Planning a Healthcare Budget

At The Arthritis & Infusion Center, we are all too aware of the struggles many people have in paying their medical bills. And, with the most recent changes in medical reimbursements due to government regulations, it is even more important to plan ahead. But, the most significant question is: How does someone prepare for an illness, or health issues, that come as a complete surprise?

      When you are trying to budget, communicate with your  insurance agent, as well as all the physicians/clinics who service your family’s medical needs. Ask, point blank, if their rates will be increasing in the near future. You have every right to ask this critical question.  Therefore, the areas you need to include in your healthcare budget include, but are not limited to:

• Insurance premium costs: Insurance coverage can be negotiable depending on your lifestyle (i.e., non-smoker, active lifestyle, etc.) 
•  When you know what your insurance covers, but more importantly, what it doesn’t cover, make a conscientious attempt at estimating out-of-pocket costs.
•  Once you’ve come to the two estimates (above), factor into the equation your medications, visits to the dentist, and eye appointments. (Remember, your health insurance policy will outline what dental services, if any, are covered.) 
•  If you take vitamins, belong to a gym, or take advantage of specialized services like therapeutic massage, these costs need to be estimated and included in your budget as well.

“Many of our patients struggle paying their bills, and many pharmaceutical companies have programs in place to help the truly disadvantaged,” said Dr. Hulon Crayton, owner of The Arthritis & Infusion Center. “In addition, there may be other government programs that may be able to be accessed.”

People on Medicare must also understand that healthcare services, at some point, may become rationed. Their healthcare budget must allow for them, as senior citizens, to pay – out of pocket – if they want to ensure that some yearly tests (mammograms, pap smears, etc.) are covered. Otherwise, these tests will only be done every other year.

At The Arthritis & Infusion Center, we encourage our patients to ask us how to most effectively manage their healthcare, and we can certainly assist with the necessary data patients need in order to compile a comprehensive healthcare budget. Don’t wait another day to get started to take control of your healthcare finances.

What is a Prior Authorization?

Have you experienced this statement “I’m sorry, but this requires a prior authorization.”  This very common phrase has become a major complication in the medical community and it is now becoming a heavy burden on the shoulders of patients.

According to insurance companies, Prior Authorizations, also known as P.A.’s, are an extra precautionary step in your overall medical care.  The insurance companies may attach the P.A. requirement to any medical procedure or medication.  Then, they will require the ordering physician to either produce a medical record or conduct a peer –to-peer conversation to justify the medical need.  Examples of such prior authorizations would include:  name- brand medications, MRI scans, and “elective” surgery. 

What does this extra step mean to the patient?  A prior authorization essentially puts a hold on the medication or procedure until the physician meets the necessary requirements set by the insurance company.   The patient will not receive the medication, or be permitted to have the medical procedure, until the P.A. has been satisfied.  Therefore, there is a disruption to your medical care.

What should you do if your medicine or medical procedure requires a P.A.? 

1.   Contact your physician.  Do not assume that your pharmacy or medical facility (such as a diagnostic imaging center), has contacted them.  Make sure they are aware of the issue in detail.

2.   Ask questions.  There are instances that will require the physician to rely on the patients’ past medical history to prove the need for the medication or procedure.  Ask your physician if there is any information you can provide to help speed the P.A. along.

3.   Follow up.  Things fall through the cracks from time to time.  After five to seven business days, call and follow up on the status of the P.A. 

4.   Be patient.  P.A. request are used heavily by insurance companies and your physician’s office has to address each and every request.  It is estimated that each request takes an office staff member approximately 15-25 minutes to complete.

The Arthritis and Infusion Center prides ourselves in “fighting” for the rights of our patients.  We will take the time to complete Prior Authorization requests and prove the need for the medication or procedure.  This personal attention to the needs of our patients is what makes the team at The Arthritis and Infusion Center stand above the rest.

What is the difference between Deductibles, Co-Payments, and Co-Insurance?

It’s that time again.  Each New Year brings about the dreaded rollover of deductibles. The Arthritis and Infusion Center has a few important tips and explanations to help you navigate through the world of insurance.  

A basic understanding of the most common insurance terms will ease tension and frustration at the beginning of the year.  The most frequent terms referred to by your insurance and medical providers are Deductibles, Co-payments, and Co-insurance.  

Deductibles

A deductible is a set amount of money, determined by your insurance provider, which is due from the patient before the insurance provider will start to pay.  In simple terms, you, the patient, must pay that set amount of money, from your pocket, before your insurance will pay any money toward your medical bills.  Typically, deductibles run for a calendar year, and will zero out each January 1^st. 

Example:  Your annual deductible is $500.  Your medical bill is $120 and you have not met your annual deductible.  You will be responsible to pay your medical provider the $120 bill until you have satisfied the $500 deductible.  You will still have $380 remaining before the deductible it is met.

 Co-Payments

Typically, a co-payment is a fixed dollar amount attached to a medical office visit, procedures, or medications.  “Co-pays” do not apply toward the annual deductible. Co-payments are a separate expense to the insured. Co-payments are often a money saving advantage for patients that do not require frequent medical treatment.

Example:  A regular office visit to your primary- care physician has a co-payment of $20.  You are required to pay the $20 and your insurance provider will pay the remainder of the visit. 

Co-Insurance

This is much different than co-payments.  Co-insurance is a percentage of a medical bill that is due from the patient after the annual deductible is met.  Depending on the particular policy, a co-insurance may apply to physician visits, procedures, and medications.  Once the annual deductible is met, the insurance provider will pay the medical provider according to the set contract.  After the insurance provider has paid their portion, it is then the responsibility of the patient to pay the percentage remaining (co-insurance).  A very popular co-insurance scenario for insurance providers is an 80/20 split.  This means the insurance provider pays 80% of the bill and the patient pays 20%.

Example:  Your monthly treatment costs $500.  Your annual deductible is met and your insurance company pays at a rate of 80/20.  Your co-insurance is 20% of the allowable amount.

Understanding your medical expenses can be very confusing.  Don’t be afraid to ask questions in order to obtain a full explanation of charges, payments, and amounts due from you.  A good rule of thumb: always ask medical providers questions before you have a procedure.  Ask about possible charges, if prior-authorization is required, and their in-network status.  A little legwork, prior to your visit to a physician, could save you thousands!             

PPO vs. HMO: What’s the difference?

Are you responsible for obtaining your own private insurance policy?  Do you have questions, concerns, and anxiety when it comes to choosing a plan?  Don’t worry, because you are not alone.  Thousands of working and retired Americans are now finding themselves in the market for an individual insurance policy.  The Arthritis and Infusion Center understands that the world of insurance is confusing.  We have set up a few tips to help you navigate you through the process.

What is an HMO?  An HMO (Health Maintenance Organization) is the most common form of managed healthcare.  In this managed care plan, the patient is required to utilize a primary-care physician (PCP) who will oversee all aspects of the patients care.  This physician will be a member of the HMO network.  As necessary, the PCP will refer the patient to a specialist or an outpatient facility for services or treatment.

What are the advantages/disadvantages of an HMO?  The advantage of an HMO is the patient has one physician overseeing the general health and wellness of the patient.  This plan can be very beneficial in ensuring preventative medical care such as yearly wellness exams.  The disadvantage of an HMO is that the patient is required to see in network-physician, therefore removing some of the freedom of traditional plans.  Additionally, in many instances, venturing outside of the “network” for an HMO will result in nonpayment by the carrier. 

A PPO is known as a Preferred Provider Organization and is much different from an HMO.  In the PPO setting, the patient has the freedom to choose any physician and there is no need for primary care physician referrals.  Usually, this type of policy has an annual deductible and coinsurance that the patient is responsible to pay to the treating physician.  Physicians often sign up to become PPO network providers, which is a benefit to the patient.  An in-network physician will accept the negotiated contract payment schedule for the particular insurance company and then the patient is only responsible for the deductible, or coinsurance, of reasonable and customary billed services.  The disadvantage of the PPO plan is that if a patient chooses to see an out-of-network provider, then the patient may be billed for the difference between what the insurance company pays the physician and what the physician actually charges, plus the deductible and coinsurance.  In some cases, there is a separate deductible for out-of-network providers.  Be sure to read the term of your insurance policy for specific information.

Medicare Advantage Plans: What You Need To Know

Medicare Advantage plans are very popular and are a wonderful way to combine three traditional Medicare policies and even add an extra coverage without purchasing a separate policy.  However, be extremely careful when choosing this type of policy.   As with any insurance plan, there are advantages and disadvantages to these particular combined plans.

By definition, Medicare Advantage Plans are a combined Medicare policy that will take the place of traditional Medicare Part A and B and often Medicare Part D.  These plans are offered by a private insurance company that is approved by Medicare, and have a set monthly premium.  Medicare Advantage plans are not supplemental coverage to traditional Medicare.

Medicare Advantage Plans would cover the traditional healthcare cost that are usually covered by traditional Medicare to your doctors, hospitals, and pharmacy.  In many cases you may also purchase additional coverage to include vision, dental, and hearing.  However, keep in mind that additional coverage equals additional premiums. 

There are a few disadvantages to this type of plan.  Here are a few questions you should consider before choosing a policy: 

·    Are you required to choose a physician that accepts, and participates, in Medicare Advantage Plans?

·    Are you required to have referrals to specialists, outpatient or radiology services?

·    Does the policy have a flat copay for physician services, or is there a deductible and coinsurance?
·    What does the prescription policy cover?  Is there a mail-order supply company offered?

·    Am I locked into the policy for a specific amount of time before I can change back to traditional Medicare or switch to a different policy?

·    Am I purchasing this policy from a reputable company with actual patient reviews of their product?

·    Is there a limit on how much this policy will pay out in one year?

There are many more questions that need to be considered before you make such an important decision for your healthcare needs.  The point of this blog is to get you thinking about your current healthcare situation, policy, as well as your future needs.  Take time, ask questions, and get multiple quotes for coverage. 

DEDUCTIBLES: What to Expect January 1st

There are many concerns regarding the cost of healthcare these days. Now it is more important than ever to know the details of your policy and formulate a budget for your healthcare needs. The Arthritis and Infusion Center understands that healthcare language can often be confusing. We have compiled a few of the most commonly used terms that refer to healthcare insurance policies.

Healthcare definitions according to the Medicare website: 

• Assignment - An agreement by your doctor, other health care provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
•  Coinsurance - An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
• Deductible - The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
• Medically Necessary - Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.
• Medicare Approved Amount - In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. 

Typically deductibles renew on January 1st each year. In other words, the slate is wiped clean from the previous year and you are required to pay your annual deductible again. Keep in mind, when making your healthcare budget, often deductibles and coinsurance will be collected at the same time from your provider until the annual deductible is satisfied. Be prepared, before your office visit, with the necessary monetary means to satisfy your obligations at the time of the service.

The Arthritis and Infusion Center is ready to help. If you are unsure of your policy’s deductibles or coinsurance, give us a call and we will be more than happy to help you determine this information. An informed patient is a happy patient.

GETTING the MOST from Your FIRST Appointment: Getting Comfortable

At The Arthritis and Infusion Center we understand that coming to your first appointment with Dr. Crayton (or to any medical appointment for that matter), can be very nerve racking.  In fact, some people even experience a rise in blood pressure, which is often humorously referred to as “White Coat Syndrome”.  However, our team of healthcare professionals does not want your visit to our practice to be anything but a very positive experience.  In our previous two blogs, What Should I Bring? and Notes and Medicine Bottles, that discussed Getting the MOST from Your FIRST Appointment, we explained how to prepare ahead of time with your paperwork.  Now, we suggest the following. 

• As previously suggested, bring your physician’s order with you.
• Dress in loose, comfortable clothing.
• Take all your regular medications, unless your referring doctor prescribes otherwise.
• Plan ahead of time by allowing enough time to complete the necessary radiology and/or diagnostic exams and/or treatments.
• Arrange for transportation, if needed.



If you are coming for an Infusion, we suggest that you wear comfortable, layered clothing that you can adjust in case you become overly warm or cool.  Bring along an extra sweater or blanket to have handy.  To pass the time, you may want to bring:

• Games
• Reading material
• Handwork (knitting, crocheting)
• MP3 Player (We offer WiFi & headphones)
• You can also use the time for meditation.

Perhaps the most important thing you can bring is a smile and a positive attitude, knowing that you are in good hands at The Arthritis and Infusion Center.  And don’t forget:  “Pain is not normal.  Let us help!”

GETTING the MOST from Your FIRST Appointment: What Should I Bring?

At The Arthritis and Infusion Center, we want your first appointment to be a pleasant as possible.  Therefore we request that you bring the following information with you:

• Medical Records – Knowing your medical history and what care you have previously received (hospitalizations, office visits, treatments) helps us with compiling a more thorough medical history.
• Referring Physician Information – Although you do not have to be referred by another physician to see Dr. Crayton, we may want to consult with the physician who may have referred you to our practice.  Please bring addresses, with phone/fax number of your primary care and referring physicians to your first appointment.
• Medications – As we mentioned in our previous blog post, knowing what medications you are taking is important.  Please bring all bottles with you.
• X-rays -- If possible, please bring any actual x-ray films related to your condition. 
• Insurance pre-authorization form and an ID card – Your healthcare insurance coverage may have been discussed before you arrive, but please bring your health insurance ID card, along with a photo ID, such as a driver’s license.

For more information, new patient forms, driving directions and more visit our Patient Center.

This information is very important to ensure the most prompt and thorough care of you – our patient.  And remember, “Pain is not normal.  Let us help.”

GETTING the MOST from Your FIRST Appointment: Bring Notes & Medicine Bottles

About a week before you go to your first appointment with Dr. Hulon Crayton, start preparing for your visit with this experienced Rheumatologist.  Do a self-assessment of the exact spots of your aches and pains, along with making notes as to any physical limitations these areas may cause you.  For instance, can you pick up things easily and carry them from one place to another?  Can you do basic chores around house?  Then, during your first visit, Dr. Crayton will be taking a full medical history, so you need to provide information regarding any family history of you condition.  In addition, he will need to know about surgical procedures you’ve undergone or allergies you may have.  It is also extremely helpful for you to bring in ALL the medicine bottles you currently take, which includes over-the-counter pills, vitamins, as well as all prescriptions.  At The Arthritis and Infusion Center, a large portion of our very personalized service includes educating our patients.  By looking at your medicine bottles, it helps us make certain of the spelling of your meds, since many medicines sound similar in pronunciation.  Plus, we need to know the directions other physicians have been giving you as to dosage, etc., so that we can make certain Dr. Crayton prescribes the correct treatment plan for you to follow.  Your healthcare is truly a team effort, and you are at the very center of the team!  Remember:  “Pain is not normal.  Let us help.”

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