Fighting Denied Claims Requires Perseverance

Maria Carr, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other United Health patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

“I decided I would fight,” she said. “After all, what did I have to lose?”

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.

“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement.

Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”

Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.
TAKE YOUR TIME When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.

Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.

Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.

Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk. )

Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.

DO RESEARCH Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.

Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.

Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.

You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.

Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.

You also must prove the medical necessity of a treatment, especially if it is considered experimental.

Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.

For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.

Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.

GO THE DISTANCE Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.

If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.

In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.

Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.

GET HELP Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.

Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.

You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.

Prions May Help Memories Persist

Prions, proteins better known for the "negative" role they play in spreading mad cow disease, may also have a positive and important role in helping memories persist.

This tentative suggestion was the conclusion of a study by Dr Kausik Si of Stowers Institute for Medical Research, Kansas City, Missouri, Nobel laureate Dr Eric Kandel of the College of Physicians and Surgeons of Columbia University, New York, and colleagues, published on 5 February in the journal Cell.

Si told the media that:

"The persistence of memory is a fundamental problem. Experiences are temporal; they happen once, but somehow must lead to changes [in the brain] that are somewhat permanent."

These changes must come about via molecules, including proteins, said Si, but a significant question remains:

"How can you maintain a stable state with unstable biological molecules?"

In this latest study, Si and colleagues believe they may have found that prions hold the clue.

Prions are able to take on two states, one of which is dominant and self-perpetuating so that once a protein takes on this state it converts other non-prion proteins to the same state: thus once the prion state is switched on, it becomes stable and self-renewing.

For the study, Si and colleagues focused on the sea slug Aplysia, which scientists have been using for decades in experiments involving memory and learning.

When you touch this sea slug's gills, they withdraw, and when you "train" the animals by giving them a shock at the same time, the withdrawal reaction becomes stronger for up to a month.

Scientists had already discovered that this learned behaviour came about because of a specific set of sensory and motor neurons that respond to serotonin.

But in this study, Si and colleagues took a closer look at the proteins hanging around the synapse at the point where serotonin becomes active: one of these was a protein called CPEB, which when they looked at its structure, resembled prions that scientists had discovered a while ago in yeast, and which had known functions.

In an earlier study, Si had reported that slug protein did not display prion-like properties when inserted into yeast, but in this study, they found that the proteins switch to their prion state and clump together (typical behaviour for prions) in the presence of serotonin, as they did in the Aplysia sensory neurons.

To confirm this idea, the researchers used an antibody to target the clumped prion protein and found it blocked the persistence of neural connections that form the cellular basis for learning and memory.

Si and colleagues said that the findings suggest memory traces may depend on a fairly unique mechanism involving the prion form of CPEB. This adds to a growing body of evidence that prions may have a broader role in biology other than causing diseases.

They concluded that:

"These results are consistent with the idea that ApCPEB can act as a self-sustaining prion-like protein in the nervous system and thereby might allow the activity-dependent change in synaptic efficacy to persist for long periods of time."

However, Si cautioned that they haven't yet proved that blocking CPEB's ability to perpetuate itself actually blocks memory. To do that they would have to show that a slug with a mutant form of the protein would learn but then quickly forget.

The findings offer "at least an idea" of how memory might persist, said Si, who suspects that the prion-like protein's role apparent role in memory may just turn out to be a more general phenomenon.

Si and colleagues are now looking at CPEB in flies, and he noted that humans also have a similar protein.

Quasar software

Quasar software

Accounting has become more and more complex as have the businesses that use accounting functions. Fortunately, there are several excellent software packages that can help you manage this important function. Quasar is one such package.

All versions of Quasar offer comprehensive inventory controls. In its most basic use, the inventory module allows a business owner to track the locations and quantities of all inventory items. Additionally, the inventory capabilities go beyond simple record-keeping. Manufacturers and wholesalers can assemble kits using component items; whenever a kit is assembled, the inventory representing its component items are adjusted accordingly. Items can be grouped into various categories and the groups can be nested many levels deep. Vendor purchase orders can be generated for items whose quantities are below a preset level. Costs and selling prices for items can be set and discounted in a myriad of different ways. Finally, these items can be reported upon to show such things as profits, margins, and sales per item.

Sales and purchasing are another strength of Quasar. Customer quotes can be easily converted to invoices to be paid. Promotions can be created and discounts can be given based on date, customer, or store location. Margins can be reported upon for traits such as individual items, individual customers, or individual salesperson. Likewise, a purchase order can be created and converted to a vendor invoice, which can be paid in a number of different ways, including printing a check. Quasar can keep track of miscellaneous fees such as container deposits, freight charges, and franchise fees.

The intelligent design of Quasar's user interface allows for quick and easy data entry. Some programs you may encounter are not optimized for keyboard use. These programs require you to move your hand to the mouse to select frequently needed options. While some of Quasar's menu options are only mouse-accessible, the bulk of Quasar's user interface is designed in such a way that you can keep you hands on the keyboard by using special shortcuts. This allows for faster data entry, which can save time (and therefore money) in the long run.

Buying Timeshare Resale Vs Buying from Timeshare Resort

Buying Timeshare Resale Vs Buying from Timeshare Resort

It can be confusing for a starter to decide from where to buy his first timeshare from resale market or directly from timeshare resort or developer. It can be a hard decision to make with both having its own advantages and disadvantages. Buying timeshares in the resale market like auction websites or advertising through classifieds is a recent concept compared to buying from developers which has been there since its inception. Internet has brought everything to the doorsteps of the people and thus benefiting the timeshare market also. Websites such as eBay.com, bidshare.com and redweek.com provide prospective buyers with more information on the property and also wide variety of buying options.

The scenario was totally different a decade ago when the buyers used to buy timeshares through timeshare presentations hosted by timeshare developers. The decisions taken to buy timeshares were mostly based on one’s impulse rather than research and analysis. But with the advent of internet auction sites a user has more powerful tools to research the prices in advance even if he is going to a presentation. The buyer can make a more informed choice today than earlier. Buyers can also avoid the trauma of sitting through a timeshare presentation by buying through resale market. The presentations sometimes take ninety minutes and can go even longer. At the end of the presentation the buyers who were brought in on the pretext of a free gift are subjected to high pressure selling techniques, and this yield to sign a paper and buy a timeshare.

Now talking about the cost comparison, a developer’s timeshare offer includes the cost of advertisement, presentation, free gifts etc. which is whopping 40% of the cost of the timeshare and sometimes this exceeds the cost of the timeshare resale. On the other hand if one buys a timeshare through a resale market one can buy the timeshare 30% to 50% cheaper. Also buying through a resale market offers you more choice and freedom to select your desired unit. You know that you are getting the best price. It is definitely worth saving thousands of dollars by buying a resale.

But there are good reasons to buy from a developer. There are many reputed companies that have ventured into timeshare business like Marriot, Disney, and Hilton etc. When you are buying through a resale market there is a margin of doubt whether your investment is secured or not and the trust factor is low. Where as the timeshare developers spend fortunes in the development of timeshares and have great reputation and thus can be easily trusted. They give you the best and the latest amenities which you can never get from a resale unless it’s a relatively new unit. Another high point of buying through a developer is that they offer many incentives and benefits to their customers in the form of bonus weeks, discounts on attraction tickets, car rentals and much more. On the other hand these benefits may not be available to you if you bought your timeshare through resale market as many developers does not allow timeshare resale units with same amenities compared to those who bought directly from them. Also the developers usually offer many financing options that you may not get if you buy from a resale market.

Guide to Acquiring UK Credit Cards

Guide to Acquiring UK Credit Cards

All credit cards come in many shapes, colors and sizes. They come in different types and brands with their own list of great deals to offer. UK credit cards are not different from these. When you apply for a UK credit card online, there are three easy steps you can follow. First, you can search through the list of UK credit cards you might find while surfing the net. Then, you can compare the rates and the fees of these UK credit cards side by side and prepare for the process of elimination. After you have weighed the pros and cons and the advantage and disadvantages of your top choices, you can now make the final decision, which among the UK credit cards offered would best suit your needs. Then, you may proceed with your UK credit card application by filling out the form online.

Things you should know before getting UK credit cards
Indeed, "plastic" has tremendously redefined the way people spend their money. In the US alone, more and more Americans are using credit cards because of the financial convenience it brings. When it comes to the UK, studies show that the Britons owe hundreds of millions in credit card debts. Being a flexible and accessible method of acquiring credit, various UK credit cards are being offered by major lenders to provide ultimate convenience to the consumers.

Applying for UK credit card can be both easy and difficult at the same time. Well, it can be surprisingly easy compared to spending the money itself. Getting a UK credit card is quite as easy like splurging your bucks on shopping spree. But, the difficult part when you have a UK credit card or any other credit card for that matter, is when the monthly bill arrives. Before getting a UK credit card, make sure to visit some guide and glossary so you will have all the information you need. Searching for important tips before you choose your UK credit card will help you become educated in your purchasing decision. Being informed before filling out for a UK credit card application will also help you reduce the possibility of getting stuck up in a credit card debt trap.

Reading some tips will also help you decide for yourself which among the list of UK credit cards would best suit your financing needs. You can choose the right UK credit card by comparing their features, interest rates, and benefits. Among the UK credit cards available, you should find the credit card with 0%, has the best rates and APR for balance transfers or purchases. Most importantly, never forget to look for the UK credit card with lowest rates by reading the descriptions carefully before you apply for a credit card online.

Top UK Credit Cards
Since more than half a million pounds are spent on UK credit cards every minute-amounting to tens of billions spent each year-it is very important to choose the best credit card for you. Here are some of the top UK credit cards available. With their own sets of great deals to offer, it's up to you, which among these UK credit cards is best for you. First among the list is Marbles. It offers up to 52 days' interest free credit, 0% balance transfers for the 1st 6 months, and 14.9 % APR. If you're the type of person who wants almost everything customized, this UK credit card lets you choose what your card will look like. It also lets you manage your account online. This UK credit card is designed in one of the safest and secure credit card systems around.

If you are looking for a UK credit card that offers from 0% APR on balance transfers, from 15.9% APR on card purchases, no annual fees, and a free 24-hour help line, then you might want to try Virgin Card. This UK credit card can actually be your exclusive pass to an exclusive online membership online stuffed with great money-off deals.
Another is the Egg Card that automatically gives you free purchase in transit protection for items. You can actually pay for all or part of your fare using this UK credit card plus the benefit of free personal travel accident insurance.
Apart from that, the customers also get a 10% discount on home and travel insurance policies when they use this UK credit card. The GM platinum card, on the other hand, offers 14.9 % APR, 0% per annum on balance transfers and purchases for 5 months, and online account management. The best thing about this UK credit card is that the holder will receive a 100 free Rebate Points the first time you use it. This unique reward scheme makes this UK credit card more fun compared to others.

After weighing all the pros and cons, advantages and disadvantages, you may now choose the best UK credit card for you.




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Determining Where You Will Invest

Determining Where You Will Invest


There are several different types of investments, and there are many factors in determining where you should invest your funds.

Of course, determining where you will invest begins with researching the various available types of investments, determining your risk tolerance, and determining your investment style – along with your financial goals.

If you were going to purchase a new car, you would do quite a bit of research before making a final decision and a purchase. You would never consider purchasing a car that you had not fully looked over and taken for a test drive. Investing works much the same way.

You will of course learn as much about the investment as possible, and you would want to see how past investors have done as well. It’s common sense!

Learning about the stock market and investments takes a lot of time… but it is time well spent. There are numerous books and websites on the topic, and you can even take college level courses on the topic – which is what stock brokers do. With access to the Internet, you can actually play the stock market – with fake money – to get a feel for how it works.

You can make pretend investments, and see how they do. Do a search with any search engine for ‘Stock Market Games’ or ‘Stock Market Simulations.’ This is a great way to start learning about investing in the stock market.

Other types of investments – outside of the stock market – do not have simulators. You must learn about those types of investments the hard way – by reading.

As a potential investor, you should read anything you can get your hands on about investing…but start with the beginning investment books and websites first. Otherwise, you will quickly find that you are lost.

Finally, speak with a financial planner. Tell them your goals, and ask them for their suggestions – this is what they do! A good financial planner can easily help you determine where to invest your funds, and help you set up a plan to reach all of your financial goals. Many will even teach you about investing along the way – make sure you pay attention to what they are telling you!

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Financing Information

Homeowners who are considering re-financing but are not knowledgeable about the subject have a number of options available to them for finding more accurate information regarding the types of re-financing options available as well as the ways to obtain the best available rates and tips for finding a reputable lender. This information can be obtained through a number of resources including published books, Internet websites and conversations with experts in the financial industry who specialize in the area of re-financing. All of these sources can be very helpful but there are also precautions homeowners must take when using each information source. Taking these precautions will help to ensure the homeowner is receiving accurate information.

Using Books for Research

Published books are often considered to be one of the most reliable resources for researching re-financing options. However, not all books on the subject are created useful. Readers may find some books provide a great deal of useful, current information while others books are filled with outdated information and information which is not 100% accurate.

The best way to select a book or books when researching the subject of re-financing is to start the search with books that were only recently published. This is important because the financial industry is continually evolving and as a result books which were published only a few years ago may already be considered out of date.

Homeowners should also seek out independent reviews when considering books on the subject of re-financing. This is important because books which consistently receive solid reviews from consumers are likely to be worthwhile. Conversely books which consistently receive negative reviews are likely to not be worthwhile. Homeowners should seek out highly recommended books while avoiding those that are not highly recommended. This may prevent the homeowner from wasting time reading books which are not informative and may even be inaccurate.

Using the Internet for Research

The Internet is another resource which can be very valuable for homeowners who are considering re-financing their home. The Internet is filled with valuable information but there is also a great deal of misinformation floating around on the Internet. Homeowners who are completely uninformed about the re-financing process may not be able to distinguish between the useful information and the misinformation. As a result these homeowners may be led astray by inaccurate information on the Internet. Homeowners who wish to avoid the potential for this problem should consider verifying the information they find online through an outside source such as a published book from a renowned author or by conferring with an expert in the subject of re-financing.

Homeowners should also do the majority of their research on well established websites. This includes websites owned and operated by major lenders which have been in business for years. The information on these websites is likely to be much more up to date and accurate than websites which are created for profit by website owners.

Consulting with Re-Financing Experts

Finally, consulting with financial experts who specializes in re-financing can be very helpful for homeowners who are considering re-financing. This might be the most expensive option as many of these experts will likely charge a fee for their services but it can also be the most reliable source of information.

There are a number of advantages to consulting with an industry professional as opposed to researching the subject independently through published resources. The most significant advantage is the ability to ask questions throughout the re-financing process. This will help to ensure the homeowner fully understands the available options. It will also help to ensure the homeowner receives the best possible re-financing option for his specific needs. The re-financing process works best when the homeowner offers their input about the type of re-financing they are seeking as well as the benefits they hope to obtain through re-financing. The re-financing expert can than make a better recommendation which will suit the homeowner’s needs.