By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
November 24 2024
"Continuation of Care" is one of the main patients rights. What does it mean? What should
you know and do about it?
We'll explore with some tips to help you along.
It is your right as a policyholder, to continue receiving a treatment or service with
the same medical provider under the same circumstances and the same rate of payment
when the status of this provider changes from In to Out Of Network ("OON").
Why would it change? Either because the provider was in network, but your plan
changes and that provider is now OON, or because that provider terminates their
contract and becomes OON.
Or it is because the provider was contracted with your old plan, which is terminating,
and is not contracting with the new plan you are just becoming eligible for.
B. What does Continuation Of Care mean?
It means that you can finish a treatment or inpatient stay with your current physician or facility - that has become OON with your new plan - until the time when your care can be safely transferred to a new In Network provider.
Financially, it also is good for you, as In Network rates mean a higher allowance and a
higher % rate of payment. In a word, you can save quite a bit of money.
C. When does Continuation Of Care apply?
It usually applies when your treatment cannot be delayed or safely transferred
at the time you become eligible with a new plan, or the In Status of the provider changes to OON. "Safely" is understood as NOT causing any harmful or negative impact on the clinical outcome or on the patient's overall health, let alone life.
Some examples would be if undergoing radiation treatment, chemotherapy treatment,
or being inpatient in a mental health facility.
Continuation Of Care may applies if there is no equivalent, available, trained,
experienced provider within the new plan's network. And even if there is one,
if you cannot schedule an appointment within a short/safe enough amount of time, and Access to Care mandates are violated, Continuation Of Care applies.
If a medical service, treatment, procedure is already scheduled (and/or authorized)
by your previous plan, and let alone the result of an emergency, Continuation Of Care may apply.
The Federal No Surprise Act, the law that came into effect a couple of years ago, forces
insurance companies or a new plans to apply Continuation Of Care under certain circumstances:
* pregnancy
* care of a child under three years
* acute condition or undergoing acute treatment
* emergency or direct result of an emergency
* institutionalized in a facility, or inpatient in a hospital
* terminal illness
D. How to Apply for Continuation Of Care
If an authorization is already in effect with the old plan, the entity, the doctor, the
person who obtained it, must request that transfer.
If not, your current treating/prescribing provider you must request a special authorization for payment at OON services at the In Network rate based on Continuation Of Care
There might be a number of providers or offices who don't have a staff of the know-how to do the paperwork. The member can then file the request.
Transfers of an authorization or requests for Continuation Of Care must include
medical records to prove medical necessity and support the treatment decision. They should include a treatment plan and explain how transferring your care
at this point would be clinically unwise or harmful.
If you, the patient, are somehow left with the task of requesting Continuation Of Care authorizations or extended benefits: check on your new insurance portal to locate the Continuation Of Care request form. Your must include clinical justification,
copy of a current authorization if there is one, proof of undergoing treatment, letter of
medical necessity from the treating (and other) physician, evidence that a transfer
of care at this time is unsafe and harmful.
If there is no authorization currently in effect, do demonstrate that you went over the
list of In Network providers with your new plan and could not find anyone available,
trained, accomplished, specialized who could take over your care. But be aware that if services are not or no longer an emergency or life threatening, and if there is even one
provider listed as"In network" in your new plans directory that seems able to take
over your treatment or care, your new insurance has the right to deny a Continuation
Of Care request, and to offer or even order your immediate transfer to an In Network
provider or facility. Unless you file an appeal right away to try and override this type of
denial, you may be forced to either switch your care right away, or obligated to pay your current provider at the Out Of Network rate or as self-pay/cash.
If you file an appeal, remember to explain and justify how your transfer of care is not
clinically recommended at this specific time, or how the In Network choices are inadequate or unable to meet your medical needs.
E. Tips
Don't wait! If you know you will have a new plan in January, don't wait until that time when
insurance companies are overwhelmed with changes of memberships and new requests
for authorizations. Start applying a few days at the end of December. Asking for
"expedited" handling, could help you gain a few days, especially in cases such as
chemotherapy or radiation therapy, where any delay be unacceptable.
Gather your documents, treatment plans, consultation, reports, medical notes and
records, but also reasons why In Network providers are not able or trained to take your medical care over.
Try and locate an in network alternative, if not for now, but for when your treatment is over or transfer of care is deemed "safe", or if the kind of treatment you are receiving affords a little bit of delay or is not critical to your health. Go online or call your new plan to help with that search
When in doubt, ask your current doctors if transferring your care is safe or not. If yes, can they refer someone from the In Network insurance list. If not, they should provide the evidence supporting that claim.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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