Insurance Challenges and Ways to Succeed

Insurance Challenges and Ways to Succeed Beth Rader Sean Corry

Introductions • Raenette Franco, CBCS Certified Biller Coder Specialist/Reimbursement Consultant • New Jersey • Beth Rader, Independent Consultant • San Francisco • Sean Corry, Insurance Broker, PKU Dad • Seattle

Here’s What We’ll Talk About • Today we’ll talk about insurance coverage: • Different types of coverage • Tips, skills, and strategies to address challenges • Where you might find some help

When Coverage Works… • But when coverage doesn’t work, • the answer lies in one of these areas

Do You Have Coverage For Medical Foods? • Key Questions: • What kind of insurance do you have? • Does your insurance policy cover Enteral Formula/Medical foods? Or provide HCPCS Codes to identify the service such as B4155, B4157, B4162, S9435. • Are there any exclusions for Enteral Formula/Medical Foods? • How does the insurance policy cover medical foods?

Obtaining the Proper Coverage Information • Most insurance companies require a prior authorization before coverage benefits. • Even if your insurance company does not require a prior authorization ask for a pre-determination to ensure your Enteral Formula/Medical food is covered in writing. • Ask if you have Pharmacy Benefits just in case you may have both benefits. If you have both, go for the most affordable route.

Not Covered? Ask for exception • If you are not covered due to exclusions, ask your employer for a medical exception removal for Enteral Formula/Medical Foods due to your disorder. • Provide your employer a Letter of Medical Necessity from your Physician that describes the importance for your Enteral Formula/Medical Foods. • Some ERISA Plans may make an exception. • Ask to speak to the Medical Review Department.

Covered Benefit Just Like a Snowflake…No Two Issues are the Same • Laws differ from state to state • Coverage differs from state to state • Sometimes only Federal laws applies • The insurance companies handle PKU coverage in different ways • Insurance coverage can be complicated! • NPKUA provides Reimbursement assistance. Please contact our Reimbursement Coaches Team.

Covered Benefit Types of Coverage • Government (i.e. Medicaid, Medicare, Etc.) • Private Insurance • Individual or family plans • Includes “High Risk Pools” • Group Coverage (Employer-based) • Insured Plans, regulated by the states • Self-Insured Employers - Also called “self-funded” or “ERISA plans”

Covered Benefit Does Your Insurance Plan IncludeMedical Food as a Covered Benefit? It depends on your plan, but rule of thumb: • Government - except for Medicare, chances are good that medical food is covered • Private insurance • Varies widely • Depends on state and the specific insurance • We’ll explain how to find whether your plan must cover medical foods

Covered Benefit Deciding About Coverage:Sometimes You Have Choices • When can you evaluate your options? • When individual coverage is available to you • When you get a new job with benefits • During “Open Enrollment” at work More options should be available in 2014 when federal Health Reform really kicks in!

Covered Benefit Evaluating Insurance Options • Does the plan have the coverage you need? • Medical services, like clinic visits and blood draws • Formula only? • Low-protein foods? • Ask about PKU coverage before you take a job • Find out how medical foods covered • As a medical service? • As a pharmacy benefit? • Are only specific brands covered? • Any exclusions?

Covered Benefit Evaluating Potential Coverage • Find out what your cost-sharing will be • Deductibles – must pay out-of-pocket before coverage. • Benefit maximum Caps or Limits (you pay out-of-pocket after cap/limit is reached). • $ Copayments or %Coinsurance • Caution with individual health plans • Rx may be an optional benefit • Rx may have coverage limitations • (Remember, Kuvan is a prescription drug)

Covered Benefit Where Can We Read About PKU Coverage? • The “Summary of Benefits” • Only a few pages long • Offers only the plan highlights • Will probably NOT tell you what you need to know “This is only a brief summary of the major benefits provided by our plans. For information and details, please refer to the Benefit Booklet or the Insurance Contract.”

Covered Benefit Digging Deeper for Coverage Information • The Benefits Booklet • Sometimes called an “Insurance Certificate” or “Evidence of Coverage” • ALWAYS keep the benefits booklet for coverage details in writing. • Usually not given to you for many weeks AFTER coverage begins • Many pages long • Should give at least a brief description of coverage for PKU formula and/or medical foods

Covered Benefit Benefit Booklet Example Page 21 of a “Benefits Booklet”

Covered Benefit Might There Be Even MORE Detail? • The Insurance Contract • This is for insured plans, either individual or group • The “Plan Document” • This is for self-insured (ERISA) plans • These are usually big documents, and spell out almost all the details of coverage. • Sign-up/Enroll on your insured plan online. • Can you get a copy? From where?

Covered Benefit Claims With Employers That Manage Their Own Medical Plan* • The “Plan Document” determines coverage • Many plan trustees have never heard of PKU or dealt with a claim for medical foods • “Trustees” are the ones running the plan • If they do not cover PKU medical foods, you might be able to change their minds! • * Self-Insured Employers? See appendix slides for more details

Covered Benefit Convincing Employers* • Ask them to reconsider: • Ask your employer for a medical exception removal for Enteral Formula/Medical Foods due to your disorder. • Tell them PKU is very rare. • If they provide coverage, their costs will be limited because they probably don’t have other PKUers • Being off diet leads to severe, progressive mental retardation, depression, impulse control disorder, phobias, epilepsy, tremors, and other disorders • Diet is the only sure treatment! • * Self-Insured Employers? See appendix slides for more details

Covered Benefit More Reasons for Employers* • Also tell them: • A treated person with PKU lives a normal, productive life • It is less costly to cover medical foods than to cover the illnesses that come from being off diet • It is the right thing to do! • * Self-Insured Employers? See appendix slides for more details

Covered Benefit Could We Get National Coverage? • NPKUA is working on this! • Some of you may have participated in the Regional HHS meetings last summer • Your support and effort may play a key role

Covered Benefit NPKUA Efforts For National Coverage • Legislation: Medical Foods Equity Act • Conversations at Regional HHS meetings • Washington, Atlanta, Chicago, Denver • Working with lobbying firm to meet with National HHS • Advocacy table at NPKUA Conference • What does access to medical food mean to you?

Medical Necessity Is Your Prescription Medically Necessary? • Key Questions: • Do you have a Letter of Medical Necessity (LOMN)? • Do you have a Prescription? • Do you have clinical notes? • What are your plan’s rules for assuring coverage?

What documents are needed for Medical Necessity? And Why? • Letter of Medical Necessity (LOMN) is the most important piece of document needed to determine medical necessity. It is provided from your physician. • Prescription is the basis for the service and coverage. • Clinical notes show that you are following through with your dietary management and nutritional therapy.

Medical Necessity Why Wouldn’t Medical Food Be “Medically Necessary?” • The plan may have specific criteria that hasn’t been met • Diagnosis issues • Age and gender restrictions • Particular items not on the plan’s formulary • We will discuss how to appeal

Process Issues Coverage Process

Process Issues Claims Processing Issues Issues with claims processing could include: • Incomplete claim form • Coding error • Missing documentation attached to claim • Medical food is mis-categorized (food supplement, diet aid) • Other misunderstandings What can you do?

Tools to Use Be Prepared • It is common for a claim to go wrong • Know your coverage, and get everyone on board – Talk with: • The insurance company • Your clinic professionals • Your pharmacist, etc. • The company (or companies) providing the medical foods

Tools to Use Keep Copies of Everything • Get a written prescription for formula/food • Keep a copy for yourself, in case the original gets lost • May need to get your Rx “renewed” occasionally • Copy the label of your medical food product • Copy your invoice • This can help solve billing and coding issues

Claims Denials Claims Denials • Even if you have coverage, a claim may be denied due to medical necessity or processing issues! • Remember, PKU claims are not common • May be an annoying administrative error • Carefully read your Explanation of Benefits (EOB) for any descriptive errors.

Claims Denials Claims Denials • Claims mistakes can be corrected! • Simply denied in error • Coding problems • Mistaken for “Food Supplement” • Missing authorization numbers or provider National provider numbers (NPI).

Claims Denials How to Interact With Your Insurance Company • Be able to explain PKU & dietary treatment • Be able to explain what “medical food” is • Not a “food supplement!” • It is “prescribed” by your doctor or clinic • Provide a Letter of Medical Necessity that explains medical foods and the importance (provided by your physician). • It’s covered by the plan! (Show them where) • Provide your “Evidence of Coverage” from your insurance summary booklet. • If transferred to another person, be prepared to start again start at the beginning. • ALWAYS obtain a name & reference number.

Claims Denials Claims Denials: First Steps • Read your policy (again) • What’s covered, what’s not • How to file an appeal • Call “member services” • Ask them to walk you through your coverage • Ask for an explanation of the denial • Determine if a “phone appeal” can be started • Ask if your physician can contact the medical review director.

Claims Denials Claims Denials: First Steps • Does your insurer need more information? • Ask what information you should collect • Ask what information your providers should submit: • Health history? • Letter of Medical Necessity • A treatment plan? • Other details?

Claims Denials Put It In Writing • A clear statement why the denial should be reversed • Be thorough - cover all the bases • Make it factual, not emotional • State law apply? • Error regarding medical necessity? • Cannot tolerate “that” formula; need to switch to another

Claims Denials Organization and Details Count • Make copies • Ask for written confirmation of phone calls • Keep a notebook names, dates of calls, etc. • Keep a Letter of Medical Necessity (golden key to coverage) • Verify their promises to follow-up • If they don’t call you when promised, call them!

Claims Denials Possible Second Appeals • 41states plus the District of Columbia have set up independent review boards to handle appeals • It is not uncommon for state appeals to overturn insurance company denials • Same rules for you – keep good records, be persistent

Claims Denials You Are Not Alone • Your clinic • The human resources department • Your health insurance broker • State Insurance Commissioner • The medical food or pharmaceutical company • NPKUA • Tools on the website • New Insurance Coach

Resources The New NPKUA Insurance Coaches • Goal: Insurance Coaches in Every State or Region • Timing: Starting Fall 2013, as Coaches are on board and go through orientation • What you can expect if you sign up: • Orientation and training • Resources to help (sample letters, information about the law) • Call NPKUA to see if there is a Coach in your state

Resources Resources For Patients

Financial Assistance Programs

Coverage Process Roadmap We want to help you get there!

We’ll Stop Here, But More in the Appendix • The slides in the appendix provide a high level look at: • Types of coverage • Government, Group, Individual • Insured and Self-funded • State Mandated Benefits • Self-Insured Employers

Questions? Time For More Discussion

Appendix Why is insurance coverage so complicated?

Types of Coverage • Government • Medicaid and Medicare • Title V: Children with Special • Individual or family plans • Includes “High Risk Pools” • Group Coverage (Employer-based) • Insured Plans, regulated by the states • Self-Insured Employers • Also called “self-funded” or “ERISA plans”

Government Insurance - Types • Low Income Help: Medicaid, WIC, Title 5 • Health coverage for lower-income individuals and families • Coverage varies by state, can be very complicated • Medical Needy Programs through Medicaid • Medicare • Health coverage for people 65 or older, people under 65 with certain conditions or disabilities • Federal/Military employees and retirees

Government PKU Coverage • Medicare • Medical Food generally not covered except in rare circumstances • Medicaid – rules vary state by state • Plans for federal employees • Regulated by Congressional law or administrative policies • It is very complicated and mysterious!

Private Insurance:Individual (or Family) Coverage • Buy directly from an insurance company • Coverage for PKU may be required • More limited benefits • Compared to group coverage • Currently, most people have to pass a health screen to get individual coverage • An alternative: A state “high risk pool” • Guaranteed coverage but may be expensive!

Employer-Based or Group Coverage • Many people have health insurance coverage through their employer’s plan • Health Savings Account plan (HSA) High deductible plan. • Generally, two types of employer plans: • An INSURED plan, subject to state “insurance mandates” • A SELF-FUNDED plan, not subject to state “insurance mandates” • Also called “Self-insured” or “ERISA plans”

Insurance Challenges and Ways to Succeed