Obamacare solutions.

Patient Navigator worked with various families during the 2013-14 open enrollment season to help them navigate the Affordable Care Act exchanges, understand their options and make choices.  In each, the families ended up with a better plan for less money.  One family of four saw its premiums reduced by 60% (without benefit of subsidies), another was able to find coverage for their adult special needs son and a third was pleased to learn she would pass less for her medication with her new plan.  Each client was pleased to have expert guidance in what is admittedly a complicated undertaking.

Patient Navigator saved Medicare patient $10,196 by negotiating bills.

Carl’s mother, through a series of unfortunate events, let her Medicare B premiums lapse.  It was many months before Carl realized his Mom had lost coverage.  We attempted to reinstate Medicare B through a Special Enrollment request and sought the help of Mom’s Congressman.  Unfortunately, this was denied.   Meanwhile, Mom fell twice and broke two separate bones.  While Medicare A picked up the hospital bills, all the physician, outpatient and ambulance bills were not covered.  The family was faced with many thousands of dollars in bills.  Patient Navigator negotiated with each provider individually to either eliminate the debt or reduce it substantially.  Our very persuasive letter and phone calls made a strong case and in every case, the provider cooperated.   Carl’s mom reapplied for Part B and it will take effect July 1, 2014.

Patient Navigator saves our client $15,936 by negotiating a 50% discount on medical bills.

Our client was not insured.  Unfortunately, he was hospitalized after an accident and incurred enormous hospital and doctor bills.  He was very anxious about the situation, the stress of which was impeding his recovery.  Patient Navigator worked with the hospital billing office and secured a 50% discount on his outstanding hospital. Our client saved $15,936 just from his hospital bill and avoided bankruptcy. His doctors then also also reduced their bills by 50%, saving thousands more. Elisabeth handled negotiations quickly, professionally and forcefully resulting in a 50% discount across the board…She has saved me tens of thousands of dollars and most importantly, she provided wonderful personal support and empathy as I struggled to not only heal from my injuries and surgeries but to also deal with my providers. Her support greatly enhanced my self esteem and confidence.”

Patient Navigator won a $27,580 insurance on behalf of our client.

In January 2011, after months of appeal, letters, phone calls, a well-documented complaint lodged with the State Insurance Commissioner, repeated and diligent pressure and follow-up, Patient Navigator convinced a major mental health insurer to cover its share of 4 weeks of inpatient treatment for our client. His family received $27,580, the full amount allowable under his insurance plan. He wrote us to say “You are a hero, a champion, a medalist, a gladiator!”

Patient Navigator saves client over $9,000 by cutting bill in half.

An uninsured, non-English speaking patient came to us in desperation after an emergency hospital stay.   Her hospital bills were over $18,000 and she was at a loss.  Patient Navigator intervened to negotiate a 50% reduction of the hospital bill, a discount her doctors then honored as well.   A payment plan was set up and the client feels more secure about her financial future now.

A family finally wins.

A family with a medically fragile young child struggled for years with its insurance company to obtain the care, treatments and equipment the child needed.  They were overwhelmed with all the paperwork, denials, missed payments and constant roadblocks erected by the insurer.  When Debora Harvey, our insurance specialist, got involved, we began a systemic effort to sort things out.  The final victory came in a meeting with the insurer, the employer and the family during which Patient Navigator produced reams of documentation to prove the insurance company’s obstructionism, mistakes and shenanigans.  As a result of that meeting, the insurer provided a personal, high level representative to solve problems and to implement systems so that this family’s claims would get paid fully on time.  The family wept with gratitude and the new system is working smoothly.

Victory in insurance appeal allows teenage girl to get help.

A teenage girl was suffering from a debilitating, but little-known, mental illness. Despite her parents’ persistent efforts to obtain the specialized services she needed following several emergency hospitalizations and treatment attempts, the insurance company refused to allow treatment in the one hospital equipped to help. After futile efforts through the insurance company’s internal appeal process, the family turned to Patient Navigator. We immediately prepared a detailed, documented case and appeal submitted to the Insurance Commission and Ombudsman of that state. The appeal was again denied, but Patient Navigator lodged another level of appeal. The insurance company finally agreed to cover the hospitalization that would save this teenager. She has returned to school after missing an entire year while the insurance company refused to help her. Her parents said, “Words cannot express how fortunate we are that we hired Patient Navigator to advocate on our behalf in dealing with a denial of medical service for our daughter. They were well organized, professional, familiar with medical insurance policies and guidelines, and dedicated in providing the best advice and information possible to ensure a successful outcome. They showed compassion in their work and for our family, they truly cared. Our daughter is being treated at the right hospital now, and she wouldn’t be if not for Patient Navigator’s help.”

Medical bill negotiations save family $10,000

When his daughter-in-law’s uninsured hospital bills were coming due, Patient Navigator helped our client seek financial assistance and an audit of the invoice, which revealed multiple duplicate and unsubstantiated charges.  The hospital issued a clean bill with a 50% debt reduction.  Another bill was already with debt collectors, but Patient Navigator negotiated a 70% reduction and the bill was settled.  The family appreciated our dogged persistence and the nearly $10,000 in savings we earned for them.

A peer-to-peer phone call gets test approved.

The client had been sick and home-bound for ten years.  He was reluctant to seek treatment because he felt that doctors had failed him over the years.  The one physician he still saw prescribed a PET scan to begin a new diagnostic effort.  Not surprisingly, the insurance company denied this vital test.  The physician was not willing to try to appeal this decision.  Our own Dr. Zorrilla, who had been working with the family, intervened with insurance company in a peer-to-peer call with the medical director.  After her thorough clinical summary and explanations, the medical director promptly approved the test.  The family and patient were immensely grateful.

Disability benefits reinstated with Patient Navigator intervention.

Patient Navigator had been working with the client’s mental health providers to ensure a steady stream of information to the disability insurer when suddenly, the benefits were cut off.  The family was frantic.  The mental health provider had failed to provide a detailed letter to the insurer.  Patient Navigator drafted the letter for the doctor using records available to us.  The mental health provider reviewed it, made minor edits and we sent it along to the insurance company.  Within 48 hours, the insurer called to tell us the client’s benefits had been retroactively reinstated. The family was ecstatic.“Awesome news!! Thanks so much!!

Patient Navigator recuperates $14,600 from long term care insurance.

Melinda’s mother had paid her premiums for many years before she got sick.  But when Mom needed help, the long term care insurer used every tool in its arsenal to complicate her access to the payments she was owed.  She died before the company ever paid her.  However, Patient Navigator worked doggedly to make the insurer paid what was owed and recovered $14,600 for the family after many months of persistent efforts. “You have done it, thank you!”

Patient Navigator helps family avoid financial hardship.

Theresa’s father had a painful back injury that required surgery, and significant recuperation time.  Theresa was concerned that her dad’s company would not provide a short term disability benefit for his recovery time, but could not get a straight answer from the Human Resources department. Patient Navigator contacted the disability carrier and determined that Theresa’s father was not yet eligible for short-term disability, but that he would be in another six weeks.  The surgery was delayed until his recovery would be covered, thus avoiding significant financial hardship.“The Patient Navigator team has been an invaluable resource in helping us make informed decisions regarding my husband’s care.”

Patient Navigator successfully appealed a denial to obtain additional insurance coverage for an extended stay in a nursing home.

Melinda’s mother had already spent over 100 days in the nursing home and had exhausted Medicare’s coverage.  However, when Patient Navigator reviewed the nursing home’s  submission to the secondary insurer requesting additional coverage, we discovered several key documents were missing.  Patient Navigator helped the social worker prepare a proper and complete request.  Since then, under Patient Navigator’s supervision, Melinda’s mother has been given three extensions totaling over 105 days, covered fully by insurance.

Patient Navigator unraveled an impenetrable paperwork error to win an insurance appeal worth over $1,400 for our client.

The client’s tests and surgeries had been improperly billed to the insurance company by the hospital.  The client was subsequently sent overseas for work, and had no idea the claim had not been paid.  It wasn’t until bill collectors started calling him that he realized something was wrong.  Patient Navigator got to work and solved the problem.  The claim was paid and the bill collectors stopped calling.

Health insurance benefits reinstated after a late payment.

When Sharon became very ill, she was late paying her monthly retiree insurance premium to her former employer.  After a complicated series of events, the insurance was cancelled even though Sharon needed to begin cancer treatments.  Patient Navigator assisted with the family’s appeal and requested an expedited review.  The insurance was reinstated, much to the patient’s relief.“Advice that we got in our initial consultation and follow up emails supported a ruling that reinstated our insurance – more than $200,000 value.”

Nancy’s inflammatory breast cancer and its aggressive treatment left her unable to work.

The company providing her disability compensation was reluctant to continue benefits. Patient Navigator gathered clinical information from multiple doctors, submitted and tracked the paperwork, and convinced the insurance company to continue paying Nancy’s disability benefits. And we have made sure those benefits were renewed for the last four years, each time compiling reports with a dozen doctor statements, test results, and medical and financial records.

Matthew was dealing with a chronic and painful condition.  To make matters worse, his insurance company would not pay for to cover $1,617 for a series of medically necessary physical therapy treatments.

Patient Navigator was told by the insurance company that the therapy services were not covered because pre-authorization was required and not been obtained beforehand.  The Navigator escalated to a supervisor who finally confirmed that retroactive pre-authorization was possible, but rarely approved.  Patient Navigator re-submitted the claims on Matthew’s behalf and after weeks of follow-up phone calls, the retroactive pre-authorization was unexpectedly granted. Since Matthew had paid out-of-pocket, the Navigator worked with the office manager to redirect the insurance payment back to Matthew.  Ten days later, Matthew received a reimbursement check from the physical therapist for the $556 covered by insurance.

Irene’s Medigap insurance had lapsed inadvertently even as she was undergoing cancer treatment.

Patient Navigator researched the best options to reinstate her coverage. We also researched and analyzed the Medicare Part D Prescription Coverage options available in her area.  Irene regained coverage during the open enrollment period.

Elizabeth was a Federal employee dealing with cancer.

She called Patient Navigator to ask whether she should file for disability because she was running out of sick days at work. Elizabeth’s personnel office hadn’t told her about the Government’s leave donation program, which allows colleagues to donate leave to a sick employee. When Patient Navigator launched a leave donation drive among Elizabeth’s colleagues in Washington, D.C., she received over 700 hours of donated leave, thus allowing her to keep her job and avoid going on disability.

Steve had suffered from debilitating infections as a result of an unsuccessful colostomy.

Although a Vietnam veteran, Steve was having trouble getting assistance from the Veterans Administration (VA), lost his insurance and was deeply depressed.   His sister Ginny planned to visit him in Kansas City.  Patient Navigator arranged a meeting with local Congressional staff to enlist their support for intervention with the VA.  Ginney was armed with briefing materials, talking points and a schedule of appointments to advocate for her brother. Later, Patient Navigator negotiated a follow-up operation to repair the colostomy. Steve’s insurance benefits were restored.

Stacy asked us for help to appeal her young son’s medical claims that had been denied.

Because the boy had a rare genetic condition, the insurance billing codes did not easily correspond to the services he needed. We helped Stacy build a strong, well-documented case of medical necessity to appeal the denied claims, and the insurer ultimately paid them in full.

Phyllis’ ailing father, a World War II veteran, needed access to Veteran’s Benefits.

His records had been lost in a 1973 fire at the Defense Department. Patient Navigator tracked down his discharge papers through employment, state and county records. We helped Phyllis enroll her dad so that he received the benefits to which he was entitled.

Bernard needed help procuring Letters of Medical Necessity to document his wife’s claim for benefits.

Since the doctors involved in her care were difficult to reach, Patient Navigator enlisted the help of nurses and staff.  In one case, we drafted the Letter of Medical Necessity that the doctor ultimately signed and took care of all communications with the patient’s insurer.

Sharon’s mother had cancer and Sharon was having trouble getting chemotherapy drugs covered by her insurance.

We resolved this. When her mother passed away, Sharon asked us to help her father find a new insurance plan because the couple’s small group plan was now unaffordable. Patient Navigator presented several options so that Sharon and her father could make an informed and cost-effective choice about new insurance and helped them procure documentation proving creditable coverage.

A concerned doctor referred Victor to Patient Navigator.

Due to a degenerative vision disorder, Victor felt he could no longer do the information technology work he loved, and reluctantly planned to apply for long term disability. While helping him with the disability forms and necessary medical statements, Patient Navigator also listened to Victor’s real concerns about wanting to be productive. We encouraged him to explore alternatives with his employer, potentially using assistive technology. Ultimately Victor’s company provided the assistive technology, and Victor happily and thankfully returned to his job.