Open Enrollment – Confusion Spells Opportunity

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What a MESS Open Enrollment is this year!  No matter where your health insurance comes from – an employer, the Obamacare exchanges, or Medicare – it’s changed up, switched up, and more confusing than it has ever been.

YOU, as an independent health or patient advocate or care manager live (and fight) in this world of “let’s make money from patients even if we have to deny the services they need” world. You know what it’s like having to get a treatment, or claim, or hospitalization approved for someone who has inadequate insurance coverage. You know what it’s like when they ask you to help them get a bill reduced, or when the doctor they have been seeing for years suddenly won’t accept their insurance anymore. You know what it’s like when they realize that the hospital they were rushed to in an ambulance isn’t even in their insurance network.

You understand their confusion. You may even be confused yourself.

This year we’re going to experience the added confusion of the changes the new administration in Washington has made, including reduced subsidies, reduced Open Enrollment period, and the resulting upset when people find out their current coverage is no longer being offered (several of the largest insurers have dropped out of the ACA marketplaces). And that’s just Open Enrollment. What’s going to happen when the reality of 2018 sets in, and we all have to function under the new rules?

But – here’s the good news. We are business owners!  As such, we never hear negativity in the word “confusion.” Instead, when we hear the word “confusion” – we hear OPPORTUNITY!

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The Advice That May Tick You Off

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In 2012, I blogged about this very topic. One ticked-off reader then attacked me on Twitter. A day later, both she and another member of The Alliance of Professional Health Advocates left the organization, both citing the post.


But it was good advice then, and it’s still good advice today. So at the risk of provoking additional readers, I’m going to wade into those waters again. Since most of us are self-employed, in the process of either starting or growing a professional practice, you’ll find that this advice will serve you very well, even if it IS maddening or frustrating to you.

Why now?  Why this timing? What is it about this time that compels me to offer this advice again?

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Sorry. That’s Not Good Enough

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scoldingwomanOne of the most visible changes in the new health insurance reality are the medical bill surprises people are receiving that they never received before, for services covered previously as a matter of course. You know – whereas their insurance automatically approved a CT scan for purpose X in the past, now patients need pre-approval. Without that pre-approval, payment for that CT scan comes out of their own pockets – totally unexpected and usually very expensive.

Most of us learn the hard way that we need to get permission for many of the services that used to be automatically approved. I know I did. About two years ago I received the full billing ($350) for my annual trip to the dermatologist. I had been referred by my primary, the check-up was a covered benefit, but because I hadn’t gotten it approved ahead of time, I received the bill, and was told I was responsible, for the full ride.

I was stunned! And angry, too…. When I called my insurer, the customer service rep told me that was their new policy, and I was out of luck; there was nothing she could do to help me. When I asked when the rule had changed, she told me she wasn’t really sure. When I asked why I had never been notified, she said she didn’t know… Bottom line, I got NO information from her. I finally asked to speak to a supervisor who was even less helpful – until I told her I would be in touch with the state insurance department. Only then did she say she might be able to help me sort out the billing. Eventually they did cover the cost of my appointment – because they couldn’t prove to me that I had ever been notified of the change in policy.

I’m not going to lament here the fact that it seems like nothing can be done by customer service these days without threatening them first. Instead let’s look at some lessons for advocates; that is, that when we know we need something, or when we are stonewalled, the only real answer is “that’s not good enough.”

I raise it today because it almost happened again last month, as follows:

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The More Things Change, The More They…

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2books-newold… seem to change.

Yes – I know that’s not the way that saying is supposed to go, but in this case, it’s true.

Healthcare – and the pursuit if its best outcomes – changes constantly.  Just think about the changes over the past few years!

I suggest to you that all the changes in healthcare, ranging from the ACA, to updated research results, to use of the internet, to changes in DRGs and CPTs, to outright FRAUD – all create opportunities for advocates to market themselves and their services.

All these changes have been on my mind in a big way for the past six months:


Here’s my shameless plug – in a moment I’ll return to the point of this blog post….
There were enough changes to the healthcare system, that last winter I decided to update my first book:  You Bet Your Life! The 10 Mistakes Every Patient Makes (How to Fix Them to Get the Healthcare You Deserve)*  First published in early 2010, it turns out that there were more than 100 changes in only 300 pages. I’m not talking about typos. I’m talking about changes that result from the Affordable Care Act (Obamacare) and the ways patients are making decisions (Shared Decision Making process). I’m talking about the regard for high technology (those surgical robots aren’t so in favor these days.)  The list goes on and on.  Here’s more information about the updated version, just published in early August, and a photo so you can see how many changes were made.)


… All the while I was rewriting my book, I kept thinking of all the ways patient advocates could take advantage of the changes to further their marketing efforts.

Three examples:

Shared Decision Making is written into the ACA. It is expected that doctors will deal with it by parking their patients in front of a computer (or handing them an iPad or tablet) to watch a video or two, and then will expect their patients to sign something that says they’ve been informed of their options.  Yes – well – we all know what that’s going to look like  That makes Shared Decision Making RIPE for marketing – both to individuals and to doctor’s offices who don’t want to deal with it (and don’t really want their patients to understand additional options.)

Electronic Health Records make it easier than ever for mistakes to be replicated throughout a patient’s entire posse of doctors.  EHRs are a great place for advocates to begin their work with patients, going through the records and helping them correct those errors (and learning about the patient’s challenges overall.)

Hospitals are taking a financial hit on Medicare patients who return to them within 30 days after discharge. Of course, the hospital discharge process has never been very useful for patients or caregivers – and frankly, since they could make ever more money if patients were readmitted, then hospitals never cared to clean up their acts.  But now that it’s costing them money, hospitals are far more interested in the patient’s outcomes.  There’s a role in there for advocates – are you taking advantage of this knowledge?

The bottom line for advocates is that we MUST stay up with changes in the healthcare landscape – not just to be sure our clients are getting their best advice, but also to look for those additional marketing opportunities that come our way, too.

Have you kept up?  What other changes are you familiar with – and have you used them for marketing purposes?


*These books are great gifts for clients. APHA members may purchase them in bulk.

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Agree? Disagree?

Share your experience or join the conversation!


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The Affordable Care Act / Obamacare Defines Perfect Roles for Private Professional Patient Advocates

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ACAThe healthcare reform law called the Affordable Care Act (ACA) – or Obamacare if you prefer the moniker (preferences seem to run about 50/50) – is being implemented over time. Of course, as most of us realize, the major portion described as the individual mandate, kicks in January 1, 2014 – only a few months from now.

No matter how you feel about the legislation for your personal situation, you owe it to yourself to become familiar with the aspects of the law that define excellent roles for health advocates, no matter what type of advocacy they practice – medical navigational, research or decision-making, medical billing, hospital bedside advocacy or others.

Last week, members of the Alliance of Professional Health Advocates were privileged to spend an hour with Linda Adler, a member of the Alliance, who has studied healthcare reform long and hard, talking about the important aspects of the ACA that clients may ask about, talking about resources to help answer client questions, and then, importantly, the many opportunities the ACA creates to help advocates market our advocacy practices.

It was one of the most useful hours any of us have spent in a long time.

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