Health + Fitness

Open Enrollment 101

After my Lumpectomy Post Surgery visit, I was told by the Surgeon that the protocol for my “early stage Breast Cancer” was 6 weeks of Radiation Therapy. This seemed ominous to me. Every day, except weekends I asked? Yes, I was told.

Welcome to your new life as a Cancer patient. But, I was told, “You’re one of the lucky ones”; you’ll be just fine. They quoted me a 99%, 5 year relative survival rate. I knew with our Healthcare Choices during Open Enrollment that I would be maxing out with our In-Network PPO coverage and paying a substantial out of pocket expense.

After a $1,000 deductible, my PPO plan pays a 70/30% split of all allowable costs. I pay the 30% with an out of pocket max of $4,000. With my $1,000 deductible already paid in advance for my surgeries, via our FSA, (Flexible Spending Account) kitty, I made an appointment with a Radiation Oncologist Doctor.

The Dr’s office sent me a breakdown of the 6 week Radiation treatment therapy. Note: they already have your insurance information, and gently prepare you that you will meet the out of pocket max before treatment concludes. The office staff was truly empathetic of my deer in headlights, “I’ve got Cancer attitude” and told me you have “great insurance”! So as you can imagine, as a patient who is stressed out about hearing “you have Cancer” to now figure out a way to pay for it all! That’s when I used my previous Benefits Consulting background to reduce our out of pocket costs.

Every day our mail contained EOB’s, (explanation of benefits) that you need an advanced degree to decipher. It is definitely to your advantage to read these EOB statements that are sent to you from your Healthcare Insurance Carrier – We have United Healthcare PPO. Mistakes are made all the time and patients are paying for things they shouldn’t be. Usually, it’s not the Carrier that makes the mistakes, it’s the Dr’s offices not coding correctly. For instance during one week of my Radiation Therapy I caught a most unusual error. I called United Healthcare and had them look along with me online. For a few days of treatment all the sudden I wasn’t covered! News to me.

UHC is not allowed to go into a claim and change the coding for you even though they can see an error as well. There are privacy laws; HIPAA provides federal protections for personal health information held by covered entities and gives patients rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. So I had to call the office and have them resubmit the claim with correct coding.

FYI: Based on my experience, Dr’s office staffs don’t like when you have the expertise to catch errors and have them resubmit claims.

Anyway, bottom line I was covered and met my out of pocket max. When I received my total Radiation bill portion, I called the billing office and asked for a reduction in my $3,000 bill. I negotiated another 30% off which brought me down to $1,900 if I paid in full within a 3 month period.

Win, win for all involved and they were so easy to work with. All you have to do is call and ask. Another billing office wrote off my entire $361 portion for an expensive test called BRCA 1 & BRCA 2. This test helps to genetically identify if you have the Breast Cancer gene. They were more than happy to assist with the write off and moved me to tears with their compassion and generosity.

[Continue to Open Enrollment – Part III]
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