Media Niche

From time to time, I’ll be offering vintage and older (1700’s to early 2000’s) wellness media as I find them. Most of the information is timeless–it’s just as relevant today as it was when it was published. Some of the very old ones are just fun for learning the history of various wellness techniques.

These are one-of-a-kind books from my own personal library and that come into the Thrifter’s Niche online thrift shoppe from friends and family.

The books are posted at various selling sites so clicking the link here will take you there. If the site requires you to have an account to use it and you don’t want to sign up, send me an email at niche@healthylifestylesmedia.com and I can find another way to get the item to you. Please copy and paste the link to the item or page you’re on so I know what you’re looking for, in the event of changes on this page.

Here’s the first title being offered:

BonniePrudden-AfterFiftyFitnessGuide

Bonnie Prudden’s After Fifty Fitness Guide – $5.70 + shipping

This is one of the original wellness books that discusses  ‘myotherapy’ or what we now know as trigger point therapy. There lots of photos to show you how to use myotherapy and also how to do a variety exercise and workout routines. There are also sections on pain management. Even though it was published in 1986, it’s the type of book that has information that never gets old.

Click here to view and purchase at eBay.com


Are You Looking for Something Special?

If you’ve been looking for certain books, DVD or VHS videos, or relaxation/meditation or workout music CDs  and just can’t find it, let me know–I might have it or know where to find it for you.  I have access to a lot of media on lifestyle change, psychology, fitness, wellness, spirituality, relationships  or environmental topics.

If you’re not sure of titles, you can indicate what the book is about and the name of the author if you know it (or as close as you know it).  If you’re just interested in a topic with no particular author or title in mind, let me know that too and I can get you a list of things to choose from.

Fill out the form below to let me know


 

Week 1: Occupational Therapy

Occupational Therapy helps you with what are called “Activities of Daily Living” or ADL’s as they’re commonly known. These are things you do every day like walking, sitting, dressing, bathing, cleaning house, driving, lifting, or things you might do on your job or around the house.

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We began by working on plans for things we like to and need to do but have some trouble with. My list includes:

  • “Shopping walking” – that slow stroll with occasional stopping, reaching up or down, squatting and getting back up again.
  • Minor household repairs requiring looking and reaching up over my head or kneeling on the floor. Same as the Shopping but without the walking.
  • Sitting at my desk – I slouch when I’m working because I don’t have ergonomically-correct furniture–it’s way too expensive. I’m now trying to sit in my office chair in a semi-lotus position  so my spine is straight and that helps until my legs start cramping.

I’ve gotten so I when I go shopping, I don’t even look at anything on upper or lower shelves anymore. If I do, I’ve learned not to squat down to take a closer look. It’s embarrassing when my friends have to help me back up again.

We also learned about Pacing, which means doing whatever you do sitting or standing for about a half hour then switching to another task that requires the opposite movement for another half hour. You should also take time to gaze out the window to refocus your eyes for 10 – 20 minutes, especially if you’re doing computer work.

The occupational therapist told us about the “20-20-20 Rule” where you work for 20 minutes, break or switch to an opposite task for 20 minutes and look at something 20 feet away.

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I tried this but stopping work every 20 minutes broke my concentration too much. I decided to try 40 minutes working with a 10-minute stretch/breathe or do an opposite task like putting in a load of laundry and putting away what came out of the dryer. Then I look out the window for 10 minutes.

My OT said my 40-10-10 Rule was good. So, for my short 10 minute break projects I’ll prep a salad for dinner or walk around the yard and water flowers, or put a load of clothes in the washer or fold what’s in the dryer.

It seems that the switching up of tasks this way–alternating sitting and standing–allows me to get more done during the day. I’m incorporating short bouts of housekeeping, prep cooking, gardening, and laundry into break-from-sitting-time. I feel more productive now.

break-time

Try the 20-20-20 Rule (or 30-15-15 or 40-10-10 or whatever works for you).  Use a kitchen timer or a timer on your computer and set it for the number of minutes for your break time.

This ‘rule’ is especially good for those who work in cubicle or desk jobs where you’re mostly sitting. Try to stand up and stretch and move around as much as you can. Look at something distant from you–a window or the far wall of the call center or office to get refocus your eyes to prevent strain.

If you do this, share how you did it and if it helped you. If it helps, how? If it doesn’t help, why?

 

Week 1 – Fitness Class: Physical Therapy and Movement (“Phy-Ed”)

Physical Therapy and Conditioning

In my weekly routines, Morning Stretch is followed by one hour of fitness-and-conditioning machine workouts. State-of-the-art fitness and conditioning machines are new for me because I’ve never worked out on anything more than a treadmill or stationary bike while doing physical therapy at my home clinic.

healthy woman legs dark

When I first entered the pain program’s workout center, I was intimidated. It looked like the set for a movie about the Spanish Inquisition, or maybe a football team documentary.

 

OK–maybe not that bad. The machine  that strengthens my neck muscles actually made me feel pretty good. They say that stronger neck muscles should help alleviate the pain caused by the degenerative discs.

 

girl head-banging to rock musicThe repeated back-and-forth motion of my neck while using this machine brings back memories of my old heavy-metal head-banging days, except in slow motion.

 

I told my 20-something-year-old therapist that I’d be ready to start head-banging again after this treatment. That made her giggle. Imagine old people like me head-banging. We still do, you know.  

 

Come to think of it, could head-banging be the reason why I now have degenerative disc disease? Do Baby Boomers have more neck problems than Gen Y’ers and Millennials?

 

The Gen X’ers of the Disco Era probably also have neck issues. There was all that pointing up and down and following their pointing with their their eyes with a steady up-down neck twist. It’s a variation of the head-bang only with a slower beat.

 

disco-dancers

Dance Mishaps

Now that we’re pondering whether dancing might be harmful to your health, let’s also consider tripping, falling and getting (accidently) decked:

Have you ever:

  • Taken a hard fall on your butt on a dance floor?
  • Been socked in the jaw by a wild elbow?
  • Tripped over a kicking foot and gone flying?

There are a lot of videos of this phenomena out there and most of them seem to be at marriage celebrations–so therefore, wedding accidents.

 

Injuries from falls very often show up later as chronic arthritis and myofascial pain: inflammation of the muscles and facia (FACE-she-ah) which are the tissues covering and connecting the muscles to the bone.

man-falling-down-img

Dancing mishaps can also occur at clubs, celebrations and community events too. Anywhere where there’s wild music.

 

Polkas are especially dangerous. All that spinning and getting dizzy and hopping on one foot then the other. All at the same time.

 

If you live in the Upper Midwest US or South Canada, you know what I mean. Oh, and watch out for that Butterfly Dance, eh?

 

If you’re wondering what that is, watch a clip here. It seems safe enough for the first couple minutes but then…all heck breaks loose. 

NOTE: to my knowledge, no dancers were harmed in the making of this video.  

 

They were having fun doing something healthy: burning up the calories consumed from the wedding feast, the cake, and the beer. OK–the beer isn’t exactly healthy for everyone but it can get people up to dance who otherwise would not do it anywhere else. And they laugh and have fun. Social connection is also recommended for healthier living. That’s for a future discussion.  

 

Dancing is a great cardio workout, no matter how you do it. It doesn’t have to be vigorous–you can do a slow waltz or just sit in a chair and move your arms and legs to music (as your mobility allows). Any amount of movement for even 10 minutes is better than not moving at all. Start out simple and easy. The more you do it, it starts feeling so good you want to do it more. 

 

“Housecleaning Aerobics”

woman dancing with mop

 

This is one of my favorite workouts:

  1. Put on your favorite dance music
  2. Crank it up (if it doesn’t bother your neighbors or housemates)
  3. Grab a broom or mop or dust rag
  4. Boogie down 
  5. Sing along (again, thinking about who may hear you and if you mind) 
  6. Sweep! Mop! Dust! Turn–and step–and wipe–123. 

 

Singing is an excellent workout for the lungs, diaphragm and stomach muscles. And it boosts endorphins too. Those are the brain chemicals that make you feel good and happy when you’re feeling that way. But when you’re not, singing and dancing can activate those little endorphins which help lighten you up, lessen the pain, and make you feel better. (Granted you don’t trip and fall while dancing with the broom!) 

 

So, to wrap this up, my recommendation is that if you don’t have access to a fitness center or conditioning machines, try singing and dancing. Doesn’t matter whether you’re any good at it or not–just do what works and makes you feel better. 

 


PS: for you aging head-bangers out there, watch for the upcoming  “Heavy Metal Aerobics” video at DIY Healthy Lifestyles’ YouTube page.

 


Comments, Questions, and Suggestions


 

 

 

 

 

 

 

Week 1 – Starting the Day

red school blur factory

Wow. I feel like I’m back in high school again. I’ve got a locker and I’m running from one class to the next. I’ve got “gym” (physical therapy and conditioning) and “swimming” (warm pool therapy), occupational therapy, health psychology, Yoga, mindfulness and spirituality, mind-brain science, and lifestyle management.

 

It’s spread out between two days a week but it’s still a full day of activity each day.


MORNING STRETCH

The day begins with one-hour of neck-to-toe stretching using a combination of simple Yoga positions and muscle-stretching exercises. Years ago, I used to do Yoga in the evenings before bedtime because I found it relaxing.

 

Aside from the fact that it was many years ago and I can no longer do Yoga like that anymore, I’m realizing it makes much more sense to move and stretch when you first get up because it does five important things that you need more so in the morning than in the evening:

  1. Gets your airways and blood circulating
  2. Wakes up your brain and jump-starts that for the day
  3. Warms up your muscles and loosens stiff joints and tendons
  4. Gets your energy flowing
  5. Prepares you for whatever you do during your day: sitting, standing, walking, or lifting, work, activities, chores or projects.

 

But morning exercise/movement doesn’t necessarily mean jumping right out of bed and hitting the exercise mat first thing. I’ve heard of people who can do that but I’m not one of them. What works for me is to pour a cup of coffee, take a look at my planner, and plot my day. Then Morning Stretch and a light, healthy breakfast and I’m ready to face the day.

 

I recommend stretching be your first task of the day, regardless of when you wake up. If you’re not a “morning person”, just do them when you get up (after the bathroom visit and a cup of coffee).

 

It doesn’t need to be every day. Just start with twice a week and work your way into it. You’d be surprised at how this can wake you up and help you feel more motivated for the rest of the day.

 


 

Introduction to Lifestyle and Behavior Change

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Talk of lifestyle and behavior change is scary for a lot of people.

There may come a time when the realization hits that the only way to feel better is to become aware of your health behavior and move toward changing your lifestyle.

That’s what happened to me when I developed fibromyalgia. I’d been caught on a merry-go-round of prescription medications and physical therapy that would work for a while and then have no effect at all.

After about four years of this, I said “ENOUGH!” and decided to undertake some research and create my own treatment plan.

Fortunately at that time, a new physician’s assistant arrived at my clinic and I was just able to get in as the last of his quota of patients. He was the first practitioner I’d met who believed in natural healing and he supported my do-it-yourself wellness plan.

The more I learned and practiced, the better I began to feel. After awhile, it was wonderful to start feeling “normal” again that I wanted to keep it going.

Starting a lifestyle and behavior change plan can be hard but it does get easier with every success you achieve.

In this section, I’ll explain what I’ve learned about lifestyle and behavior change. It’s not as scary as it seems and surprisingly easier than you might think.

Making Lifestyle Change Easier

Discussions of lifestyle and behavior change can sound complicated, but these topics are so important to the entire DIY Healthy Lifestyles program that this is the first of the “5 Essentials for Healthy Lifestyles.”

Nothing else can happen until you understand lifestyle and behavior change.

My goal for this section is to try to explain behavioral psychology in a way that everyone can understand.

By the way, if there’s ever anything you have a question about in this section or any of the others, click this link to Raise Your Hand and ask. Don’t be afraid because “the only stupid questions are the ones you don’t ask.” That quote was posted by a Facebook friend who said a high school teacher of hers used to say it. I thought it was cool so I stole it to use here.

Health Behavior Explained

Health Behavior is defined as “the actions we take to keep ourselves healthy” like eating right and exercising. It can also refer to negative actions that harm our health, such as smoking cigarettes or eating too many high-calorie foods on a regular basis.

Our health behavior is formed by beliefs, values, motives, personality traits, behavior patterns, and habits as they relate to health. Here’s a very simplified explanation of how health behavior is formed:

It begins as children when we’re told that fruit and vegetables are good for us and that candy is bad for us. But, as children will, we decided that most vegetables didn’t taste so good and that candy did.

As we grew older, that belief may have stayed with us and it turned into the idea that anything that we were told was good for us tasted awful and whatever was bad tasted great.

That’s why as adults, we often balk at trying out health foods. We’ve prepared our minds from childhood to believe that healthy food tastes bad and junk food is great.  

Do you see how that works? As children, we form the beliefs that drive our health behavior for years to come. The behavior we formed from the belief that junk food tastes better is what lies behind our troubles today with overweight, fatigue, diabetes, cardiovascular diseases, and other ailments. Many people are reluctant to change their diets because of the popular belief that “all health food tastes like cardboard”. This is a very common complaint that I hear whenever I talk about lifestyle change.  

I agree–there is a lot of cardboard out there, and styrofoam too (think rice cakes).

When I started venturing into a whole foods diet, I tasted a lot of very bad stuff. My belief is that food manufacturers tried to jump on the “health food” bandwagon without really knowing much about whole food nutrition.

They figured they could just make the same stuff the way they’d always made it but remove the fat, salt and sugar. And not replace it with a healthy alternative that would still make it taste good. Fortunately, health food manufacturing has advanced and now there are some great products out there.

In future lessons, you’ll learn the secrets of great-tasting health food. We’ll look at reviews of really good-tasting, pre-packaged foods you can find in almost any grocery store, plus recipes for making your own healthy foods at home.

You won’t believe you’re actually eating stuff that’s good for you! You’ll even learn not to miss sugar or salt–two of the biggest contributors to obesity, chronic pain and cardiovascular disease.

Behavior Change Models

Health behavior theories have been laid out in concise models, or simplified illustrations that show us how the theory works.

The DIY Health Lifestyles program taps into five behavior change models. (There’s that ‘five’ number again!) We’ll look into those models in detail in future sections. The discussion today is to make the term “behavior change” sound less scary and complicated.

I’m going to assume that if you’re reading this, you’re interested in making lifestyle changes. I’m also going to assume that you’ve read books and articles, watched videos or tried different programs but they were too hard to understand, too complicated to follow, or they just didn’t seem to work. That’s what most of the people who join the Center say when asked what they’ve done before.

The reason why so many wellness plans and programs don’t seem to work is that many don’t address health behavior or health beliefs.

They don’t ask about your personal reasons for wanting to change or the beliefs you have about your ability to make changes. They just tell you that you have to do this and eat that without helping you find out why you balk at doing what they want.

Learning a little about health behavior helps you discover why something doesn’t work for you or what you can do to make it work.

It can help you see where your beliefs and feelings about what is or isn’t good for you come from. It can help you learn how you can change beliefs that have been working against your health.

An understanding of health behavior and behavior change models goes a very, very long way toward helping you overcome past “failures” and succeed in finally making lasting changes.  


Good News from the Food Industry

grocerystoremomentoftruthA couple of years ago, I posted a video link to the ABC News documentary, How to Get Fat Without Really Trying.  In that video, the late Peter Jennings interviews the president of the Grocery Manufacturers Association (GMA).

His responses so blithely dismissed the needs of the consumer in favor of the needs of the GMA, which are increased sales without regard to food safety or the negative effects of marketing junk food to kids.

The GMA is one of the largest and most powerful lobbying groups that wields great influence on food policy in Washington, D. C.  Most often, not to the benefit of the consumer.

I was totally disgusted by the GMA president in the video. That documentary, along with a few others, was one of the biggest influences for me to quit eating popular brand-name processed food.

If you haven’t seen How to Get Fat… you can access it here.   It’s several years old but the message is timeless–especially in light of the news I read today.

My favorite food policy guru, Marion Nestle, via her blog, Food Politics, tells us that many national food manufactures are feeling the pinch of the public demand for better food. I say its about time.

They’re caught between the consumer and the GMA, which opposes anything that would make food safer and more nutritious. In their mind, that translates to “less profitable.”

Professor Nestle tells us that several national food manufacturers have now left the GMA over disagreements on many issues. Some of those companies’ products had been old favorites of mine that I gave up buying after watching the ABC documentary.

I’m happy to hear of their defection from the GMA but it remains to be seen if they change the nutritional profiles of their products.


Here’s Professor Nestle’s report:

I’ve written many times about the Grocery Manufacturers Association (GMA), an organization so locked into the interests of its food-company donors that you can count on it to vehemently oppose every consumer-friendly measure that gets proposed. A couple of weeks ago, Politico’s Helena Bottemiller Evich and Catherine Boudreau wrote what they discovered about the unraveling […]

via Defections from the Grocery Manufacturers Association: Rats leaving a sinking ship? — Food Politics by Marion Nestle

Learn Something New This Week

VirginiaPublicLibrary

My own local public library

You’re never too old to learn something new.

In a way, I’m glad I finished my degree and don’t have to worry about getting ready for another quarter. In another way, I miss the new learning and the sparking of ideas from that learning that would excite me about whatever I was studying.

You don’t need to be in school or enrolled in any course to be a student of something you’re interested in. It doesn’t have to be academic–it can be a hobby or a fascination with something in particular, say gardening, woodworking, playing an instrument, or whatever absorbs your interest.

Studies have shown that curiosity and a desire to learn new things go a long way toward strengthening your memory and cognitive functions. It is said that people who read more, watch educational television or videos, or spend time on a hobby maintain higher brain function into their 80’s and 90’s.

All you need for exercising your mind is a public library. Free media everywhere on anything you ever wanted to know about. Books, videos, recordings, newspapers, magazines plus digital formats of paper media.

It’s the best of both worlds: free information on nearly anything and everything, in paper and/or digital formats, for people with or without computers.

I’ve been a library bookworm since childhood. But, during my recent studies, I got used to getting books on Kindle, and using downloaded e-books instead of ordering $300 textbooks or $18.00 paperback novels (that’s ridiculous!). We could also download research material to print if we wanted to but I like saving the forests.

Because of that, I hadn’t been to my library in years. I do pick up a lot of books and videos from garage sales but that’s different: you’re not seeking out a specific topic, you’re picking up books that interest you that just happen to be there.

You walk into a library and pick a section related to your interest and BAM–suddenly you don’t know where to start. Me, I always go for the “beginners’ guide to…” or “an introduction to…” if I’m learning something new.

If it’s something I’ve been learning about and want to know more, I’ll look for “techniques in…” or “the (practioner’s) guide to…(interest)”. These would be like the ‘watercolor painter’s guide to flowers’ or ‘the gardener’s guide to organic vegetables’. You already know about gardening but now want to learn to do it organically.

My particular favorites for exploring either new or familiar topics  are the For Dummies and the Everything (Topic) series. There’s almost nothing that hasn’t been covered by someone in any line of work. Many of those authors are university professors or professionals in that area so you know you’re getting good, solid  information–for the most part.

I have read some that confused me because the author of a “‘beginner’s guide” assumed the reader already knew a lot about the topic. If they assume that then why are they writing a “beginner’s guide”? Something I’ve often wondered.

Many authors of these series update their work every year, especially if the subject is one that changes frequently, like the Internet, economics, or social media. Others are timeless, like arts n’ crafts instruction using techniques that haven’t changed for centuries such as fiber arts, preserving, or wood-working.

Your library’s how-to video section is a good place to go too. I find it easier to watch something done than to read how its done. Some of the For Dummies books are also on video, which is very helpful for visual instruction like fitness workouts, Yoga or using the Internet.

If you already do use the Internet regularly, you can find literally zillions of free how-to videos from YouTube, Pinterest, Facebook and other social media sites as well.

Libraries also make use of the Internet to assist people. They offer access to all sorts of online information databases, can help locate media and get it from other libraries, and provide you with your own library ‘home page’ where you can keep your lists of things to look for and manage your loans, returns, and holds.

Now–what’s really cool about libraries: if you don’t own a computer, you can get time at your public library, and if you need to, you can have someone walk you through learning how to find stuff.

No matter your age or learning style, there are many ways for you to learn about something you’ve been interested in–or something entirely new–for FREE at your nearest public library.

So, in honor of Back to School Week, get out there and learn something new.

 

 

 

 

March is National Nutrition Month

Arranged Vegetables Creating a Face

National Nutrition Month comes at the perfect time of year! With warmer weather on the way, we’ll soon be taking our Spring and Summer clothes out of storage.

We hope everything still fits after a long Fall and Winter filled with many holidays and high-calorie foods! For those of us in the colder parts of the world, we also get less activity when it’s too cold to be outside.

To help you get started on your Spring eating and activity plans before you put on your first pair of shorts, check out these tips from the U. S. Department of Agriculture’s Choose My Plate site.

You’ll find tip sheets and interactive tools to help you make healthier choices yourself and your family.

If you’re a health educator, school teacher, or home-schooler, there’s also the My Plate for Schools section where you can find learning materials to use in your health lessons.

My favorite tip is “Make Small Changes”. Rather than trying a total diet overhaul, just decide to change one thing. Try eating fruit for dessert instead of ice cream. Do that for a few weeks until it becomes a new habit, then make a new change, like going out for a short walk after dinner.

Every little change you make moves you closer to your fitness and wellness goals.

So, click here and started on your diet and nutrition plan today!

https://www.choosemyplate.gov/national-nutrition-month

Share the small changes you plan to make this month or your favorite health and wellness website!

 

 

 

Health Care Information Hacks: Bogus Alert

hipaa-violation-claims-hack

This is a ‘hack’ that has been going around on Facebook that is so full of misinformation and fallacies that I felt the need to address it. People should not be allowed to post bogus medical information on Facebook.

The writer of this hack appears to have not done any research into how insurance companies really do process claims. My research comes from having worked eight years as a customer service representative in a health insurance company, explaining how claims are processed, why they deny, and what can be done to contest a denied claim.

First of all, you need to know that no one who is not trained in HIPAA is going to be reviewing a claim. EVERYONE from the lowly high school graduates to the CEO is REQUIRED to go through HIPAA compliance training in order to work at the company.

By the way, HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

Second, you need to know that claims do not get denied because of HIPAA violations.  The only thing HIPAA has to do with claims processing is ensuring that your data does not get shared with anyone not authorized to have it.

Therefore, the funniest thing I read in this ‘hack’ is when the writer advises people to ask for the “credentials” of everyone viewing claims. There is no “credentialing” process beyond the required HIPAA training that gives employees an official license or degree that authorizes them to process claims.

Training completion is recorded in the employee’s records and they sometimes receive a certificate upon completion to hang in their cubicles to let others know what they’ve been trained in. So, if you ask for ‘names and credentials’ of everyone authorized to view claims, you’d have to be prepared take down thousands of names, depending on the size of the company.  That is, if you could get the names.

Because you know what?  Employee records are also privacy protected so the company cannot release employee names or ‘credentials’ to anyone who calls and asks for them. So, if you’re thinking about following this hack, prepare to get absolutely nowhere. And very likely laughed at after you hang up, if not before.

Third, insurance claims processing and customer service are not minimum wage jobs like those in a telemarketing call center where anyone can do the work, as the hack writer would like you to believe. If you think that a high school kid who has just graduated and has had no college education or post-high school training would be hired to work as a claims processor or a reviewer who makes “medical decisions”, you’re just as mistaken as the writer of this hack is.

Since it’s fairly easy to lose a good-paying job with good benefits for even the slightest HIPAA violation, it’s very unlikely this is going to be a basis for your claim denying. If you’re planning to play this ‘HIPAA Violation’ card to get your denied claim re-processed, you are in for a BIG surprise!

By now, it should be clear that the person who wrote this ‘hack’ has either never tried this herself nor researched it with anyone who knew something about claims processing.

So, if it’s not HIPAA violations or untrained high-school grads given the power to make medical decisions, then why do claims get denied?

Here are the biggest reasons, roughly in order of the frequency in which they occur:

  • No pre-planning by the patient (that’s you!)

The patient does not read the coverage manual that every insurance company is required by law to give to their enrollees, nor do they call the customer service department of the insurance company to verify that a procedure is covered before they have the procedure.

NOTE: Customer service representatives can legally only verify coverage per the coverage manual. They cannot evaluate medical procedures or situations nor can they ever guarantee coverage.

In fact, every insurance company’s recorded greeting advises that they cannot guarantee coverage. You can rely on the information in your coverage manual for common or routine procedures but more complex procedures require more research. (See below on ‘prior authorizations’)

  • Health care providers (doctors, nurses, lab technicians, etc) tell patients procedures will be covered when they don’t know for certain themselves.

Don’t let a provider tell you, “Oh, don’t worry–your insurance will cover that.” Check your insurance manual or call the company. Health care providers don’t read insurance manuals and are not the ones who submit claims; the clinic or hospital’s billing department does that.

  • Some complicated, very expensive, or recently-approved procedures require what is known as a ‘pre-authorization’ or ‘prior authorization’ (also called a ‘PA’ or ‘pre-auth’ or ‘pre-cert’ by health care billing staff)

This involves your health care provider submitting a report of your condition and their plan for treatment (surgery, therapies, or prescription medication). This plan is reviewed by a team of physicians and medically-trained staff at the insurance company to determine if the plan will provide for a positive outcome on your health.

A PA can take quite a bit of time to approve, especially for a recently-approved or very expensive procedure that may require a great deal of documentation and time for review.

DO NOT ever let your provider say, “Aw, let’s just go ahead and do it, I’m sure they’ll approve it” unless you have thousands–maybe even millions–of dollars to cover your procedure if the PA is not approved after you’ve already had the procedure. You do have the right to appeal the denial based on “my doctor told me it would be covered” but don’t expect to win the appeal.

  • Incorrect coding submitted by the clinic or hospital billing department

Billing departments use numeric codes for diseases and conditions and for the procedures done to treat them. Coders pull the treatment information from the patient’s records then look up the codes for the illness and the treatment and submit these on the claim

Coders and billers are regular people, and regular people are known to misread or transpose numbers if they are hurried, overworked or fatigued and submit an incorrect code

They may be in a time crunch because there are time limits on when claims must be submitted.  They may be reading too quickly and see ‘angiogram’ in the chart but pull up the code for an ‘angioplasty’.  The first is an imaging procedure, the second is an operation. If the procedure code applied is not one that would be indicated for the treatment of the condition, the insurance company computer will deny the claim for “procedure does not match the condition.”

Items (b) and (c) can often be fixed by calling your clinic or hospital and asking them to review the claim for possible errors. You can’t tell them they made an error and they’d better fix it because you are not trained in clinical billing; you can only request them to review it. Most of the time, they will see the problem and correct it.

DO NOT EVER ask the billing office to change a code for an uncovered procedure to one that is covered. It’s unethical not to mention illegal, so they can’t and won’t do that because they could lose their jobs. Also, DO NOT ask the insurance company representative to tell the provider to change a code–the same applies to them as well.

Insurance companies have provider service representatives (PSR’s) whose job it is to work directly with the clinics, hospitals, nursing homes, pharmacies, therapy centers, and medical supply stores to resolve problems with claims.

When you receive a notice from your insurance company that a claim has been denied, you can call your clinic or hospital’s billing office and ask them to work with their PSR at the insurance company to resolve the issue.

DON’T let the provider or billing clerk tell you that you have to call your insurance company and ask them to reprocess the claim. The insurance company cannot change information on claims–only the provider’s billing office can do that.

  • Computer-denied claims

Forms are used to submit claims that are then ‘read’ by the computer, much like the scanner that reads numbers from a bar code at the grocery store.

Billers may enter characters like a dot or a dash in a number where there is not supposed to be any character so the computer misreads the code or rejects it completely, resulting in the claim being denied. This too can be fixed by the billing department and resubmitting a corrected claim.

There you have it. These are the most common–and REAL–reasons why a claim might deny and what you can do about it.

Save yourself, your health care providers, and your insurance company a lot of time and headaches by completely disregarding the above misguided hack for getting your claims reprocessed.

Oh, and by the way, there is no such thing as “the US Office of Civil Rights” at ocr.gov. so don’t try looking there for information–you won’t find it.

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