Continuation Of Care: Take Advantage
By Martine G. Brousse
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
January 2, 2024
What is Continuation Of Care? Why should you be aware of its benefits and how to obtain it?
Let’s explore the topic.
A. What is Continuation Of Care?
1. Continuation Of Care (“COC”) is a policy holder’s right to continue ongoing treatment/service, with the same medical provider, under the same terms of coverage and payment, when that provider’s status changes from In Network to Out of Network under a new plan, or through cancellation of contract.
2. It means that a new plan, or an existing plan must continue paying an out of network provider at a higher In Network rate, even if that provider is now Out of Network.
B. When does COC apply?
1. When treatment cannot be delayed or interrupted, or when care cannot be safely transferred at that time. A good example is chemotherapy and its specific protocl which cannot be compromised without harmful consequences.
2. When there is no adequate, equivalent, trained, experienced, available In Network providers with the same specialty or expertise. A good example would be a specialist for a rare disease
3. An upcoming non-elective, scheduled, medically necessary treatment or surgical intervention is already scheduled or the direct result of an emergency. A good example would be a hip replacement after fracture or a breast biopsy after mammogram and labs show cancer.
4. The No Surprise Act mandates that certain conditions are met to prompt COC for specific time frames:
· Pregnancy
· Member under institutional or inpatient care
· Patient under prolonged chronic disease care
· Terminally ill patient under treatment
· Acute condition
· Care of a child under 3 years
5. An authorization is already in place, if the provider is In or Out of network with the previous plan or if an Out Of Network provider is being paid at the In Network rate
C. How to apply
1. Provider:
· Must request transfer of authorization or extension of existing care with new plan or if they are cancelling their contract with the existing plan
· Transfer is NOT automatic, nor guaranteed!
· Medical records and justification must show medical necessity, and adverse consequences if transfer of care to an In Network provider is forced
2. Member/Patient
· Must submit a special form to their new plan or current insurance (if provider cancels contract). Form is found on insurance websites or call a representative
· Must provide proper documentation: special or current authorization, scheduled procedure, lack of equivalent or available In Network option, risk of harm due to unsafe transfer, treatment plan etc.
D. Exceptions
1. Insurance has legal right to deny COC if:
· Treatment or services are no longer life-threatening, or the result of an immediate emergency
· If transfer of care to an In Network facility or provider is deemed “safe”
· If the patient is declared “stable” pending further medical care
· If an In Network provider is determined to be an adequate, equivalent and available option
E. Tips
1. Don’t wait:
· If you know your current plan will end soon,
· or if the provider has indicated they are cancelling their contract
2. Gather Documents
· Treatment plan, assessments, consult notes, reports, medical records, letters of medical necessity, scheduled surgery paperwork etc
3. Do your due diligence:
· Try and locate an In Network provider
· Note why potential options are not possible or adequate (i.e do not accept new patients, not specialized enough, no access to an appointment within legal dadline etc)
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.
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@martine brousse 2024 @ the medical bill whisperer 2024