Health Anxiety and Solutions

It’s always important to take care of oneself using all the principles of good health. Regular check-ups, proper nutrition and healthful living all enable one to keep on top of their health in a careful yet reasonable way. Often one becomes overly concerned with health issues and caught up in a cycle of health worries. One health issue is reconciled when another immediately pops up to take its place. These worries become all encompassing and exhausting after a while.

Eventually, the individual realizes that this cycle of health anxieties has intruded upon the quality of their life. A dark cloud, always hovering over daily living, this intrusive form of anxiety has to be addressed. One begins by determining why this is occurring, what purpose does it serve and how to interrupt this behavior.

Reason for Health Anxiety

Health worries actually serve a purpose and this purpose is not difficult to detect if one looks deep enough into this pattern of behavior. Often this pattern involves the brain distracting from specific emotions which the individual finds difficult to address.

Many emotions are so overwhelming, such as anger, grief or fear, that the brain looks for ways to distract. Health worries fit the bill because when one worries intensely about their health, there is little room to address an upsetting emotion.

Health worries blanket every other thought and this WORKS. This is the perfect distraction from unsettling emotions. When one worry is reconciled, another takes it place to veil the unaddressed emotion. Each health worry has a strong purpose, as it masks the true upsetting emotion, which is much more difficult to face in the long run.

Solution

– Recognition and acknowledgment of the Health Anxiety habit, one worry quickly following another in a noticeable loop that never ends. Awareness of this cycle is always the first step to reconciliation of the issue.

– Determining if this health worry is a true physical problem by visiting one’s primary physician and ruling out a definite physical cause for the difficulty. Always rule out a physical cause before assuming it is merely health anxiety.

– Noticing that these health worries settle down when you become intensely interested in another topic or swept into a new relationship, job or cause.

– Identify your patterns. Do you experience twinges of symptoms that often jump from one area of the body to another? Do you find yourself overestimating physical intrusions and instantly jump to the conclusion that they signify danger or warrant the attention of an alert?

– Find interests that involve your entire being. Lose yourself in things that allow you little time for inward thinking. True illness does not surface through boredom as do these behaviors. True health problems do not generally follow the same time table as health anxieties do. Health worries are stronger during times of boredom and when one lacks interests. An intelligent mind requires challenges and goals.

– Activity is an important therapeutic tool against health worries. Exercise and movement invigorate and stimulate the mind and body in a positive way. Endorphins are released and Serotonin levels are boosted naturally when activity is a part of a daily routine. Moderate walking, jogging, tennis, swimming and dancing are all helpful activities that bring forth positive results.

– Nutrition is also essential to good health which in itself helps eliminate the strong habit of negative thinking, often concerning health worries. When eating properly, Serotonin levels are naturally boosted and blood sugar levels remain stable. This helps settle down an over-reactive mind, leading to a lessening in health anxieties.

– Talk back to the brain by firmly telling it to stop when health worries enter the mind. Shift into a more positive mode of thinking because you always have a choice in what you think about.

The mind will respond by quieting down as negative thoughts subside. The brain, caught red handed in this behavior is instantly embarrassed causing it to suspend this cycle of negative thought. This is comparative to a child being caught with his hand in the cookie jar. Embarrassment at being caught, stops this intrusive behavior.

– Be aware of “what if” thinking. If the majority of sentences you think begin with “what if” then this is proof of a strong health anxiety habit. Change “what if” thinking to “so what” and watch the cycle break.

Most of all, understand that worry solves nothing. Health worries, in particular will only serve to exhaust and deplete both mind and body. Consciously make a concerted effort to change the way you think and you will succeed in changing your life. You will go from self victimization to freedom from the intrusive habit of fearful worry.

You always have a choice. Life can be wonderful and fulfilling when you learn to alter your perspective and chose a more positive point of view. You always have a choice. Never define yourself by your habit of worried thinking. Do not be victimized by health anxiety and fear. With a few simple corrections, especially in thinking, you will find your life changes from being difficult and upsetting to becoming easier and much more fulfilling on a daily basis.

Health Care Fraud – The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with ‘sleight-of-hand’ precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

– “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]

– The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

– The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don’t know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care – vary from state to state and from payor to payor – are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid – in some cases codes that do not accurately reflect the provider’s service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government’s reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws – presuming new laws will result in more fraud detected, investigated and prosecuted – without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments’ capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What’s one person’s fraud (insurer alleging medically unnecessary services) is another person’s savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

– DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

– REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn’t paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient…

– REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

– PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

– PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters – steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud – on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.

Australian Health Care Benefits

Moving to Australia is an exciting prospect. However inevitably the question of health care is raised. No one wants to become ill or injured while living in Australia and then be left with an enormous bill to pay.

Does Australia have free health care?

Medicare is Australia’s publicly funded health care system however it does not provide 100% coverage. Medicare provides eligible individuals access to free or subsidised medical, optometrical (eye care) and public hospital care. Medicare does not pay towards ambulance costs, physiotherapy, spectacles, podiatry, chiropractic services, or private hospital accommodation.

Medicare also does not cover dental costs, with some exceptions for low-income earners. A nationwide Denticare Australia program may be extended in the next government budget, however the specific details are yet to be announced. Some dental organisations provide interest free payment plans, member discounted services that attract an annual fee, or discounts for regular patients to help manage costs.

Individuals can also choose to access private health services that charge for their services, and may choose to take out private health insurance to cover these types of costs.

Will I be eligible for a Reciprocal Health Care Agreement?

The Australian Government also has Reciprocal Health Care Agreements with some countries that provide ‘restricted access’ to public health care while in Australia. Restricted access usually limits care to ‘medically necessary’ treatments eg. Ill health or injury which occurs while you are in Australia and which requires treatment through a public hospital before you return home.

Individuals from New Zealand and Ireland do not get issued with a Medicare card and instead present their passport at public hospitals or pharmacies. Non-hospital care, such as attending a local GP doctor, is not covered. Other reciprocal agreements will pay Medicare benefits for out-of-pocket medical treatment provided by doctors through private surgeries and community health centres. All agreements cover subsidised medicines under the Pharmaceutical Benefits Scheme (PBS).

Note: Reciprocal agreements technically only cover individuals if they have come directly from the reciprocal country eg. If you were previously living in another foreign country prior to coming to Australia you may not be eligible, as you have not been recently been part of the health system for your country of nationality. However application of this requirement varies between Medicare staff.

Medicare Information Kits for migrants are available in 19 different languages.

What amount is subsidised by the government?

The benefit (or refund) that you receive back from Medicare is based on the Medicare Benefits Schedule (MBS) for that specific service which is set by the government. Doctors and other health service professionals can choose to charge over the schedule fee or bulk bill. Bulk billing is when doctors bill Medicare directly, accepting the Medicare benefits as full payment for the service. If doctors charge a higher amount the patient wears the extra costs.

Many doctors now offer to process Medicare claims electronically at the end of the appointment. Alternatively you can lodge most claims online, visit a Medicare office or post in your claims. Refer also to How does Medicare work?

Patients may also be required to pay for additional tests or vaccinations that their doctor requests as part of their treatment.

Some benefit examples based on the current schedule (1 Nov 2011) are below:

Standard doctor Level B consultation for less than 20 minutes with a GP (General Practitioner) in their consulting rooms: Fee = $35.60 and Benefit = 100% so you receive a $35.60 rebate. Therefore if the doctor charges $65.00 for an appointment you will be out of pocket by $29.40. If the doctor bulk bills they would charge the $35.60 fee direct to Medicare resulting in no out of pocket costs for the bulk billed patient.

Specialist doctor consultation initial appointment in a hospital or their consulting rooms: Fee = $83.95 and Benefit = 75% (hospital in-patient) or 85% (out-of-hospital) so you would receive either a $63.00 or $71.40 rebate. Therefore if the doctor charges $130.00 for an appointment you will be out of pocket by $67.00 or $58.60. You will need a referral letter from a GP to see a specialist so will need to budget for both out of pocket costs. Specialist fees can also vary considerably with some charging several hundreds of dollars if they are highly specialised and sought after. It is worth checking fees prior to making appointments so you are prepared for any out of pocket costs.

Comprehensive dental oral examination, limited to 1 per provider every 2 years: Note: Any preventive services like removal of plaque and/or stains, or any fillings etc are billed separately and can quickly add up to a sizeable bill even with the rebates: Benefit = $40.50 so if the dentist charges $95 for this item you will be out of pocket by $54.50

Medicare concession card holders will usually be charged a lesser rate or receive some services for free.

Note: If you are not eligible for Medicare you will have to pay the full appointment fees. However you are also exempt from paying the Medicare Levy and any surcharges (see below for more information on these).

The Pharmaceutical Benefits Scheme (PBS) details the medicines subsidised by the government, which must be purchased through a pharmacy. Non-PBS medications will be charged at full price.

The government also protects high users of medical services from big out-of-pocket costs through the Medicare Safety Net, and provides pension and health care concessions for pensioners and low income earners. The PBS Safety Net is available for individuals who need a lot of medicines in any year.

Individuals may also be able to claim a tax offset of 20% for net medical expenses over the threshold, currently $1,500 for the tax year for eligible expenses.

Note: The above protections may only apply to individuals on full Medicare so check further with Medicare before applying.

Are there any costs when I use an ambulance?

Ambulance cover varies between the different Australian States & Territories.

In Queensland and Tasmania, ambulance services are provided free for local residents.

In all other States & Territories, fees may be charged. The fees can vary depending on: how far individuals travel by ambulance, the type of transport eg. helicopter, the nature of the illness, whether an emergency or not, and any concession eligibilities.

Residents living outside Queensland or Tasmania can insure against ambulance costs, either through membership schemes provided by the relevant ambulance service (in the Northern Territory, South Australia, Victoria and country areas of Western Australia) or through a private health insurance fund (in the Australian Capital Territory, New South Wales and metropolitan Western Australia).

Note: Check the details of any ambulance cover provided by private health insurers carefully as it may only be limited to ’emergency’ transportation eg. not covering trips between hospitals or non-critical call outs. Membership with ambulance services may be more comprehensive.

In most cases, local holiday or business visitors to other States & Territories will be covered if they were covered in their home State or Territory due to reciprocal arrangements. However it is worth checking this before travelling to other States or Territories.

Do I have to pay anything towards Medicare?

Medicare is funded by a Medicare Levy tax deduction taken from your income with the contribution level based on how much you earn. The Medicare Levy is currently 1.5% of taxable income.

In addition, the Medicare Levy Surcharge of 1% is levied on high-income earners who do not have private hospital cover. The income threshold for 2011-12 year is $80,000 for singles and 160,000 for couples / families increasing by $1,500 for second and subsequent dependents. The surcharge is designed to encourage individuals to take out private cover and therefore reduce the demand on the public Medicare system.

If you are not eligible for Medicare then you may qualify for a Medicare Levy exemption and will not have to pay the Medicare Levy or Medicare Levy Surcharge. You must however complete a Medicare Levy Exemption Form in order to be exempt from the tax.

What are the differences between Medicare and Private Health Insurance Cover?

The Health Insurance Ombudsman has a good comparison of Medicare and Private Health Insurance.

Do I have to take out private health insurance?

You do not have to have private health insurance unless it is a requirement of your Australian visa to make arrangements for a minimum level of health insurance. A sponsor could still offer to pay the insurance, however if not the visa holder is responsible. Student visa holders are required to have Overseas Student Health Cover, although students from Sweden or Norway may have special arrangements.

However you may still want to consider taking out private health insurance to give you more health care options, to cover items which aren’t covered on Medicare such as dental costs, or if you are not eligible for full Medicare.

There are two types of private health insurance: 1) Hospital policies and 2) Ancillary or extras cover for treatments such as dental and physiotherapy. Most health funds offer combined policies.

Insurance policies may also have exclusions and restrictions, excess payments and waiting periods for certain claims. Insurance claims may also be subject to annual limits for certain types of claims. Insurers often have preferred suppliers who may offer higher benefits for members.

How much does it cost to have private health insurance?

The costs of insurance vary considerably depending on what health cover plan and insurer you choose. You should only choose a registered Australian insurer and one way of choosing is to use the many free comparison sites available. The Private Health Insurance Ombudsman website also has excellent information.

If you are currently with a recognised international health fund you may be able to obtain an insurance clearance certificate and transfer without incurring waiting periods for some claims. Continual coverage will depend on the old and new policies being similar. Many Australian insurers refer to the International Federation of Health Plans to determine whether a fund is recognised under their transfer policies.

Health insurance rates can increase on 1 April each year in line with government regulation and in 2012 this resulted in average increases of 5.06% for new and existing premiums.

In addition to the Medicare Levy Surcharge, the government also has two other key private health insurance incentives.

Private Health Insurance Rebate – 30% to $40% rebate (not applicable for overseas visitors health cover)

Lifetime Health Cover – Additional loadings that increase the later you take out health insurance during your lifetime with a maximum loading of 70%.

1 July 2012 Changes

From 1 July 2012, the Rebate and the Medicare Levy Surcharge will be means tested. This could result in substantial benefit reductions for high-income earners, particularly singles earning $130,001 or more, and couples/families earning $260,001 as their rebate will drop to zero.

You can read more about these changes at privatehealth.gov.au.

Moving to Australia raises many questions. In addition to health queries there are educational, employment and accommodation issues to consider to name a few. It is important to get reputable information the first time. You also need to know when to complete the hundreds of tasks involved when moving to Australia.