How to get insurance companies to work with you

Transcription

1 Paying for Quality ACHD Care How to get insurance companies to work with you Christy Sillman, RN, MSN ACHD nurse coordinator Inpatient ACHD Nurse Educator The Adult Congenital Heart Program Stanford Lucile Packard Children s Hospital Stanford Hospital and Clinics Susan Fernandes, LP.D., P.A.-C Program Director The Adult Congenital Heart Program Stanford Lucile Packard Children s Hospital Stanford Hospital and Clinics

2 What we ll discuss: The AHA/ACC 2008 guidelines Upcoming changes in ACHD care Using the guidelines to advocate for care Navigating insurance RAF s, TAR s, and appeals oh my! Know your rights

3 Simple Congenital Heart Disease Unrepaired conditions: Isolated small atrial septal defects (ASD) Isolated small ventricular septal defects (VSD) Mild pulmonic stenosis Isolated detrocardia with no other CHD Repaired conditions: Patent Ductus Arteriosis (PDA) Secundum atrial septal defect (ASD) Isolated ventricular septal defect (VSD) Repaired or unrepaired conditions: Isolated aortic valve disease Isolated mitral valve disease Isolated patent foramen ovale (PFO Moderate Complex Congenital Heart Disease Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) Anomalous Pulmonary Venous Drainage (partial or total) Atrioventricular (AV) canal/septal defects (partial or complete Ostium primum or sinus venosus ASDs Coarctation of the aorta Ebstein s anomaly Infundibular right ventricular outflow obstruction (mild to severe) Pulmonary valve regurgitation (moderate to severe) Pulmonic valve stenosis (moderate to severe Sinus of Valsalva fistula/aneurysm Subvalvular or supravalvuar aortic stenosis Tetralogy of Fallot Ventricular septal defect (VSD) with any valve problems or obstructions Highly Complex Congenital Heart Disease Repaired or unrepaired conditions: cctga or L-TGA Double Outlet Ventricle Mitral Atresia Pulmonary atresia (all forms) Pulmonary arterial hypertension Shone s syndrome Single Ventricle all forms Transposition of the great arteries (d-tga) Tricuspid atresia Truncus arteriosis/hemitruncus Other abnormalities of the AV connections All patients who have undergone any of the following procedures: Arterial switch procedure Blalock-Taussig Shunt Any Conduit(s), valved or non valved Double-switch procedure Fontan procedure (all types) Mustard procedure Norwood procedure Rastelli procedure Senning procedure All patients with Eisenmenger syndrome All patients who are cyanotic ( blue )

4 AHA/ACC 2008 Guidelines Simple CHD s: General cardiologist can usually oversee care. One visit to an ACHD program to verify diagnosis and health status is recommended. Moderately complex CHD s: These patients should be seen every two years or more frequently at an ACHD program Highly Complex CHD s: These patients should be seen every year or more frequently at an ACHD program.

5 What makes an ACHD program? Regional ACHD Centers should provide: Patient counseling; Operating rooms specially equipped with personnel familiar with CHD surgery, fully trained congenital cardiac perfusionists, as well as a full array of diagnostic equipment; Cardiac surgery at least two congenital heart surgeons to provide 24-houra-day coverage; Cardiac anesthesia; Intensive Care; In-patient service; Transplantation; Catheterization laboratory with staff specifically trained in the needs of ACHD patients; Noninvasive imaging service 24 hours a day, 7 days a week; Electrophysiology service; High-risk obstetrics; Cardiac pathology.

6 Updated Standards Board certification in adult congenital heart disease cardiology subspecialty. First exam will be in fall 2015 for practicing physicians. Fellowships in ACHD starting 2014 Program accreditation: ACHA accreditation standards for regional ACHD programs

7 The road to ACHD care Primary Care Physician In-network/Local cardiologist ACHD regional center

8 Navigating Insurance Establish a contact person with your insurance Case worker Nurse Authorization specialist Medical director Get their direct number Point person for approving care

9 Navigating Insurance Establish a contact person at the ACHD center Nurse coordinator Authorization and referral coordinator Medical Billing Social worker Ask about the necessity of tests Case study #1 - MRI

10 Navigating Insurance Get any approvals or denials in writing Keep all insurance related documents Don t be afraid to ask questions

11 Before signing up for coverage Check with the ACHD center to see if they accept the insurance for all aspects of care Case Study #2 Understand the plan premiums, deductibles, and yearly out-of-pocket maximum Utilize the consumer assistance program if your state has one

12 RAF s, TAR s, and Appeals (oh my!) RAF (Risk Adjustment Factor) insurance approval for higher than expected coverage TAR (Treatment Authorization Request) request for treatments/studies outside of expected coverage Don t hesitate to appeal any denial you receive. Escalate, advocate, and use the guidelines. Insurance companies don t understand CHD. Changes in your coverage? Buzz word Continuity of care

13 Know your rights Can not be denied on the basis of pre-existing condition Can stay on parents insurance up to 26yrs old Guaranteed right to appeal both internal review and independent external review. Access to consumer assistance program. Ends life-time limits on coverage Emergency care at any emergency room they will treat without proof of insurance.

14 Case Study #3 Tying it all together Patient moved from out of state changed insurance Transferring care from one ACHD program to another ACHD program Rural area with limited PMD options urgent primary care visit submitted a RAF RAF automatically denied Patient getting sicker and sicker Emergency Department Appeal process Continue to advocate for higher level of care

15 Template Letter To whom it may concern: I was born with _[severity level of CHD] congenital heart disease: [your diagnosis]. According to the ACC/AHA 2008 guidelines, adults with congenital heart disease in this category should be seen every [guideline frequency] or more frequently with active issues at an adult congenital heart program. According to the same guidelines an adult congenital heart center consists of a set number of recommended services please see attached guidelines. For continuity of care I am requesting my cardiac care at [name of ACHD program/facility], a program that fulfills the ACC/AHA guideline recommended services.

16 Template letter example To whom it may concern: I was born with complex congenital heart disease: tetralogy of Fallot with pulmonary atresia. According to the ACC/AHA 2008 guidelines, adults with congenital heart disease in this category should be seen every _year_ or more frequently with active issues at an adult congenital heart program. According to the same guidelines an adult congenital heart center consists of a set number of recommended services please see attached guidelines. For continuity of care I am requesting my cardiac care at The Adult Congenital Heart Program at Stanford, a program that fulfills the ACC/AHA guideline recommended services.

17 Resources Your insurance handbook or website US department of Health and Human services State website - managed care division ACHA for guidelines and advocacy The ACHD program authorization and financial aid departments

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