A 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 […]
It’s Back to School time for the kids and the college students of whatever age.
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.
(I do have references on this stuff, just not handy right now. I eventually hope to have them available in some form down the road.)
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.
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!
Share the small changes you plan to make this month or your favorite health and wellness website!
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.
If you have any questions or comments, please submit them in the ‘envelope’ provided below: