How to save hundreds on a MRI

Hopefully you never have to get a brain or spine MRI. However if your doctor recommends one, you should know that you can save hundreds by choosing a for-profit MRI center.

I didn’t even know about low-cost MRI options until recently. Like many Americans, I would have gone to the radiology lab referred by my doctor, or at least one that is in-network with my insurance company.

That reasoning made sense in the good old days, when your insurance company co-pay would likely be the best deal. If someone has pricing amounts from 10 or so years ago, let me know!

Nowadays, many people pay through the nose even if they have employer-sponsored health insurance, especially those with high deductible plans (HDP). As the name indicates, HDP insurance plans have low premiums but high deductibles (a specified amount of money that the insured must pay before an insurance company will pay a claim). It is intended to incentivize people to compare prices for healthcare services.

One of my favorite cousins has a high deductible plan with a 30% co-insurance for most services, including MRIs. While she is young and in fairly good health, last year she experienced mysterious dizzy spells. Her doctor recommended a MRI.

My cousin called several in-network radiology labs for pricing. No one could or would give her an exact price. The cost would depend on a variety of factors: 1) Negotiated price they billed to the insurance company, which varied widely; 2) the individual’s co-insurance, co-pay and deductible; 3) medical code used; and 4) the biller’s mood that day. (#4 is kind of a joke).

When she went for a second opinion, her new doctor requested another MRI. I forget the reasoning for a 2nd scan but almost a year had passed since her first MRI.

At that point, my cousin had already paid $520 out of pocket for the first MRI and could not afford another costly scan. After some research, she found several for-profit MRI center with good online reviews that charged $200 – $250 for the same scan — basically a 50% saving!

My cousin reported that the facilities and personnel were very good. Her doctor had no issue with the MRI, which means that the quality was good.

A quick Google search for ‘low cost MRI’ pulled up a half dozen results, including Radiology Assist, Nationwide MRI and Affordable MRI. I can’t vouch for any of these so be sure to do your own research.

I wonder if other lab services, such as mammograms or biopsies, have for-profit options that cost less than insurance. As shown by my cousin’s experience, it never hurts to look for alternatives!

HTSMC: Compare Prices On Prescription Meds

A few months ago, I wrote about pharmaceutical assistance programs that help people who have trouble paying for their medications.  This was written before Martin Shkreli became the poster child of pharmaceutical profiteering and corporate greed. I hate that our system allows for astronomical price mark-ups and forces us to compare prices on medications (and medical care) the same way we compare cable and shoes, but for now it is what it is.

I neglected to mention another way to save money on medications: GoodRx.  On their website (and app), you type in the medication you’re looking for and it’ll show you prices, coupons and discounts for your prescription at pharmacies near you. You can also print out a discount card to present to the pharmacist.

There are times that convenience is more important than price. However, prescription meds can have HUGE differences in pricing so it pays to shop around, even if you have insurance coverage.  The biggest saving I’ve had was $15-18/ per month for pet meds.

The GoodRx blog is a surprisingly good source of information:

5 ways to get the most out of your prescription insurance

How the Target pharmacy switch to CVS will affect you.

In general, Walmart and Costco seems to have the lowest prices.  Target is/was relatively inexpensive if a medication was on their generic med program. Sadly, Target will no longer have a list of $4 generics (30-day supply) once CVS takes over their pharmacy program.


This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant. 

 

News: Skyrocketing Drug Costs

Turing Pharmaceuticals recently raised the price of Daraprim, a standard medication for treating a life-threatening parasitic infection, to $750 a tablet from $13.50 per tablet, bringing the annual cost of treatment for some patients to hundreds of thousands of dollars.

Rodelis Therapeutics had raised the price of the tuberculosis drug, Cycloserine, to $10,800 for a supply of 30 pills, up from about $480 that the Purdue Research Foundation had charged. Elsewhere in the world, it sells for about 22 cents per pill. It is considered an essential medicine by the World Health Organization.

The company claimed that they would start a patient assistance program at no cost for the uninsured. However, if you look into any pharmaceutical patient assistance program, there are restrictions in place that would leave out most of the middle-class. Luckily,in this case, the foundation stepped in and re-acquired the rights to this drug.

Both of these are examples of a disturbing trend of pharmaceutical companies acquiring rights to old, off-patent drugs and jacking up the price. What can the average consumer do about this? A national group of more than 140,000 physicians is trying to fight this problem. Democratic candidates Hillary Clinton and Bernie Sanders are both proposing possible solutions to battle rising drug costs. However, any government proposal that benefits the lower to middle-class will likely have to endure a major a political battle in order to get enacted.

HTSMC: Letters to Blue Cross (and other insurance companies)

In my ideal future world, people will no longer have to deal with profit-hungry insurance companies.  Yes, we’ll still have government bureaucracy but that’s a post for another day.

If you’ve been around long enough, you’ve probably had many dealings with insurance companies over benefits.  I’ve heard horror stories of being denied needed services due to the pre-existing condition clause, which I hope is no longer an issue under the Affordable Care Act. Because I enjoyed company-sponsored plans, my family and I did not have to deal with the pre-existing clause issue. Our most common battle was over covered vs. non-covered services.

Denials can happen if you’re trying to get pre-approval for services or if you obtain a service thinking it was covered only to get a bill for the entire amount.  Over the years, I’ve received many denial of services from insurance companies and I’ve gotten pretty good at fighting back.

In the beginning, I would call or write angry letters that got me nowhere.  Luckily, I was able to find good advice online about how to fight insurance companies.  Since then, I have won all challenges except for one case. That’s because 9 times out of 10, a denied service is actually covered.  Insurance companies just don’t want to pay it.

I will break it down to easy steps and I guarantee you have a chance to win if you do this.

1) Don’t bother calling unless you’re checking to see if it could be a billing code error.

2) Get your hands on your plan’s Explanation of Coverage (EOC) booklet.  This is a thick booklet with detailed explanations about coverage, term definitions, exclusions and more. This is your bible.

3) Go through the EOC and mark all clauses that back up your claim that the service is covered.  In all but one of my cases, I was able to find supporting documentation in the EOC, because as I wrote a few paragraphs ago, insurance companies just don’t want to pay.

Original

Original “Hate Mail” Postcard designed by Mr. Bingo.

4) In a letter, state your case in a calm, professional manner.  When you cite something from the EOC booklet, include the page number in the body of your letter and write “see attachment”. Include a copy of that page with your letter. If you have multiple attachments, refer to each by letter – attachment A, B, C etc.. – and write this letter on the corresponding documentation.

5) Tell them you’re requesting a 2nd review of this matter.

6) End by putting the burden of proof on them. Ex: “If you decide to deny my request, please inform me of the section of my plan description upon which you base your decision to deny my benefits. Please provide me with the names of the persons who have made the decision to deny my payment.”

7) Make copies of letter and supporting documents.

8) Send registered mail with someone signing to receive it. Make sure you’re sending it to the right department. All EOC booklets should include an address where you should send this type of request.

Under the Affordable Care Act, there is a standardized process for appealing claims. Read more here.  I haven’t done this but I believe many of my tips would still apply.

Final Tip: It may take a while to get a response. This can be tricky if you owe money to a doctor or hospital. You can cc: your medical provider’s billing office in your letter or call to let them know that you’re addressing this bill. Writing is always better!

Good luck! Please share your experiences and helpful tips in the comments.


This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

Hard Choices Part 4

It’s time to update my current list of our family’s wants and needs. As I’m learning, prioritizing among various needs and wants is a never-ending task.  Once you cross one item off the list, another major expense usually jumps up in its place.

I should update this more often so that big expenses are top of mind. I didn’t even realize that I had two pricey personal care items on the list until I wrote this post.

1) Car #1 Repairs (Spouse) – $1,500 – Have been putting this off for many, months. Check Engine light keeps coming on. This is the primary family car. 

2)  Airplane ticket to home country (Spouse) – $1,300+ – Spouse has not been home in 4 years. 

smile3) NEW! Retainer replacement (Me) – $400+ – It’s time to replace my old retainers. I have a feeling that this will move to the top of the list very soon. $400 is my estimate for retainers but I would probably have to pay out-of-pocket for the consultation. 

4) NEW! Private Speech Therapy (Kids) – $1,000+ – We’re figuring out how to get much-needed lessons through the tangled web of school district rules, regional center and private insurance. While we’re in this holding period, I’m desperate enough to pay out-of-pocket so that my kid can get a good therapist who doesn’t accept insurance. At $70 per session for at least two 1/2 hour lessons per week, it ain’t cheap! Even if my kid does well with this therapist, it will have to be a short-term solution since we can’t afford this indefinitely.

5) NEW! Spa Day (Me, Gift for Mom) – $300. I already spent $160 on a livingsocial spa deal. Tip would add about $60 to the total. I also have a $50 spa gift card that must be used before September 1st. I don’t know if I can find a spa service for exactly $50 and also need to include tip.

6) Car #2 Maintenance (Me) – $500+ – I need to get the brakes checked.

7) Dental Work (Spouse) – $500 to $2,000  – This is #6 mainly because I have little control over my spouse getting the work done. For my dental work, I want a second opinion.

8) Foam mattress or topper (Both) – $1,000 – $2,200 – This may not move up in ranking until the mattress falls apart.

Other Notes:

ipad-airYou may notice that a new iPad is no longer on the list. I had estimated $600 for this expense but we were able to get one through a generous foundation.

Even though we bought a semi-pro camera for my spouse, we left the airplane ticket on the list. We spent much less on the camera by buying used instead of new.

I just found out that it will cost $120 ($60 per adult) to volunteer at our kids’ school next year. This is for fingerprinting, background checks and office fees. Small items that don’t make the “Hard Choices” list can really add up.

This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

Lend You My Money

Inspired by this Bloomberg article, I’ve decided to give peer-to-peer lending a try. For those who don’t know, peer-to-peer lending connects borrowers with investors who lend money at a lower interest rates, allowing people to bypass financial institutions.

Lending-Club-NYSE

If you think about it, peer-to-peer lending is a great tool for middle-class to help other middle-class households.  It’s a win-win situation. You cut out the middle man. The borrower can use the money to fund anything from medical procedures to loan consolidations and benefits from a lower interest rate, especially if they have good credit. A regular person has the opportunity to make money as a lender if the borrower does not default on the loan.

I figure I could start small ($2,000) and consider it “fun” money with a good chance to make more than the measly 1% interest from my savings account.

There are two ways to invest — automatic or manual. Automatic is easier but I want to try my hand at manually selecting loans to finance.  Lending Club (and Prosper) gives each loan a grade based on the borrower’s credit score and other indicators of credit risk from their credit report and loan application. All loans have either a 36- or 60-month term, with fixed interest rates and equal payments.

I’m exposing my naivete when I say that I did very little research before signing up for Lending Club.  Maybe I should have read this article first? For example, I thought there would be a lot more information about the borrower and their needs, sort of like a Go Fund Me Page with pictures and back story. I’m also not sure how taxes will affect my returns.

It will take a while to see if this type of investing will pay off but it’s an interesting gamble.

A Week In The Life Of Special Needs Parenting

Every week, my spouse and I face a mountain-load of paperwork related to managing a special-needs household.  Below is a sampling.


Monday

Spouse handles medical appointment for one kid.

I schedule extra service hours for this Wednesday.

Tuesday

I take a day off from work.

I attend 3-hour parent training seminar required by Regional Center

I pick up dental referral form for one kid

I email back and forth with Service Provider re; insurance denial for one of kid’s services

Spouse and I participate in a therapy session with kid.

I fix a mistake that I made earlier in one of our service provider’s schedule.

Spouse sends in medical supply order and questions to service provider

Wednesday

Spouse brings kid to hospital for check-up.

I research and complete paperwork for a government program.  I hope I get all the necessary forms!

I call Insurance about a denied claim.  Hear a message saying they’re too busy and to call back another day. Search for most recent approval paperwork!

Spouse completes paperwork for IHSS.

I discuss upcoming vacation time with a therapist.

I notice a possible error in schedule for next week and note to bring this up with provider.

I print and save copies of lab results for one kid.

Thursday

Spouse discusses parent training schedule with consultant

I TRY to submit information online for a government program. I get an error message and contact the agency for help. I would have submitted the old-fashioned way but I cannot find a paper application anywhere on their site.  During this research, I also notice that there are a few additional supporting documentation on their site that were not required in the online application.

I email important documents to kid’s doctor for his signature.

I email insurance about the denied claim.

I call provider about services that is supposed to start for one of my sons in April.

Friday

I email Regional Center about services that is supposed to start for one of my sons in April.

Weekend

We realize that we have 3 special needs related meetings next week.

Add stuff to the To-Do List:

  • Get ready for IEP by reviewing progress reports and decide strategy.
  • Get paperwork ready for foundation meeting.
  • Set a schedule for weekly parent training for both of us
  • Email provider about not being happy with one of the therapists.
  • Find out if one of our recent appointments qualify for a claim with AFLAC.
  • Note to self: Research if we should continue paying for AFLAC insurance.
  • Must follow-up (again) with IHSS
  • Must follow up with kid’s doctor about completing form.

Some weeks are definitely more hectic than others.  It was a fairly slow week at work so I was able to tackle multiple projects.  Many times, I’m just too busy at work to do much else. Unfortunately, it’s not uncommon for it to take-up 2-3 weeks for me to follow-up.

All of the above must be taken care of while we manage a household with two young kids, freelance career and a full-time job! We could not do this without local family support (thanks Mom!)

HTSMC: Work The Corporate System Part II

In an earlier post, I discussed government programs that have been priceless for me and many low- to middle-class families.  Now I want to talk about financial assistance programs from corporations that can help middle-class folks.

buildingCorporate Assistance –  Many pharmaceutical manufacturers have medication copay assistance and this is very useful if you require any medication on a long-term basis. For example,  AbbVie Inc., a major pharmaceutical company, states that they “consider many factors when reviewing an application. Examples include: family size, the medication you are taking, and other special circumstances.”  You may have to dig around to find information. I was able to get co-payments waived for two years in a row through a corporate assistance program but this program isn’t mentioned anywhere on the company website.  A kind employee told me about it after I had corresponded with her a few times and told her we could not afford the co-pays.

hospital

Hotel or Hospital Lobby?

Hospital Assistance Programs – Many hospitals are run like a corporate entity, so it’s not surprising that may also offer charity programs to help with medical bills. Income is a factor but don’t let that deter you from asking.  If you have extremely high bills, you may get assistance even if you make too much money to qualify for government programs.

I have asked for financial assistance twice in my life from two different hospitals.  In one case, we did not qualify for funding due to income.  However, in the second case, the hospital took expenses as well as income into consideration.  Because we had many medical bills, high premiums and live in a high cost-of-living metro, we were able to get two bills waived.

Private Foundations –  Some private foundations provide grants to individuals, not just to non-profit organizations.  For example, the Act Today foundation provides $100 – $5,000 grants to families affected by Autism.  According to their guidelines, they do not set an income level cap but incomes below $100,000 per year are reviewed first.

Although I haven’t received any private foundation grants yet, I plan to keep trying.

Unlike government programs, which are fairly straight-forward, your ability to state your case in writing may make a huge difference in getting help. When I apply, I usually include a cover letter that highlights special circumstances that affect our ability to pay. It can’t hurt to bring a human element to the application process.

Short List of Pharmaceutical Company Assistance Programs

A good place to start is the Partnership for Prescription Assistance website (PPA) which connects to more than 475 patient assistance programs.  However, it does seem to emphasize helping those without prescription medication insurance.  I would still check individual company websites for details because exceptions can be made even if you don’t meet the set criteria.

GlaxoSmithKline – The GSK Co-Pay Assistance Program is for people who have prescription coverage who need extra help paying for certain oral oncology and specialty medicine

Pfizer – Patients with private insurance coverage may receive co-pay assistance through Pfizer RxPathways.  These patients will receive a Pfizer RxPathways co-pay card to use at their local pharmacy to cover the entire cost of their co-payment.”

Merck – “At Merck we realize that sometimes exceptions need to be made based on the patient’s individual circumstances. If you do not meet the prescription drug coverage criteria, your income meets the program criteria, and there are special circumstances of financial and medical hardship that apply to your situation, you can request that an exception be made for you.”

The bottom line is: There are a few assistance programs out there for middle-class folks. You just have to dig harder to find these.

Better Definitions For Insurance Mumbo Jumbo

If you don’t understand common health insurance term, you may choose the wrong plan for your needs or lose out on benefits. Here’s run-down with definitions taken from a mix of health insurer websites, health.com and Money Under 30.

Premiums – The monthly fee for your insurance. If you belong to an employer-sponsored plan, the premium is likely deducted from each paycheck as pre-tax dollars. If you purchase your own healthinsurance plan, you may have the option to pay your premium annually, quarterly, or monthly.

Co-pays – A fixed amount you pay for a health care service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.

Co-insurance – Your share of the costs of a health care service. It’s usually figured as a percentage of the total charge for the service.   Typically, the lower a plan’s monthly payments, the more you’ll pay in coinsurance.  Co-insurance is in addition to your deductible. So if your plan has a $100 deductible and 30% co-insurance and you use $1,000 in services, you’ll pay the $100 plus 30% of the remaining $900, up to your out-of-pocket maximum. I don’t think I’ve ever had a plan with co-insurance, hence my confusion.

Deductibles –   Amount you pay for health care services before your health insurance begins to pay. Let’s say your plan’s deductible is $1,500. That means for most services, you’ll pay 100% for most of your medical and pharmacy bills until the amount you pay reaches $1,500.  After that, you share the cost with your plan by paying coinsurance and copays.

To add to the confusion, your insurance often covers preventative health services from the get-go, meaning you don’t have to meet the deductible to get the benefit of lower co-pays. In other words, your insurer will cover most of the bill and you just pay the co-payment.

Out-of-Pocket Maximum – It is the most you will ever have to pay out of your own pocket for health care during the year, not including premiums, but definitely including the deductible AND the copays and coinsurance you will continue to pay after you hit the deductible. If you hit your OOP for the year, your insurance will pick up 100 percent of costs thereafter. The trick is: You are responsible for letting the insurance company know when you meet or exceed the deductible.

OOP_chartv2

Does A Chart Make More Sense?

Finally, my Woman/Man on the Street thoughts and revised definition of the above terms.

Premium – First, why is this called a Premium? That makes it sound like a privilege or reward. No, it’s just money you pay to get insurance in the first place.

Co-pays – In addition to premiums, you also pay co-pays for doctor visits, hospitalization, medication and other medical-related services and supplies.

Co-insurance – In addition to premiums and co-pays, you may also have to pay co-insurance. I don’t know why.

  • Co-pays and Coinsurance seem like the same thing but they’re not!  Does it really matter if you call it a co-pay or co-insurance if you’re paying?

Deductibles – After paying premiums, you pay X-amount in deductibles BEFORE you can even get the benefits of having insurance. That’s right. You pay for insurance premiums which are not cheap, and then you have to keep paying 100% until you reach that magic deductible amount. I’ve been fortunate to have zero deductible plans but if you don’t, you probably have to track of your spending and let the insurance company know that you met the deductible amount.

Out-of-Pocket Maximum – If you’re “lucky” enough to rack up tons of medical bills in one year, you may meet the out-of-pocket maximum. After you hit this magic number, you are not responsible for any co-pays or co-insurance.

  • Deductibles and Out-of-Pocket Maximum seem like the same thing, but they’re not! 

Do you have a headache yet? No wonder we can’t solve world hunger. We’re too busy trying to figure out health insurance. If you can come up with better definitions, please do so in the comments.

HTSMC: Work The System

It’s hard to write about government assistance programs without getting into a debate whether there should be a societal safety net or not.  Many people view all welfare programs in a negative light — as inefficient bureaucracy at best or assistance for the undeserving poor at worst.

From my observations, it seems that most liberals / Democrats believe that the government should help all of its citizens. Most of my Republics/ conservatives friends and family members put their faith in the American Dream of “pulling yourself (and your family) up by your own bootstraps”.  They tend to support a program or service only if they know someone who benefits from it.

Many states offer home buying assistance for first time buyers and/or for low- to middle-income households.  I did not end up using this type of program but I learned many national and state government program are available even for middle-income people.

Before I get into details, I want to “out” myself up-front as someone who has benefited greatly from receiving support during tougher times.  I also admit that we were not the poorest of the poor.  We had a little family help, too.  Without the myriad of government-sponsored programs, however, I know we would be much worse-off today.*

Here is a quick run-down of government services that I’m thankful for:

1. Disability Insurance – In California, disability tax is taken out of every pay check. It’s not a larger amount.  Should you ever become disable, you can tap into these funds and get approximately 55% of your regular paycheck. This short-term benefit made it much easier for us when I had to quit earlier than expected for a difficult pregnancy.

2. Paid Family Leave – I also took advantage of paid family leave benefits after my children were born.

3. Regional Center – I have a special needs child and we’re fortunate that the state offers services for people with developmental abilities such as Autism, Epilepsy, and Cerebral Palsy. Services provided include speech therapy, occupational therapy, respite and much more. They do require that you first try to get services paid by private insurance and Medi-Cal, which is fair.  If private insurance approves services for your child, that means you are responsible for co-pays.  Our ABA therapy alone adds up to approximately $480 per month!  Luckily the Regional Center is able to help us with these co-payments.

baby

4. Medi-Cal – There is a special Medi-Cal program for individuals with disabilities. First, it’s been a great relief to know that my child would get medical coverage even if I were to lose my job. (It may be different now with Obamacare but I haven’t looked into it.)  This program has helped my family by filling in gaps in insurance coverage.  When my child needed an expensive specialty formula, prescribed by the doctor but not covered by most private insurances, we were able to get the formula through Medi-cal.

5. In-home Supportive Services (IHSS) – This is a lesser-known program that works with families to keep a developmentally disabled individual in a home setting (versus being institutionalized).

In all cases, our income was documented to ensure that we qualified for services.  We had to submit financial information and send them a copy of our tax return every year.  I’m not saying fraud is impossible but we were rejected for two other government programs for having a little too much savings. There is also a lot of follow-up by case workers in order to prevent abuse.

It can be intimidating, confusing and frustrating to navigate the system to get government services.  Government resources are limited and you have to act as an advocate to get enough services. We’ve been lucky to have a few good Case Managers at the Regional Center who have helped us navigate the process. However, I do most of the legwork and research on my own and follow up a lot (phone, email, fax, mail, you name it).

As with private insurance dealings, you’ve got to be very persistent and know your rights. Nice but firm gets better results. Tell them about worse-case scenarios.  Do as much as you can IN WRITING. Make copies. Follow up, follow up, follow up.

* I would like to add that funding cuts have greatly affected the quality and quantity of government services available.  It’s a lot of people fighting for a small slice of pie.


This is one in a sporadic series of tips/ideas to help you stay middle-class.  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.