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Frequently Asked Questions: While we realize the questions below may not capture all your concerns, we only suggest these questions and answers format as a guide, please feel free to contact us for further details:
A: The Almaden Group
manages your care or your loved ones care by: coordinating care and
collaborating with every provider involved in your care, help you access
services that you/your loved one may need and make arrangements for delivery of
these services whether it involves home health (nursing, physical therapy,
occupational therapy etc), attendant care, transportation or equipment. If you
are denied services, The Almaden Group can appeal on your behalf to help you get
these services when necessary. A: Life care planning (LCP)
is a higher level of managing your care. It involves mapping-out your/your loved
ones care and services you may need throughout the life expectancy if you are
living with an illness or disability. For example, a stroke, a spinal cord
injury, a brain injury, a degenerative neurological illness, a child with
disabilities, an accidental injury, or cancer etc. A life care plan includes
financial planning and legal paperwork for decision-making representation and
Advanced Directives. It helps people visualize or see the dollar amount that
health care services will add up to over time. At times, a life care plan is
used for disability claims settlements or litigated cases. A: The Almaden Group can
help you by: allowing you to focus on adjusting to this new change in your life.
Often times, families have to worry about work and making a living, rushed with
children or parents to take care, or just the sheer shock of the news of the
illness or disability can be too devastating to manage, yet life goes on. We
take a big chunk of these worries off your plate so that you can focus on the
usual routines (or pressures) in your life. Well talk, on your behalf, to
doctors, hospitals, nursing homes, therapists, and the like. Well make
arrangements for services, transportation, or appeal for denied services, if any
and guide you through the maze of the complex health care system.
A: In the insurance
world, there is commercial membership and public-funding membership. What
that means is: 1. Commercial benefits are pre-purchased benefit options. 2.
Publicly-funded benefits range from Medicare benefits, Medicaid/Medical (in
California), & other types of funding. Insurance companies have standards for
reviewing requests for services initiated by your doctor as well as standards
that they must follow if their response is adverse (a denial). However, errors
happen all the time and it takes proficiency in understanding benefits, medical
necessity guidelines, and proper determinations or logic for the denial.
Insurance companies do fail, at times, in meeting these requirements and an
advocacy group like The Almaden Group can flag these errors and reverse the
decision to the benefit of our clients.
A: The first thing that
The Almaden Group would do for you is find out who made the decision and what it
was based on. The second step would be either appealing it on your behalf, or
pursuing options that'll give you the care you need and the continued progress
in your health that you deserve. Please refer to question 4 answer for
additional information, and keep in mind that not all decisions, such as ending
your rehabilitation services, are correct or reasonable, and it takes
professionals like The Almaden Group team to judge that and challenge it if
necessary.
A: The Almaden Group will
investigate this billing and the original claim submission. What patients get
from a doctors office or a hospital for a bill is different from the claim
submission forms (usually referred to as UB-92/04 & CMS-1500). The Almaden Group
has taken cases where patients were turned to collection simply because of
errors committed by their payer/insurance or errors committed by their
provider (doctor or hospital) not knowing who to bill. In the managed care
environment, aka HMOs, with the vast variety of the contracting agreements, it
is too complex for a biller to know what full risk, shared risk, or
capitation agreement entails, or which party is responsible for what, and what
address to send the claim to. Often times, the provider wants payment and they
choose the easiest way out which is billing you, the patient. So, if we get
involved, we track these details and get every body off your case unless there
are copays or deductibles that should be met particularly if you had PPO
coverage at the time of service.
A: Patients and families
are often overwhelmed by the illness, which is understandable. The love and
caring they feel for each other make them believe that they can do whatever it
takes to help their ill-stricken family member. What happens after discharge, as
this question suggests, is all too often a combination of things: services that
were arranged are not delivered, be it a home health nurse that needs to give an
IV dose or change a dressing, to a physical therapist that has to do a home
evaluation along with the first treatment at home, or to a wheel-chair/hospital
bed that has to be there. Not having the promised services may mean immediate
compensation by a family member till matters are resolved. The common occurrence
is certainly delays and more delays which may adversely affect the patient. The
Almaden Group is all too familiar with these situations. Our knowledge of the
providers and the system and how it works, we can expedite service-delivery for
you and make sure you get the best type of providers. We deal with the best and
not the ones that are known only because they deliver cookies or lunches!
Patients are our top priority and we work for patients and their families to get
them to healthy, happy, and functional levels. A: If you are on our
website, we have a referral form to fill and submit. If you do not want to do
that, our home webpage has contact phone numbers, email, and address. We also
accept referrals from doctors, nurses and social workers in hospitals, or other
clinics. We pride ourselves on referrals through word of mouth. We want you
satisfied so that you can spread the word and help other people, like you, that
may need our services.
A: The first thing we do
is an assessment of your situation to see if there are immediate needs that have
to be addressed. Well also need you to sign a representation form that allows
us access to speak to doctors, nurses, hospitalsetc that are involved in your
care and to be able to access your medical record or information. HIPAA
Regulations pose stringent rules on information exchange about patient care. We
realize that some of the information is too personal but with your permission
and trust in us, well hold your information with the utmost regard and make
sure that your privacy is protected. A: The Almaden Group fees are based on the initial agreement with the client as well as the anticipated work involved in each case. Typically, we either charge an hourly fee or a case rate depending on the type of case. Industry standards are used and
well be happy to discuss that further upon the initial consult. Please ask for
$ 50. discount coupon if you are a new client. |