Ever felt lost in the labyrinth of healthcare billing? Ruby Simmons, our resident expert in revenue cycle management, joins me to unravel the mysteries of medical billing, equipping you with the knowledge to prevent the sting of unexpected medical costs. Together, we traverse the unfamiliar territory of pre-certification, pre-authorization, and predetermination, offering insights that could save you from financial woes. Ruby's expertise doesn't end there; she delves into the nuances of insurance plans and policies, discussing employer coverage for services typically outside your plan, and your rights and responsibilities as a patient.
Facing major surgery is daunting, both physically and mentally, and our conversation doesn't shy away from the aftermath of such life-altering procedures. We open up about the emotional rollercoaster that follows weight loss surgeries and organ transplants, emphasizing the importance of a robust support system. The chat also gets real about the impact of drastic physical changes on mental health, and we compare a variety of health insurance plans to ensure you're armed with the best fit for your post-operative needs. We've got your back, highlighting resources to help manage both the costs and lifestyle changes you'll encounter.
In our final chapters, we share heartrending patient stories, like battles with sarcoidosis, underscoring the power of patient advocacy. We spotlight the critical work of case managers and social services in guiding patients through healthcare challenges, from managing medical expenses to ensuring safe discharge, especially for the most vulnerable like the homeless. Our aim is to illuminate the breadth of resources at your fingertips, whether you're struggling with healthcare funding or recovering from a trauma. So plug in and prepare to be informed, inspired, and empowered on your healthcare journey with us.
Ever felt lost in the labyrinth of healthcare billing? Ruby Simmons, our resident expert in revenue cycle management, joins me to unravel the mysteries of medical billing, equipping you with the knowledge to prevent the sting of unexpected medical costs. Together, we traverse the unfamiliar territory of pre-certification, pre-authorization, and predetermination, offering insights that could save you from financial woes. Ruby's expertise doesn't end there; she delves into the nuances of insurance plans and policies, discussing employer coverage for services typically outside your plan, and your rights and responsibilities as a patient.
Facing major surgery is daunting, both physically and mentally, and our conversation doesn't shy away from the aftermath of such life-altering procedures. We open up about the emotional rollercoaster that follows weight loss surgeries and organ transplants, emphasizing the importance of a robust support system. The chat also gets real about the impact of drastic physical changes on mental health, and we compare a variety of health insurance plans to ensure you're armed with the best fit for your post-operative needs. We've got your back, highlighting resources to help manage both the costs and lifestyle changes you'll encounter.
In our final chapters, we share heartrending patient stories, like battles with sarcoidosis, underscoring the power of patient advocacy. We spotlight the critical work of case managers and social services in guiding patients through healthcare challenges, from managing medical expenses to ensuring safe discharge, especially for the most vulnerable like the homeless. Our aim is to illuminate the breadth of resources at your fingertips, whether you're struggling with healthcare funding or recovering from a trauma. So plug in and prepare to be informed, inspired, and empowered on your healthcare journey with us.
Good afternoon everyone. This is Carolyn Coleman with Gentry's Journey. Our honored guest today is Ruby Simmons and she is an expert in the subject matter of revenue recycle management. We're going to let Ruby introduce herself, but first of all we're going to start off with something inspirational and then we'll let Ruby take it away. Every good thing given and every perfect gift is from above, coming down from the Father of light, with whom there is no variation or shifting shadow, and that's from James 1 and 17. As I mentioned, ruby Simmons expert subject matter in revenue recycle. There are some things that patients get, a lot of things confused. When it comes to billing, we get it. It's not your area of expertise. My job as a case manager is to explain, but when it gets too hairy I send you over to the billing department. No-transcript.
Speaker 2:Hi, my name is Ruby Simmons. I'm your medical billing mentor and owner of Block and Revenue Cycle Solutions LLC, and I am also a course content creator when it comes to revenue cycle management, and if you don't know what revenue cycle management is, it's basically managing the revenue cycle of a healthcare provider or organization or facility. I've had experience in several areas, both working in hospitals, working in physician organizations and now, as in my own business, for private practices, and some of the lingo is just very confusing for patients. So I'm here today to help unconfuse you and or help answer any questions that you may have today and didn't know, and just clarify some things for you as far as the bills that you may be receiving in the mail when you should, should not pay them and things like that. So one of the things that Carolyn just mentioned is pre-authorization, so I'm going to read some descriptions off for you when it comes to pre-authorization, pre-certification, predeterminations, and this will help you understand the difference between the three.
Speaker 2:So a pre-certification involves obtaining a certification or approval from the health insurance provider before receiving specific services or treatment. This is often required for non-emergency surgical procedures, expensive tests or treatments to ensure that they are covered under your health plan, sure that they are covered under your health plan. The aim is to verify the planned service is medically necessary and appropriate, and this is so you won't be stuck with a bill for getting services done that your insurance did not approve of. Then the next one is prior authorization, and when you get a prior auth it's similar to a pre-certification, but a prior pre-authorization is the process of getting approval from an insurance company before assessing certain healthcare services. This may be required for medications, surgeries or other types of care. The health care provider usually submits a request to the insurance company detailing why the service is necessary, and that's called a plan, a plan of care that the provider has to submit to the insurance carrier, and the insurance carrier takes that plan of care into consideration when authorizing pre-authorizing the services that you need to have done or that you want to have done. And this is also so that you know to make sure that it aligns with your coverage and that you don't end up getting a bill for something that you thought that your insurance was going to cover and then you have predeterminations. This is a process where a determination is made about the amount of coverage. An insurance plan will provide for a specific procedure or service before it's performed, just to determine the expected payment amount, which can help patients understand their financial responsibility after insurance coverage is applied. And so I'll give you an example of where you would have a predetermination done.
Speaker 2:So let's say you want to have weight loss surgery, want to have weight loss surgery, you're overweight, it's messing with your health and at this point you may be starting to have back problems, feet problems and certain things that you just really can't deal with anymore, and you want to have weight loss surgery to relieve yourself. But your insurance plan may not cover this type of surgery. So what your provider would do is write up a plan of care for you and what you would need to do to begin the process of this surgery. If there's any kind of services that need to be done before starting it, what would happen in the in-between and what would happen in the end. So that would be your entire plan of care, and then he would submit that to the insurance carrier. The insurance carrier will check the benefits and probably say, well, she doesn't have any coverage for this And'll cover whatever portion is deemed to be your responsibility. Things going to cost, what's going to be done, what's going to come out of pocket for you and what your employer may have to pay the insurance carrier for covering this particular service for you.
Speaker 2:Now, sometimes they already do cover the service, but they may not cover the service in the extensive way that you may need it. So you may need additional services. Let's say that you have to get some type of special physical therapy that they don't cover after having the surgery and they may not cover that, and you want to get that covered. So that would be have in the surgery and they may not cover that and you want to get that covered. So that would be included in the predetermination. And you would say, okay, they'll say, well, we already covered this portion of it, but if you want us to cover additional, you have to tell us why you need us to cover this additional service. So that, in a nutshell, is pretty much what pre-certification is, pre-authorization is and a predetermination is. Now a lot of people don't know that they can go to their employer and ask their employer to actually approve payment for a service that's non-covered on the plan. They don't do it very often, but you can ask and see if they will approve it.
Speaker 1:Another thing I really want to I hate to bother you because I really am enjoying this. So it is determined by their plan document. What is a covered benefit, correct?
Speaker 2:So it's determined by their policy. So you know you have your plans, you, and under the plan is a policy Okay. A lot of people get that kind of confused. So when you get your benefits, at whatever time your company renews there's some people do it in November, some people do it at the beginning of the year, some people do it in the middle of the year what they do is they hand you a packet and the packet's got a bunch of information in it. Sometimes it's a very small packet, sometimes it's a larger packet.
Speaker 2:It depends on the type of different plans that your insurance carrier I mean your employer has, I mean your employer has. So you sign these contracts and you give them to your employee and say, yeah, I things like that. So you choose your plan, whatever they have in the list. You choose your plan, how much you're going to pay, what type of coverage it is. Sometimes it's high deductible coverage, which means you pay more out of pocket. Sometimes it's low deductible coverage, which means that you may get a higher out-of-pocket and some of them you may not have a deductible, depending on the plan and depending on if it allows you to go out of network or if you have to stay within network or you're going to have to pay more out of pocket. So there's so many different plans and that's what gets confusing to people. But what people need to know is that that little pamphlet you get from your employer is just a brief explanation of your plan when you sign that paper and give it to your employer.
Speaker 2:There's a policy behind all of that and you can actually most of the time you can sign on to the insurer's portal, create your own portal where you will be able to see any of your EOBs.
Speaker 2:You'll be able to see any denials or rejections or things like that that you've gotten for certain services.
Speaker 2:Any authorizations that you've had to get are requesting one where your insurance has approved something for your provider and you want to make sure that you know the information, or you didn't get the letter in the mail so you want to print it off to keep it for your records and things like that. A lot of times. That portal will have your policy in there and you can read through your policy more thoroughly to see exactly what type of coverage you have and what your plan does and does not cover, and that's important for you to know. A lot of people don't realize that there's more information outside of the paperwork that you signed and you, as a patient, have the right to request this. You can request it in writing, you can call them and have them send it to you. If you don't find it on your portal. You have that right to request a copy of your policy, your insurance policy, and I would suggest that everybody do that if they can't find it on their portal.
Speaker 1:I agree, I'm one of those people who likes to have paper around so I can refer back to it in a timely fashion my time because you don't want to be rushed when you're reading through some things and sometimes you have to read it several times to get a little bit more clarity in what it's saying, because it is confusing. The verbiage is very confusing.
Speaker 2:And you have to call them and ask them well, what does this mean, what does that mean, and things like that. And some people think that they can't ask questions to the insurance carrier. It's very important that you ask questions to your insurance carrier because you'll end up getting stuck with certain things, certain bills, if you don't understand how to use your insurance and you use it wrong. And then, if you don't understand how to use your insurance and you use it wrong, and then, if you don't understand how to use your insurance, you'll never know what services you can and cannot get, because there may be services that you need, but you're scared to get them because you don't want to have to pay out of pocket or you don't want to have to pay a deductible for it. But it could be a service that's fully covered and if you find out that, you would find out that it's a service that's fully covered and you don't have a deductible out of pocket for this particular service. So that's the importance of understanding your policy.
Speaker 1:That is very true. Now can I back up to predetermination? Sure, let's say you use the example of gastric bypass surgery. Now, at one time they would cover the gastric bypass but you had to meet the criteria, and the criteria was more than you, more than six weeks or six months. They wanted some historical data to prove that you had done some of the things that needed to be done. How many weight loss plans had you been on? Were you effective in losing your weight? Is that any other? This that any other? So at the time when I was doing those pre-serts, they would not cover the excess tissue that needed to be removed or the patient felt needed to be removed. That would come out of pocket. So with your definition, you basically say you can go back and ask if they will. You know you pay a portion. I pay a portion because this is really causing me problems. So is that a good example to use for that?
Speaker 2:Yes, because, let's say, you have this extra skin, you've lost this weight, you got this extra skin and now you're finding that, you know, when you exercise you're having pain because the skin gets sweaty, the skin starts cracking. You're finding that you're getting rashes, you know, and you can't work out like you used to because of too much pain and or you could even get an infection. You know, if something like that, at that point the excess skin becomes medical, and that's true, that's true and that's because it's causing you issues. Now, if it's that you just want to get rid of the excess skin, you can request, say I want to get rid of this excess skin.
Speaker 2:Um, yeah, and would you pay for it? And I pay a certain portion of it. You can always ask that. All they can say is yes or no. One of the other things that you can also do is you can say you know, I'm having mental issues behind this. It's really affecting me mentally and I don't like the way I look and I'm having trouble with moving forward in my life because of it, and that happens, and in that case that becomes more of a medical, behavioral health kind of thing.
Speaker 1:Okay, of the criteria point for having the weight loss surgery, you are to see a mental health specialist, a psychiatrist, to determine if you are mentally ready for the surgery, and I've read some of the notes.
Speaker 1:Me personally, like I say, personally, I don't see where one visit is good enough. I think they need a visit before and I think they need one after. Now I'm not writing any planned documentation, let's be clear. But the first visit is to say they are aware that this is going to change their lifestyle, but they are not from what you just said, which is very reasonable, they don't know really how is going to change their lifestyle because they have a whole new look.
Speaker 1:Um, one lady told me she was getting compliments she had never gotten before in her life and she said I can't deny I was flattered, but it's bothering me now that I'm getting all these compliments. And I was like, wow, you know, I just never thought about it that deep. A lot of times we just don't go real deep in that thought. But I don't think one visit initially, but that was the criteria for that. So I'm glad you mentioned that, because you do. You may need to see someone afterwards because your life has changed in ways you never thought that they would have changed, and this is just an example with the gastric bypass surgery and there are other surgeries that can alter your lifestyle as well Transplants. You know people can't socialize the way that they used to, the way they want to. They have to really be cautious of whom they're around and things of that nature. So I'm glad you brought that point up about needing more psych visits.
Speaker 2:Yeah, definitely that was something they added a few years back. Yeah, definitely, if that was something they added a few years back, it depends on the plan too, because certain insurances make you see more behavioral, have more behavioral health visits at the beginning and maybe even at the end, but some of them will pay for more visits than just that one. Okay, I remember I had a coworker who actually went to have the surgery done and she did her psych visit and everything she had to do. But after she had the surgery she could not deal with not being able to eat the same way she used to used to eat. So she was trying to save her life by getting the weight loss surgery. But her husband her husband loved her the way she was, so for her it was more of a life-saving thing. She wanted to be with her husband, she wanted to be around for her children and her grandchildren.
Speaker 2:But she had a really hard time dealing with not being able to eat the way she did previously. And a lot of times you would catch her at her desk. She would be sick, she would be choking or gagging up something because she went to the McDonald's on the corner, because it was right on the corner and instead of getting a salad or something like that, she got chicken nuggets and fries. And as soon as she ate it, what happened? She got sick and then she had to bring it up because it messed with her stomach and, um, she never went to a therapist or anybody to help her with that and it just happened that she went on a honeymoon Was it honeymoon? It was an anniversary and she suffered complications and she didn't survive them. Really, no, she didn't survive them Really.
Speaker 2:No, she didn't survive them. It was really bad. She wasn't ready, so she was not doing what was expected of her. She just expected to get the weight loss surgery and the weight to just fall off, and it did, but then after a while it slowed down yeah, I have seen that myself.
Speaker 1:Um, for lack of a better term, there is a price to pay. Um, a lot of people don't like to exercise after they have their surgery.
Speaker 2:Yeah, but I've had people who who've done that and what I don't like is it gives you that melting look. It looks like your skin's melting off of you. That's true, that frumpy look. So you look like you got a like soft, squishy skin around your waistline, things like that. You need to tighten that skin up and other people expect that when they lose that weight in such a quick time that their skin is just going to shrink up with all of the fat loss.
Speaker 2:And it depends on your skin type. Some people have tighter, thicker skin, some people have thinner skin and that means that your skin is going to lay differently depending on how much weight you lost and depending on what type of skin you have. You know, some people can lose weight and just look snatched right back. But some people can lose weight and even if they're like small, a small person they lose, still have stretch marks, they still have loose skin and they're like well, I wasn't really that big, why do I have stretch marks? And it just depends on their skin type. That and that can cause you you mental issues too.
Speaker 1:So I agree, I agree with all of that, um, it's just such a in my humble opinion a large surgery to have and that one pre-psych visit and I go back to that in my humble opinion is not enough.
Speaker 1:I agree it needs to be some follow-up because, as you stated, this woman didn't count the cost of she enjoyed eating and could not enjoy her food. We've had other people who didn't count the cost of the skin that being an issue, with them that being a problem, and people who don't want to follow up and try to tone by exercising. There is no quick fix. In a lot of things that we do it's gradual. Healing is a gradual thing.
Speaker 1:It's just gradual, no matter what type of surgery that you've had. When people go in and have an endoscopy, oh, my throat's sore. It's been sore for like two, three days. Yes, there's going to be some discomfort discomfort but a lot of times we go in to have the procedure done and they print out your side effects and things of that nature. But until you're uncomfortable is when it clicks in your mind that this has happened. And we can dive into this so much deeper.
Speaker 1:But I want to ask you about deductibles. You mentioned high deductible, the low deductible. Can you talk about that just a little bit more in detail, please? So?
Speaker 2:it depends on the plans that you have, which plan that you choose when your employer gives your plan to you. Some people, they have no choice. The employer may go with a high deductible plan and that's all they present you with, and then you're stuck with a high deductible plan present you with, and then you're stuck with a high deductible plan. And a high deductible plan means that you pay more for your deductible and you pay more out of pocket at the beginning of the year. But once you pay all of that at the beginning of the year, the rest of the year you don't pay anything.
Speaker 2:And that kind of benefits people who go to the doctor a lot like myself. I suffered from sarcoidosis and it was something that just came out the blue. Did not expect it to happen. I got it in my spine, in my brain. It started.
Speaker 2:I had it for so long because we were busy treating like it was affecting my elbow and my leg and we were doing treatments physical therapy and pain meds and I was busy also trying to take care of my mother and start my business. I didn't pay attention to how far this had gone and by the time I made it to the neurologist I had actually lost my ability to walk and the doctor said I can't treat you clinically At this point. It's emergent and you have to go to the emergency room. And, uh, I ended up going to the emergency room and I ended up staying in the hospital for about a month two weeks in the hospital, two weeks in a rehab and I had to learn how to walk all over again and then I had six months of rehab after that and then, till today, I'm still getting. I was getting infusions and my body built up antibodies to the infusion medication.
Speaker 2:So now I am on Humira where I have to stick myself with the needle now, and so I've been doing that for like three years now. So I go to the doctor very often, and because I'm on this medication I'm immunosuppressant. So my husband comes home one day with a virus. I catch the virus. For him it was five days in bed, For me it turned into RSV, it turned into a urinary track infection which went into my blood system and it turned into sepsis, and by the time I made it to the hospital it was affecting my kidneys and my heart function.
Speaker 1:You know, Ruben, go ahead, sweetie.
Speaker 2:So for me, I've been through that medical, those emergency medical issues that cost you a lot of money, and I remember at one point I was just like I don't know what I'm gonna do with this. I don't know how I'm gonna survive. You know how I'm gonna pay these bills. I can't work, I'm disabled, my husband's handling everything, and it was funny because I guess God kind of put this in this person in my life at that moment. But this is when I met Ms Sandra Washington and she taught me some things that I did not know about being a patient advocate and she turned me on to a lot of different services that you can get for free to help you as a patient to pay your bills A lot of different avenues.
Speaker 2:Now, being a medical biller for 30-something years, I started my career. My longest stint was at Shock Trauma Associates in Maryland for University of Maryland and we dealt with a lot of trauma patients that would come in and then they would have all these bills after and some people didn't have insurance after and some people didn't have insurance. So while I was working there I kind of created a process where we screened every self-paid patient or patient that did not have insurance was screened and put into a category of pending Medicaid so that every patient that came in emergently through shock trauma would apply, will automatically be assigned a switched from being mostly Medicaid to Medicaid I think it was Medicaid from being mostly Medicare Blue Cross Blue Shield to mostly Medicaid self-pay, and then it was like Medicare Blue Cross Blue Shield. It was something just happening at that time where the AR switched, and it happens because neighborhoods and communities change, and when that happens, so does the type of insurance that they have, so does the type of work in the area, and it's just so much social things that can affect a hospital, and so we put things in place to help patients understand that they were eligible for certain things that they did not know that they were eligible for.
Speaker 2:So in that position I made it a point to utilize anything that I knew of. So if a person had a car accident, they would be referred to I think their name was MAIF, which was the Uninsured Motorist Fund. If they were assaulted, they were sent to Victim's Assistance Fund, and not all states have these, but a lot of people don't know about Victim's Assistance Fund. They also have different funds to help you if you're a battered woman, and there's also free clinics and sliding scale clinics that you can use okay, go ahead for me.
Speaker 2:I would utilize the free clinic and sliding scale clinics a lot, especially for people who they were eligible for emergency Medicaid, but now the emergency is done, they just need additional treatment to heal all the way.
Speaker 2:So now I'm going to have to call, oh excuse me you're fine so now they need care and they can't afford any insurance. They're no longer eligible for medicaid. What do they do and where do they go? And I would refer them to the free clinics, to the sliding scale clinics. But if none of that could help them, the only other things I could do was put them on a payment plan, put them on financial assistant plan, or or have them fill out a financial hardship application.
Speaker 2:Okay, so those are the kind of things that I knew of, but Ms Washington just brought me into other organizations that I could utilize for myself, being that I was having so many medical issues, like Patient Rising is one of them. Up and find other organizations that offer assistance and they'll actually assign somebody to you, to your case, and help find you assistance. And they don't just find you assistance for your medical care, they help find you assistance for gas and electric food in your house, electric food in your house, water bills, things like that. They'll find people that will donate money to help you pay your stuff. Yeah, and that's wonderful, because I didn't know of that before.
Speaker 1:Sure, I often tell patients you don't know because you haven't been through. It's no way you can know about certain services because you've never had to utilize them. And the reason I say patients because I'm in the hospital setting and I'm a case manager. I'm a case manager and even some of my leadership didn't have the answers that I had because I had come from a different background, because I worked in a third party administrator's office. So you learn more about the insurance from that aspect, yeah, but if you don't know, haven't been through, you really don't. Now, when I was inpatient case manager, if a patient came in, let's say they were self-pay and I want you to expound on this a little bit more Self-pay and we had a finance person, would cover as well and we had a great working relationship. You learn so much from other people because it's their department, but I want to know a little bit about it myself. So I would always call her and say, hey, is this a true self-pay? And I would give her the needed information. And she said I'll be down on a little while because they have an open line of credit, so they have some money coming in some way. And then she would also tell me on another one, no, they're truly a self-pay. And she would come through and ask to get their permission. There are some charitable services out here. Would you like for me to apply for those for you? And so I was like, wow, you know. So I'm just saying you can always learn something.
Speaker 1:I had a patient's family member because of the hospital that I worked for. He said you guys don't take Medicaid, do you? And I was like yes, sir, we do. I can't believe it. I can't believe a hospital of this magnitude would take Medicaid. I said, well, if they didn't, they would fall. And he was like what do you mean? I said anytime you take and I hope I'm phrasing this right, because I had that phrase down really well Anytime you take government assistance, basically Medicare assistance, basically Medicare Medicaid you have to take a degree of charity cases. And he was floored that that would happen. So it just lets you know when we're not in certain situations or in certain avenues, we are just one-sided in our thinking. But he was truly bothered by the fact that the hospital took charity cases. But you have to, it's up to them. I mean, there's somebody else who's keeping up with the numbers on that, but I learned that in nursing school way before I became a case manager.
Speaker 2:That's just the way it goes, but there are some people who are unaware of Some grants that they get, some grants that they get, basically tell them that they have to take Medicare or Medicaid patients in order to get away.
Speaker 1:And it still makes sense it depends on the area.
Speaker 2:It depends on the community and the area as well. If it's a community where most of the people are wealthy, you wouldn't see that hospital really accepting medicaid or medicare but, this because the area shows that most people can afford to pay out of pocket. Yes, but if it's a hospital that needs help and they want certain grants and to be able to do certain things and certain monies, it'll tell them what you need to. You have to participate in the federal and state programs.
Speaker 1:And that makes sense. What you said, and I guess that's what he was thinking, because it was in the middle of a couple of fluent communities but at the same time, people from other areas come from, come into that facility.
Speaker 2:Yes, especially if they specialize in certain things.
Speaker 1:Yeah, they were a large hospital.
Speaker 2:They had specialties. And you also have the elderly Absolutely, even though they're affluent and a neighborhood is Absolutely, absolutely also get Medicaid, medicare and sometimes, depending on the type of social security and pension and things like that that you're getting, they're still eligible for Medicaid, secondary and sometimes and Medicare is one of those things that you have to take you can't really just say I don't want the Medicare, I already got enough money. You know, once you turn a certain age, you get it automatically. So in some cases, you know, in that area, even though it's an affluent area, they still have to take Medicaid because the neighborhood has aged.
Speaker 1:And that's true because we age every day. And he just was so put out that we had to admit patients with state aid. And I get it. I kind of understood where it was coming from, but I also didn't understand. Because it's a hospital, you have to take patients who come through the door. You know you can't just turn everybody around Because guess what, even if they don't have their information with them, they're, you know, somebody is eventually going to bring it up. You know, a car accident or something like that, things get scattered, but once they present with their information. But you've already done your due diligence as a physician, as a facility to care for people, for people and it's not just these people but for people yeah, you know some have like, like you said, you like to follow up with your billing area, your financial coordinator, find out on your help.
Speaker 2:So I just want to talk about that. Remind me of something I saw like a couple months ago, where a hospital had literally dumped a patient on the sidewalk because his Medicare would not pay for any additional days for him to stay in the hospital, and I was like what? I didn't know that hospitals could do that, but it seems that nowadays more hospitals are doing that. They're just letting patients go. They're leaving them on the street and the police are being called. And these people are homeless.
Speaker 2:They don't have any family and with this particular patient they said the social worker called around to try and find a place for him to stay, but the place that they used was full and she couldn't find anywhere else for him to go and she found. She called another spot that they would use and they said that they were full but they would take him and that's what she had in the notes. But when they discharged him they didn't take him to the place, they put him out on the corner and when the news, people went to talk to the place that said that they would take them even though they were full. They said that they told her that they were full and they could not take him. So I don't know what happened with that social worker, but to me I was like she didn't do her due diligence as a person that has a job of service, like being a social worker or case manager in a hospital where you take care of people who are homeless.
Speaker 1:I agree with you 100% because being a case manager you learn the discharge plan has to be a safe discharge so it's not safe to dump someone on the corner. Now I have seen additional reports that you saw they were in other hospitals and what galled me because some people have these street cameras out and they see what you do so you can't say you didn't do it. But they still have on the gown with the hospital's emblem on it. They put them right out there, yeah they're easily Right out there.
Speaker 2:This one guy, they did it too. It was cold out. They didn't even bother to put his coat. They didn't bother to put his coat on him correctly and they just left him there. He, the wheelchair fell over. They left him there on the floor. They didn't even just try to sit him up or anything in the wheelchair. Make sure he. You know, it was like I understand, the man can't pay his bill and if you're going to put him out, can you at least make sure he's all right? Well, it's throwing him on the ground like that. You know? I mean what happened to human courtesy?
Speaker 1:I want to know how they're getting away with it, or if they're getting away with it, because once the news get it, you can't reel it back in. Now we've had several, several and they are complex discharge. Everybody does not have family, they don't do not have a safe place to go. There are some people who came in homeless. You think they're gonna leave out and have a home built by the time they leave out. No, it's not going to happen, but you still have to ensure that it's a safe discharge, okay. Now there are some that are going to be homeless when they are discharged and they know the rules because they were homeless before they came in. They know the rules, they know the regulation, but you have to still make sure that they are able to care for themselves once they are discharged, okay. And some come in homeless because they have ignored their signs and symptoms.
Speaker 2:I had to, but they have organizations that help with stuff like that to a degree. To a degree she said that one particular one was full. But I'm like did she try any churches? Did she try to get Medicaid?
Speaker 1:he could have got Medicaid, that's my point you can apply for some things.
Speaker 2:Yeah, she could apply for some things. You know, now Medicare is like I'm not covering anymore, that's not that. In that case, then Medicaid would pick up.
Speaker 1:Yes, now what I learned, and it's an eye opener. When you haven't worked in certain areas, it's an eye opener. I was like, oh, he said he, he lives in a shelter. So I always had to go back to people who are more experienced than I was and they were like well, the shelter is where he will resume, where he will go back to. And I was like, ok, fine, but this particular gentleman needed care for a wound or he needed care, oh he needed wound care, and so I was like, what do we do?
Speaker 1:So I called a couple of shelters myself, because he gave me the names of some that he had been in, a couple of shelters myself, because he gave me the names of some that he had been in. And so they said well, he cannot stay here during the day. No matter what is wrong with him, he has to be able to leave out, because our goal is to make sure that they are actively looking for day work. They cannot lay around here all day. That's just one of the rules, and they know this. I said, even though he has this wound that needs to be cared for, and this, that and the other. She said honey, I hear you, I promise you I do, but if we do it for one, we'll end up doing it for so many more who don't have a doctor's excuse, who's lost a doctor's excuse, who's lost a doctor's excuse, and we just can't start it. Yeah, you know, and so you see it, but at least I did the research on it.
Speaker 2:So this is one of the things too. With things like that, depending on how bad his wound was, you may have been able to get him into a nursing facility that would have been able to get Medicaid for him True Of his nursing visit. That's dependent on how bad his wound was.
Speaker 1:And it was not as bad as I've seen others. I mean it was doable and it was. You know he could care for it. Now we made sure he knew how to care for himself, because you're not helping them if they can't care for themselves. But he could care for himself. He was not one who could not.
Speaker 1:But like the people at the facilities say it can't do it, they cannot lay here. Um, they have to be out and about because they really need. You know we're really enabling them if we let them all allow them to do that. Somebody else she said now they're smart, they're very smart, they're cunning. So if they see him laying around, they're gonna want to know why he laying around and why they got to get out and he doesn't get. So then you're creating, you know this snowball effect and you can't have that because they do have rules and regulations about cleanliness, about fighting, about, you know, drug use, alcohol use. You know they have those rules and regulations and I can see someone easily taking advantage of that. But you still need to ensure that they have a safe discharge and that it's not going to bounce back on you.
Speaker 2:And yeah, and they're correct, and that's why you have a lot of people. You'll see a lot of people that stay at the VA in the lobby. Sometimes they will stay in the VA in the lobby, sometimes they will stay in the emergency room. If they can stay in the emergency room, they'll find other places to stay during the day. They'll walk around the mall.
Speaker 1:The library. The library is a big hit.
Speaker 2:The library, the library is a big hit. Yeah, the library, the library is a big hit. And if you can afford a little cell phone with your social security that you may be getting with disability, you get free internet.
Speaker 1:Yes, yes, and I saw someone on the corner the other day said free cell phones, and she was. You know, you had to qualify. But you know, and I was like you know, it's not, that's not a bad service, it's not a bad service at all, because everyone needs to be able to get in touch with someone, and there are people who are truly fall on hard times, on hard times. One gentleman I had I don't know how he got to our city because he lived in another state, and so I called his wife because, you know, we're always supposed to be in contact with the next who can because he was on her, not because he was on her insurance, but she needed to know that he was in the hospital. And so I was telling him, you know, that he was in the hospital and she said, well, I don't care where he is, as long as he doesn't come back here, because we're getting a divorce, whether he knows it or not. And I'm like, okay, so where is he going?
Speaker 2:Oh, he must be doing something bad.
Speaker 1:I said so you know me being me. I said so where is he going? So you know me being me. I said so where is he going? You know when he's discharged? She said I don't care, Just don't give him a one way ticket to my house, I am done. And so you're like, okay, you know. So.
Speaker 1:The case manager sometimes gets the bulk of it all, whether you want it or not. And so when I went to explain to him his safe discharge, where was he going to go for when he's discharged, he said I got a buddy of mine that I'm going to stay with. I said have you spoken with your wife? He said no, not yet. So I didn't bring up the subject, because I think that's between husband and wife, or girlfriend and boyfriend, however you want to put it. But she said, yeah, he's on my insurance and as soon as we get a divorce he will be off. And so that was it. But he went to stay with his friend. That lasted two days because, guess what, he was back two days later and I'm like, oh man, you know what are we going to do.
Speaker 1:But he was alert, he was oriented. You know, he had the ability to do a lot of things for himself. But those are some of the basic questions you have to ask who's going to be your support system? You know who. You know who can you depend on at home. You know and you know our Courtney what's going on with you. Sure, we're going to send you to a skilled nursing facility, you know rehab, you know long-term care facility, wherever you need to go to get the help that you need.
Speaker 1:But there does need to be some Medicaid or an insurance that will take you. And so, yes, we do apply, starting at the hospital, and it takes about six weeks and after about three weeks they're still in the hospital for three weeks and then we'll get the OK that is going to be approved so we can start looking for facilities who can take them. So it is a process. It's not as simple as people think, but there is a process. So for people who don't really understand the ins and outs of it, it's because they haven't had to deal with it, and that's not a negative on anyone. That's not a negative. It's just that for people such as yourself who are an expert in this, you can talk them through, tell them what they need to do for the needs of the patients. That helps as well, because she has given me resources I did not know about, and I have been a case manager since many years, but I always try to glean from other people.
Speaker 2:Yes, and then she has her organization MediHelps.
Speaker 1:Yes.
Speaker 2:That also helps people find resources and educate the patient on bills and things that they can do when they have issues and need assistance and help. True, that, very true, very true. Coordinator in your office, if you are a group or a clinic and you see patients whether it's for mental health or orthopedics and things like that just having someone to talk to your patients about their bills, because patients will stop getting care once they can't afford to pay you anymore. And you need to educate your patients to let them know that if they fall into a financial situation, that there is programs out there that they can help you with. That can help you financially. Even some practices have taken on their own loan system, their own credit cards and things like that. Or they also have financial credit cards that help people so that they can afford the payment plan, because some places they want to make you pay a large amount of money to pay them back the money, but other places will give you a loan so that you can afford that.
Speaker 2:The only thing I would say about things like that is you have to be careful because you have to look at the percentage rate you got to make sure it's a reputable company, because you don't want to get scammed and things like that. But I think it's important that doctors start looking at this because I'm finding that a lot of smaller organizations, smaller practices, are not collecting their self-pay like they should. And you can a doctor can lose contract with an insurance carrier if they do not allow their patients to pay their out-of-pockets, their co-pays and their deductibles, because it is part of their bill. It's a part of their payment, of their bill. Someone was telling me that there was a case I'm not sure what state it was, but it was with Aetna, and Edna was basically saying to the provider that if he didn't want to get paid from the patient, why should they pay him? Wow, so doctors have to understand the danger and the things that they do.
Speaker 1:Okay, now let me make sure I get this right. The doctor wanted them to pay out of pocket and not go through the insurance company.
Speaker 2:No, okay, the doctor was billing the insurance company. Then the insurance company would tell them well, the patient owes this amount for a deductible copay, and then you know he would bill the patient. The patient would either make noise, say I ain't got the money, blah, blah, blah, whatever you know, whatever the situation was. But he was not collecting his co-pays, deductibles and out-of-pocket from his patients and the insurance found out that it was a regular practice for this provider. Insurance found out that it was a regular practice for this provider and insurance basically told him well, if you're not getting your money from your patients.
Speaker 1:Why are we paying you? Okay, okay, meaning everybody needs to pay their fair share right, everybody needs to pay their fair share.
Speaker 2:Okay, so you know people. People tend to think that doctors make good money, but it depends on what type of doctor it is. Like a general medicine doctor. They make, they get paid regular, I agree.
Speaker 1:I mean, I've been preaching that story for years and it's not a story. I've been preaching that fact for years and this was before Google. I knew it, you know. So you don't have to go to Google to figure that out. It depends on the special.
Speaker 2:I was working in a hospital. I was working on a mother-baby ward and I had come in with a lot of the new interns in the hospital and I'm the unit secretary. Now, after about a year, I found out I was making more money than the interns was Absolutely. And I was like this is ridiculous. And it got so bad that a lot of them started to think you know, I went to school for all of this, they're not paying me enough. I'm suffering, I'm struggling, I'm tired of losing sleep. Me enough, I'm suffering, I'm struggling, I'm tired of losing sleep.
Speaker 2:And several of them actually changed the direction that they wanted to go in to medicine. Some of them did. Some of them dropped it. Some of them was like I can't afford to drop it, it's all I have, this is what I've dreamt of. Some of them was like my parents would kill me and it was just crazy listening to the stories that these young people would come in with struggling with school and struggling in staying in a field they didn't want to stay in. And a lot of these doctors don't always make good money. The biggest doctors are sports medicine doctors, orthopedics, neurosurgeons, other surgical doctors, but anything that's not special. Even radiologists don't make a lot of money and a lot of people just you know they throw it off like well, doctors make enough money. You can't just throw it off up in the air like that willy-nilly. Because everybody deserves to be paid the way for the services that they render, for the services that they give, just like I deserve to get paid for the services that I do at my job or in my business.
Speaker 1:Okay, you know.
Speaker 2:I think patients need to understand that and it's important that they need to work with their doctor instead of against the doctor. So I try to be more of a patient provider advocate, helping patients understand why they have this bill, why they should pay it. And if I feel like the doctor built them for something that they should not have to pay, I'll also tell them that. And I'll tell the doctor you know you shouldn't, you know this is not payable, you know you shouldn't have. You know this, this, this is not payable. Or I'll tell them you can't build that according to the guidelines, according to the rules or different things like that.
Speaker 2:So I'm just truthful on both ends well, it's best to be it's yes to be that's true and then try to bring them together in a mutual agreement and build a relationship from there, Because a lot of times patients still need additional care after they've had major things happen. Some of them it's not as major and they just have a balance. They didn't realize it was their deductible and things like that.
Speaker 1:I agree. I agree it's the more they know, the more freedom they'll have.
Speaker 1:The more knowledge you have, the better you'll feel and you're more of an informed consumer and you need to be and nine times out out of ten, you can pass that information on to a family member, a friend. What to look out for, uh, what to expect, ie financially, more so than just the surgery, more so than just the procedure. Uh, there's other components, because there are some people, when they have an outstanding bill, it bothers them. Now you have another crop of people who said they'll get paid when they get paid. And I get it. You know I don't have it, you know, but, like you said, there's resources out here who can help you with this.
Speaker 1:Just be careful and make sure that you're researching appropriately for these payers, because when you have facilities that are for profit, they want their money. They don't want to hear any of these stories you have to tell. They just want their money. They want you to pay that balance, and I get it. I mean, mean, we all need it to survive because they have employees. They need to pay, like you say, um, physicians that need to be paid because some of the positions are on staff, you know, at that at that facility. So, and it's not like they have more money than me. Please don't say, when people say that to me it just kind of rubs me the wrong way. They might not have more money than you. You know because they have. They have expenses to pay you know.
Speaker 2:Think about the, the many school loans that these people have.
Speaker 1:They do not, they do not school they owe.
Speaker 2:Some of them owe almost a million dollars in school loans and they have to pay that. And school loans you cannot get written off. No, no, no. And that's why I feel, and that's one of the reasons why I feel like, um, a patient's care isn't done until the bill is zero. Yeah, so many patients they'll get sick. Yeah, so many patients they'll get sick over owing a bill. Them find somewhere where they can get help to pay the bill.
Speaker 1:Now, before we close, I have this to say I have been in nursing 38 years at least Most of the physicians I mean like 95% of them will treat you without knowing your ability to pay. They will not cut you short, they will not rush you out. I have heard some say I'm not getting paid because they don't have any. But that has been really, in my humble opinion, one in all of my years. Because they do love to see their patients thrive, they love to see them get better, because they know it's going to iron out one way or another. They know they're not going to go broke because nine tens of 10, these are specialists that we're talking about. Like you say, the specialists really, you know, really pull it in. But you have to be honest. You as a patient, you'd have to be honest Doc, I cannot afford that medication, doc, I can't afford this surgery at this time. And I often tell patients speak with the social worker at the hospital, speak with the financial counselor at the hospital, do this beforehand, because you never know what resources they have, because most hospitals have benefactors OK. So that means I don't know how much of a portion goes to patient care. I've never been on that side of the of the table, but I know they call on their benefactors to help with things of that nature. So be open, be honest. Don't delay your care for your inability to pay. That's right. Do not do it because you're not doing yourself a favor, you're just not. So I have had the pleasure of working with physicians who cared for their patients.
Speaker 1:Now I have heard stories and, like I said, I have heard one physician in my career said nope, they don't have any insurance. And the medical director told him I would count this as a personal favor if you would do this surgery. And he still refused. He still refused. Wow, and you know he wasn't the only one could do it, but I guess he was trying to. You know, come to him first, since he was there. But I read between the lines of what a personal favor would be Meaning. We can Meaning, we can send you additional consultations to make up for this, but he said no and he meant it.
Speaker 1:But as a patient, be honest. Be honest, be open, because there is another medicine that is less expensive that can do the same thing as that most expensive medicine. And why should you choose between paying your bill you know your utility bills and eating than paying for medication? And you shouldn't have to do that because, guess what you're still not getting well because you're concerned about I'm not taking care of my home, I'm not taking care of my needs. So be open and be honest and they will appease you. They will do. They will. They will recommend something else for you.
Speaker 1:And I told him off to that, just told me you can't afford it. Just like that, miss Carolyn. I said just like that. Just like that. You don't have to sugarcoat it, because when you go into the doctor's office 9 times 10, you're looking your best, you put on your best. They think you're doing OK. They may think that you can't afford it, but let them know that you can. Once you get to the pharmacy and you find out how expensive it is, just tell the pharmacy, call him and tell him I can't afford this. They'll make that phone call for you. That's better than letting it sit on the shelf and you didn't get it.
Speaker 2:It'll pay for your co-pay and it'll pay for your medication. They'll find something for you.
Speaker 1:Absolutely, Absolutely. They will Well, Ruby. I have truly enjoyed this conversation. Thank you so very much.
Speaker 2:I enjoyed it.
Speaker 1:Any closing remarks you have.
Speaker 2:Other than being honest. I say ask as many questions as you can Always.
Speaker 1:Yes, yes.
Speaker 2:Be as proactive as you can. You know it doesn't take much to just pick up the phone and call. I agree, you know, and yeah, it's hard dealing once once it goes to collections. So collections agencies they don't, they don't follow the same rules as medical collectors. They don't follow the same rules as medical collectors?
Speaker 2:Uh-huh, because we have certain laws that are in place that says you can't talk to the patient a certain way, you can't threaten a patient, you can't do certain things, but a protection agency can. So make sure you take care of everything before it.
Speaker 1:It goes that way okay and yes, that goes back to being be proactive and be open and be honest also agree with the book.
Speaker 2:Uh, don't pay the first bill, you know, know, follow up on it, make sure that you owe it, make sure it's applied to your deductible, your out-of-pocket or something. Make sure that you reconcile your bills and that's one of the ways that you can utilize your patient portals when it comes to your bills that you get from your provider and your explanation of benefits that you get from your insurances. You know, and this also goes for people who are caretakers, because a lot of patients there are a lot of elderly patients out there that can't they're older and can't really deal with that kind of stuff. Like, I take care of it for my mother who's 75. And so I'm the person that takes care of that for her, that kind of stuff for her. Whenever she goes into the hospital, I'm the person that they call and talk to and make sure that her care is organized.
Speaker 1:And that's great, you know, because one thing is not that you're just her daughter and hearing and being her advocate, but you also know the financial side of things Right. So that's wonderful. That's a great combination. Because there are people who will tell me well, my sister's a nurse, or my uncle is a doctor, well, that has nothing to do with the bill. That has nothing to do with the bill. It sure doesn't. You know, I'm not saying they're probably not even the same specialist with the bill.
Speaker 2:It sure, doesn't you know I'm? It's probably not even the same specialist in the same area.
Speaker 1:Absolutely, and all of that matters, all of that matters. So there was one victim assistance fund and I know some states have it and some states don't. What exactly do they pay for?
Speaker 2:They'll pay the bill for the emergency stay, they will pay for any surgeries that may come out of it, anything related to the assault, and I don't know if this is every state, but I know that the person has to be willing to file charges on the person. So if the person is caught person, so if the person is caught, they will uh financially recoup anything that they paid for for you from that person. And that's what a lot of people don't know. Is that they actually they? They actually uh file a judgment against the person that assaulted you and they have to pay that money back oh, now that part, I didn't know yeah that's right, that's what they'll do, okay?
Speaker 2:well, you know, a lot of times they can't, sometimes they can't find them. You know, sometimes they can't, but you know, sometimes they do, especially in sexual assaults, things like that and shootings.
Speaker 1:Yes. You know anywhere where there's a police involvement kind of thing, Okay, Okay, Well again, Ruby, thank you so much You're. You have such a wealth of information. This needs to be a part two, but I do, I do. Thank you so much for your time and your talent you know, and may God continue to bless you on your journey. You know physically, emotionally, mentally, financially and in your employment how long have you had your business?
Speaker 2:you said Since 2020. That's great.
Speaker 1:That's great. That's great, yeah, because you have a wealth of information and you're willing to share it. You don't want to. You're not keeping it all bottled up to yourself. No one, no one wins when you do that. No one wins. So so that that is absolutely wonderful, you know. May you continue to prosper in Jesus name. May he bless your ministry. Thank you very much.
Speaker 2:I really appreciate it, thank you. Thank you for coming and if anyone wants to call me, I forgot all about that part.
Speaker 1:Yeah, please share your information.
Speaker 2:My name is Ruby C Simmons and I'm your medical billing mentor, and you can find me on LinkedIn under Ruby C Simmons. You can find me on IG under Blossom RCS LLC. You can also find me on TikTok at that same address and I am also on Facebook under Ruby C Simmons.
Speaker 1:Facebook Ruby C Simmons. Facebook Ruby C Simmons.
Speaker 2:And oh, my email address is ruby at blossom rcscom and my website is blossom rcscom.
Speaker 1:Thank, you so much. Thank you so much. You have a good rest of your day.
Speaker 2:Thank you so much. Thank you so much. You have a good rest of your day. Medical billing and how to take care of their medical bills and the different services that are out there. I'm very big on education and that's one of the reasons why I like to create courses that assist private practices and clinics and larger organizations in training and their staff in this area.
Speaker 1:Well, it is definitely well needed. I can see a lot of people, especially physicians, coming out of med school needing this course because they're already overwhelmed, I know, with everything else they have. But this is needed so that they will know how their office or should be properly billing things, and not just them. But, you know, anyone who is in finance inside these health care facilities need to know as well, because only a few people seem to know what's going on, and everyone needs to be privy to it. That way, everyone's job can be done more efficiently. Yep, and so that's great. So thank you again. So much. You have a great rest of the evening and we will be speaking. Okay, okay, thank you, are you as well?