disease, the Patient Advocate Foundation (PAF) can help you with a range of healthcare issues, including insurance appeals and patient education (pg. 37).


Affordable Care Act rule aims to increase transparency, moderate premium costs

May 24, 2011

Last week, the Department of Health and Human Services issued a final regulation to protect consumers from unreasonably large increases in their health insurance premiums. On September 1, 2011, it will be required that premium increases of 10% or higher be thoroughly reviewed by states and federal officials. In September 2012, that 10% threshold will change to a percentage varying by state in accordance to its specific health and insurance trends.

HHS has been working with the states to improve their oversight capabilities, and has additionally awarded them $44 million in Affordable Care Act grants. Another $200 million will be available to the states as well. This new regulation, combined with other protections from the Affordable Care Act, should help to moderate premium hikes, and ultimately provide the consumer with more value for their premium dollar.

The rule also requires that insurance companies provide the consumer with clear, easily understandable reasons for any “unreasonable” rate increase (again, 10% until Sept. 2012). These justifications must be posted by the insurance company on both their own website and HHS’ Affordable Care Act website ( 

Significant premium increases will be up for review not only the states, but also the consumers. When reviewing rate increases, states must provide the public with an opportunity for input. With this rule, transparency can help to lower costs, and consumers will have a chance to have their say in determining a reasonable premium cost.

Click here to learn more.

PHA Case Study – Unexpected charge for emergency care

May 20, 2011


 Laura received a bill for an emergency service after her husband Joe, stricken with colon cancer, had to be rushed to the emergency room and admitted. Because Laura had not notified her insurance company of the admittance within 24 hours, they imposed a 50 percent penalty, resulting in a shocking $20,000 hospital bill. Laura’s Personal Health Advocate helped her successfully appeal the bill and the denial was overturned. Unfortunately, during the appeal process, Joe passed away, leaving Laura with three small children and overwhelming debt. The sizeable sum saved by the appeal helped to ease the burden during this challenging time.

 What The Healthcare Survival Guide says:

 To avoid surprises, don’t assume that your health plan covers every aspect of your hospitalization. Make sure before you are admitted that procedures and all doctors including the anesthesiologists, for example, are covered (pg. 41). Check to see if there are exclusions that include emergency room servicees. Get familiar with your plan’s appeal process. One important step to dispute a claim: gather papers, take careful notes of each conversation and every person you talked to (pg. 44).

If you would like a free copy of The Healthcare Survival Guide: Cost-Saving Options for the Suddenly Unemployed and Anyone Else Who Wants to Save Money, you can download it at

PHA Case Study: Underinsured Patient Facing Foreclosure

May 13, 2011


Edward, a part-time worker, had insurance coverage but not enough to cover several large hospital bills. Edward’s Personal Health Advocate informed him about “hardship/charity” assistance available through the hospital and helped him fill out the paperwork. As a result of this assistance, his inpatient hospital bills were cancelled. His PHA also negotiated with his physician to reduce Edward’s medical bills by 30 percent and worked with his insurance company to successfully reprocess and pay his past bills. Edward stated that without the PHA’s help, he faced bankruptcy and losing his home.

What The Healthcare Survival Guide says:

No matter what your income or health status, there are free or low-cost government and private options available. One example: free clinics for basic check-ups and screenings (pg. 17). Healthy individuals or those with a job on the horizon might consider a short-term mini-medical/limited benefit plan (pg. 31). The take-away: comparison-shop for what you need and read the fine print carefully. “Affordable” can mean exclusion of hospitalization, leaving you with big bills in a crisis. Look for drug coverage, limitations of doctor visits and other missing parts (pg. 26).

If you would like a free copy of The Healthcare Survival Guide: Cost-Saving Options for the Suddenly Unemployed and Anyone Else Who Wants to Save Money, you can download it at

Wellness Events – May

May 3, 2011

As a part of our ongoing effort to find you the best care at the lowest cost, we again bring to you a list of free & low-cost wellness events.

We would like to note that from now on, we will put up these wellness event entries on a monthly basis, editing the post over the course of the month as we find new events – keep an eye out for updates at

Take a look below for an event near you, and please feel free to leave us a comment if you know of any events we may have missed.

* Denotes a recurring event. Click on the city for full details of the event.

New York City, NY – 50+ Yoga*; Blood Pressure Screenings* Stroke Awareness (May 26th)

Silverdale, WA – Free Women’s Health Seminar w/ health screenings (May 13th; RSVP by May 11th; there’s a 20-person limit) 

Macomb, IL – Diabetes Grocery Store Tour (May 24th, Free: If you have Diabetes or are at risk for it, check this tour out; you can learn how to read labels and decipher the carbohydrate and fiber connection)

National Women’s Health Week  National Women’s Health Week – The link will take you to Women’s Health National Directory of events for NWHW, including health clinics, STD clinics, wellness seminars, and more.

Longboat Key, FL – Free Cancer Support Group* (Mondays)

Sarosta, FL – Natural Breast Health (May 17th); Hearing Health Seminar (May 18th); Free Cholesterol & Diabetes Screenings (May 24th)

Baltimore, MD – Cancer Support Groups* (1st Wednesday of every month); Caregiver Education & Support Group* (1st Wednesday of every month); Free Glaucoma Screening (May 9th); Diabetes Eye Disease and Diabetes Support Group (May 16th); 10th Annual Senior Health & Fitness Day (May 25th); Smoking Cessation Classes (Time & Date of classes depend on location); Free Skin Cancer Screening (May 9th/16th, depending on location); Free Cararact & Diabetic Eye Screening (May 17th)

Hanford, CADate & Time vary by location; call for appointments. Immunizations; Reproductive health clinic services; STD Clinic, Preventive healthcare for adults; Senior Services.

Events from these previous entries are also recurring, so check them out here and here for events near you.