National HIV Testing Day is June 27!

Some quoted excerpts from AIDS.gov:

“HIV” stands for Human Immunodeficiency Virus. To understand what that means, let’s break it down:

  • HHuman – This particular virus can only infect human beings.
  • IImmunodeficiency – HIV weakens your immune system by destroying important cells that fight disease and infection. A “deficient” immune system can’t protect you.
  • VVirus – A virus can only reproduce itself by taking over a cell in the body of its host.

HIV is a lot like other viruses, including those that cause the “flu” or the common cold. But there is an important difference – over time, your immune system can clear most viruses out of your body. That isn’t the case with HIV – the human immune system can’t seem to get rid of it. That means that once you have HIV, you have it for life.

CDC estimates that 1,201,100 persons aged 13 years and older are living with HIV infection, including 168,300 (14%) who are unaware of their infection. Over the past decade, the number of people living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. Still, the pace of new infections continues at far too high a level—particularly among certain groups.

Within 2-4 weeks after HIV infection, many, but not all, people experience flu-like symptoms, often described as the “worst flu ever.” This is called “acute retroviral syndrome” (ARS) or “primary HIV infection,” and it’s the body’s natural response to the HIV infection.

Symptoms can include:

  • Fever (this is the most common symptom)
  • Swollen glands
  • Sore throat
  • Rash
  • Fatigue
  • Muscle and joint aches and pains
  • Headache

These symptoms can last anywhere from a few days to several weeks. However, you should not assume you have HIV if you have any of these symptoms. Each of these symptoms can be caused by other illnesses. Conversely, not everyone who is infected with HIV develops ARS. Many people who are infected with HIV do not have any symptoms at all for 10 years or more.

Today is the day to get tested if you think you are potentially at risk of contracting HIV. Call your doctor or check out the AIDS test site locator to find a place near you for testing.

 

Saturday Night Plans? Rock The Park Movie Series: The Sandlot

Don’t have anything else to do this weekend? One of my favorite movies of all time (The Sandlot) is playing tomorrow night at 8:30pm at Durham Central Park. The admission is free, food trucks will be on site, and you get to watch Benny and the Beast! I bet you can’t watch the trailer without wanting to go see this great movie in the park!

 

June 15-21 is National Men’s Health Week!

June is Men's Health Month

June 15-21 is National Men’s Health Week! During this week, men should attempt to make at least one change in their lives that will help improve their health. From menshealthmonth.org:

The purpose of Men’s Health Week is to heighten the awareness of preventable health problems and encourage early detection and treatment of disease among men and boys.

This week gives health care providers, public policy makers, the media, and individuals an opportunity to encourage men and boys to seek regular medical advice and early treatment for disease and injury. The response has been overwhelming with hundreds of awareness activities in the USA and around the globe. For a partial list of activities, click here.

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National Cancer Survivors Day is June 7!

National Cancer Survivors Day

From the official National Cancer Survivors Day website press release:

This unique celebration will mark the 28th annual National Cancer Survivors Day®. Thousands of people in hundreds of communities across the globe will hold celebrations on this day to honor cancer survivors and to show the world that life after a cancer diagnosis can be fruitful, rewarding, and even inspiring.

Anyone living with a history of cancer – from the moment of diagnosis through the remainder of life – is a cancer survivor, according to the National Cancer Survivors Day® Foundation. In the United States alone, there are more than 14 million people living with a history of cancer. Major advances in cancer prevention, early detection, and treatment have resulted in longer survival, and therefore, a growing number of cancer survivors. However, a cancer diagnosis can leave a host of problems in its wake. Physical, financial, and emotional hardships often persist for years after diagnosis and treatment. Survivors may face many challenges, such as limited access to cancer specialists and promising new treatments, inadequate or no health insurance, financial hardships, difficulty finding employment, psychosocial struggles, and a lack of understanding from family and friends.

In light of these difficulties, our community needs to focus on improving the quality of life for cancer survivors. “Despite the numerous challenges they face, cancer survivors live full, productive lives and serve as an inspiration to all of us,” says the press release. “It’s time for our community to stand with them and help find ways to lessen the burdens a cancer diagnosis brings.”

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June is National Migraine Awareness Month!

National Migraine Awareness Month

From ACHE, The Fred Sheftell MD Education Center:

June is National Migraine Awareness Month, and this year’s theme is help make Migraines visible!

There are a number of reasons to help make Migraines visible. Two of the most significant of those reasons are:
  • Ridding ourselves of the myths and misconceptions about Migraines and the resulting stigma. Studies have shown that the stigma associated with Migraines increases the burden of living with the disease
  • Making Migraines more visible could result in more research funding which, in turn, would result in more and better treatments.
Educating ourselves and others and building awareness about Migraines are the best methods we have of making Migraines visible, and this is an area where each individual can make a difference. This isn’t something we need or should sit back and leave to others or to the professionals. There are more than 37 million people in the United States who have Migraines. Can you imagine what we could accomplish if just 10% of us got serious about educating others and building awareness about Migraine? That would be 3.7 million of us, and just think what we could do!

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Food Allergy Awareness Week is May 10-16!

Food Allergy Awareness Week turned into Food Allergy Action Month at some point, was created to help raise awareness for the From FARE:

In 1998, the Food Allergy & Anaphylaxis Network, now FARE, created Food Allergy Awareness Week to educate the public about food allergies, a potentially life-threatening medical condition. This year’s awareness week falls on May 10-16, 2015, but we will have activities and ways to get involved throughout the entire month of May for Food Allergy Action Month. This is a special opportunity to shine a spotlight on food allergies and anaphylaxis. There are many easy ways you can get involved in raising awareness, educating others and inspiring action.

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Determining Plan Details

Determining Plan Details

One of the most common problems that people experience with their health insurance is the frustration of having to pay out-of-pocket for a service or prescription that they thought would be covered by their insurance plan. “I thought that was covered” is a common phrase with patients and most of the negative perceptions of health insurers stem from the general distrust that this reaction causes. People are skeptical about insurers covering certain things because they have been burned in the past and see insurers as being greedy whenever they end up owing more than just their premiums for their healthcare expenses. While insurers do sometimes make mistakes and deny things that should be rightly covered (which you have the right to appeal), your insurance is usually processing your plan’s benefits exactly how they said they would when you signed up for the plan. They probably even have your signature on a sheet of paper saying you agreed to their terms. Sneaky, I know.

The problem usually begins because patients misunderstand their coverage and get surprised when they see the differences in benefits from what they thought they would have to what they actually have. The new Farmers Insurance commercials are really a perfect example. Knowing your coverage could influence your decision on where and when to get treatment and help you reduce your overall out-of-pocket expenses. It will also keep you from being surprised with unexpected bills or regretting services that you wouldn’t have done if you knew the cost. You may even change plans entirely because you realize your coverage is terrible, or if you are paying too much to have coverage for services you don’t need.

Because all plans are unique, it is impossible to make a single guide that covers everyone to determining your coverage. This post is designed to help you understand the thought processes and terminology behind determining your plan’s details so you can navigate through your own insurer’s information with a good idea of what you should be looking for.

Which health insurance plan do you have?

This is probably one of the first questions you’ll have to answer and is the starting point for all other questions you’ll be asked in every possible healthcare situation. When someone asks you what health insurance you have, what do you say?

bcbs_insurancecard
Example Insurance Card

There are two things your healthcare provider or pharmacist is always looking for when they ask this question.

  1. The name of your insurance provider. This is the most basic starting point and 100% necessary for your provider to determine your plan details. Examples include Blue Cross Blue Shield (BCBS), CIGNA, Aetna, United Healthcare, etc.
  2. The plan type and/or name of plan. This is the first subsection of the insurance provider and describes the plan option you chose when signing up with your insurer. Sometimes the plan has an actual name. Examples of BCBS plans include Blue Advantage, Blue Value, Blue Options, Blue Saver, State Employees Health Plan, etc. The plan could also only be described by letters, like PPO, HMO, POS, EPO, etc.

Depending on the situation, your provider might also need some additional information. Typically, you will be asked for the rest of this information if you are going to be receiving medical services or prescriptions, if you need a prior authorization for anything, or if you are being referred to another doctor.

  1. Your Subscriber Number. This is the first basic identifier on your insurance card. It may also be called your Member Number, Identification Number, or something else similar. This is the biggest and most important number on your card, so it is probably highlighted in some way. If you have dependents on your plan, the Subscriber Number includes the two digit suffixes assigned to each dependent. For example, Dad could be ABCD0000-01, Mom could be ABCD0000-02, and Daughter could be ABCD0000-03.
  2. Your Group Number. This is usually the second most featured number on your insurance card and allows your provider to see which pool of subscribers has a similar plan. This is usually unnecessary for most purposes, but is generally required if you need a prior authorization so it is good to have on file. The group number also helps providers figure out your plan details when you have private employer-based plans or some of the more obscure plans available that they might not see that often.
  3. The Payer ID # or the Billing Address. This is necessary for billing your insurance, but most providers already know the proper way to bill your insurance provider and don’t necessarily need it if you have a popular insurance plan. If your plan is based out-of-state or if you have a smaller, more obscure plan, you will probably be asked for this information. The Payer ID # is a 5 digit number on the back of your card and should be somewhere near the Billing Address.

That information will help your provider process your claims, send referrals, and obtain necessary prior authorizations. It will not allow your provider to tell you how much you will owe for a service or what types of benefits you have on your plan. Knowing your basic plan details only guides your provider so they can use the proper channels to correctly process your insurance benefits – it will not help them predict what those benefits will be, or even if there are benefits allowed for a service, at all.

Because plan details can vary on an individual basis, it is impossible for your provider to predict your benefits with complete certainty. We process the claims at the time of service with every piece of verifiable information we have available, but there are always surprises.

For example, you may pay a $20 copay for your visit. Then, after your plan processes the claim and says you are not covered for that service, you find out that you are required to pay 100%, instead. This is why it is important for you to know your own coverage – you are the person that is impacted by how your claims are processed and are ultimately responsible for any surprises that happen with your plan, so it is best to avoid them!

What are my benefits for this service?

The primary thing everyone wants to know – how much do I have to pay for this? There are several methods you can use to figure out your plan’s details for a particular service and the types of benefits you can expect to receive.

  1. Look at your insurance card. This is a “snapshot” of your coverage and usually shows the most pertinent details of your plan. The problem with relying on this is the lack of detail and explanation for your coverage for specific services, or the types of exclusions or exceptions that may be active on the plan. With most plans, this shows what you’ll need for the majority of the services you’ll receive.
  2. Reference your enrollment paperwork and benefits package. Whenever you sign up for a new insurance plan, your insurance provider is obligated to send you a detailed package that includes your plan’s coverage benefits. This is usually sent within a couple weeks of your enrollment and may be updated each year with a new packet of information. Usually, there is a table of information included with three columns – the service type, the plan’s in-network benefits for that service, and the plan’s out-of-network benefits for that service. Whenever you visit a provider or facility, reference their section on this table to help predict what your benefits will be for that visit.
  3. Contact your insurance provider. On the back of your insurance card, there should be a customer service number that you can use to ask any questions you may have about your plan. They will always give you a standard “this call does not guarantee payment of services and benefits will be subject to the plan’s details at the time of service” spiel to make sure they aren’t promising coverage they can’t provide, but they should be able to tell you what your copayments or deductibles are and how they apply to certain types of providers and services. Most plans have online portals with customer service emails or live chats, as well, but the process is the same. You’ll want to contact your provider for the CPT Code they will use for the service and ask your provider specifically about your benefits for that code.
  4. Look at how previous visits processed under the same plan. Past coverage is a good predictor of future coverage, but only if the plan’s details have not been changed. If you had a $25 copayment for a sinus infection six months ago, and your plan has not changed since then, you will probably owe a $25 copayment for a sinus infection today. This could be a little problematic because it refers to your benefits at a previous date, rather than your benefits today, so make sure your plan details have not been modified since the service you are using as a reference.
  5. Just hope something is covered and deal with it later. This is probably the worst option, but it is usually the one most people end up choosing because they are either intimidated or frustrated or confused with the process for actually understanding their benefits. Because this experience just ends up perpetuating the “patient-versus-insurance” mindset, when the two should be working together towards the mutually beneficial goal of reducing the cost of healthcare, I hope this post helps people avoid this option!

This was a basic summary of ways you can determine the details on your insurance plan.  This is the fourth post in a series on understanding the insurance claim process. In the rest of the blog posts in this series, I will explain the specifics involved in your EOB, including detailed information on the following topics:

  1. What is an Explanation of Benefits Letter?
  2. Basic EOB Terminology
  3. Determining Patient Responsibility
  4. Determining Plan Details
  5. Accessing Online EOBs
  6. Understanding Denials and Denial Codes
  7. How To File an Appeal

If you have any specific questions or topics you would like us to discuss, please mention them in the comments below and we will address them in future posts. If you are a patient at Family Care and have any questions about EOBs you received for claims from our office, please let us know by filling out our contact form. Thank you!

April 25 is Healthy Kids Day!

Healthy Kids Day is an annual initiative created and sponsored by the YMCA. Here is a description of the Health Holiday from their website:

Summer is the time for kids to get up, get out and grow. But for some kids, exposure to activities that stimulate the body and mind ends with the school year. In fact, research shows that kids are prone to gain more weight and fall behind in studies. On April 25, the Y will celebrate Healthy Kids Day®, our national initiative to improve the health and well-being of kids.

The goal of the holiday is to raise awareness for negative impact that unhealthy childhood eating and exercising habits have throughout a child’s life and make it a priority to develop healthy habits at an early age. This site has a lot of useful information that parents can read to make sure they are enabling their children to be able to lead a healthy lifestyle as adults. Here are a couple excerpts:

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World Immunization Week is April 24 – 30!

From the World Health Organization (WHO):

The theme of World Immunization Week 2015 is “Close the Immunization Gap.” The gap between the 1 in 5 children who still do not receive basic life-saving vaccines, as well as to the gaps in progress towards the targets set by the Global Vaccine Action Plan (GVAP). The GVAP envisions a world where everyone lives life free from vaccine preventable diseases – whoever they are, wherever they live – by 2020.

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PinWHEELS For Prevention Family Fun Day is April 19

If you need any plans for the weekend, the Exchange Family Center is hosting PinWHEELS For Prevention Family Fun Day on Sunday, April 19, 2015. The event is at the Wheels Fun Park in Durham and is designed to help prevent abuse and neglect for children in the Triangle. For $12, you can get unlimited access to the skating rink, skateboard park, and jungle gym, as well as two go-kart rides, two batting tokens, and a round of mini golf. Families or groups can even get a $10 discount by purchasing 5 passes for $50. For an extra $3 per person, you can also participate in a 1 mile fun run. I feel like I could probably run a mile for free on my own, but the $3 goes to a good cause and you are still getting a great deal on the fun stuff to do at Wheels. For more information, check out their website. Have fun!