Category Archives: Health

How to get Medicare to reimburse you for seeing a non-Medicare doctor

Health, ,

This post explains how to get reimbursed by Medicare directly, and is applicable to people who have Part B coverage. I have included the exact forms and letters that I used to get reimbursed by Medicare directly; you simply need to fill in the blanks. These forms can also be used if patients see their provider “virtually” (i.e. by phone or video conference).

The problem

I have a family member that gets reimbursed directly by Medicare for out-of-pocket costs that she pays herself. Several unusual criteria apply to our case… This family member:

  • Has a health care provider that does not accept Medicare
  • Lives in a rural, health professional shortage area (HPSA)
  • “Sees” her provider virtually. Medicare refers to these types of visits as telehealth, and they are reimbursed at the same rate as normal, in-person visits; there are no special telehealth billing codes. To be eligible for telehealth reimbursement, you must meet certain criteria.
  • Uses me as her Social Security Payee, which makes her my legal dependent. (I have to do everything on her behalf.)

Despite all of these special circumstances, we’re able to get reimbursed by Medicare directly, which is $3-4,000 a year. We had to appeal twice on our first attempt at getting reimbursed. The language and documents I have distilled below reflect this. It helps to very, very clear about why your request is valid.

Appeal letter: Word version | Google document

Need an example of an appeal letter? Post in the comments below, and I’ll clean mine up.

Supporting documentation

  1. Fill out a “Patient request for medical payment” form
  2. A signed, dated letter from your provider that states that they refuse to submit claims to Medicare, and that they are not (and don’t wish to become) a Medicare provider (Microsoft Word | Google Doc)
  3. A copy of an itemized bill for services rendered in the last however many months. This bill should contain the date of service, cost, and the service rendered. Once you’ve got the reimbursement process down, you should submit a reimbursement request every 3 months or so. (Microsoft Excel | Google Spreadsheet)
  4. A request to be reimbursed that references the pieces of documentation above. (Microsoft Word | Google Doc)
    • For telehealth reimbursement only: A letter stating that there are no suitable providers in a 500 mile radius of the patient’s address, or that the patient is in an HPSA-designated region. I included this information in the reimbursement request itself (#3). By the way: telehealth visits are generally only applicable to mental health services.

You do NOT need to include diagnostic information.

Ways you may need to change the included sample letters

  • Change the billing codes so they’re relevant for your case.
  • Change the provider’s name and credential information.
  • Look for stuff in the letters that looks <Like this>, and replace it with information relevant to your case.
  • If you are doing this for yourself or for someone who is not a dependent: Each of the sample letters is written by me on behalf of a legal dependent. If this doesn’t apply to you, modify each document so it’s written from the perspective of the patient themselves: use “I”, “me”, etc., and have them sign it.
  • If you are not trying for telehealth reimbursement, remove the sections that talk about being in a health professional shortage area and/or telehealth references.
  • Make sure the Conclusions section in the request letter is relevant. For example: my version includes comments about telehealth; yours may not, so delete them. Make sure they make sense for you.

Send the paperwork certified mail

You won’t be sending your 3-4 pieces of documentation to Medicare. You’re going to be sending them to a Medicare Carrier, which varies by state. Find yours here.

We did not send our first appeal certified mail, and it got lost. This cost us three months. Save yourself the time and aggravation, and send your documentation certified mail.

Be prepared to wait

It took me over a year to finally get reimbursed by Medicare. It took three incomplete attempts, and two appeals before I won my case. You may not succeed the first time… but keep at it. If you can push through the bureaucratic apathy, you will probably succeed.

Good luck! Ask any questions in the comments below, and I’ll do my best to answer them. Getting Medicare to reimburse you for covered expenses is NOT easy.

Update 2014-09-06: The second round of reimbursements went off without a hitch. No appeals, no additional documentation. Just a large check a little over a month after the reimbursement request was filed!

Slow carb: week 2

Health, Personal

This past Saturday marked my second cheat day on the slow carb diet. This will be a much shorter post, with the addition of Recipes section.

Recipes
This week we decided we wanted to eat more savory foods, as the diet can be quite bland. We tried spaghetti squash with home made marinara and turkey meatballs with almond flour. It was OK… the squash wasn’t cooked enough, and the marinara recipe we used wasn’t very good, either (it was essentially tomatoes with onions, and not much “sauce” ugh). Next time we’d bake the squash longer, and use a better marinara recipe.

We also made chili with black beans, kidney beans, and garbanzo beans (chickpeas). We added WAY more veggies: mushrooms, broccoli, red peppers, and we also threw in one ear of raw corn cut off the cob. (Yes, we “cheated”, if you could call < 1/8 of an ear of corn per serving “cheating”.)

It was amazing. So. Bloody. Good. Best food we’ve eaten since being on the diet.

Quantitative

  • Weight: 222.5 (down ~1lb)
  • Waist: 40″ (no change)
  • Hips: 40″ (no change)

I spent first 3 days after my cheat day above my weigh-in weight. I suspect I may have weighed in at the perfect time: just evacuated everything, slightly dehydrated, didn’t eat much the day before. (All of these things were unintentional.)

Qualitative

  • Energy levels are still higher and smoother than what I’ve been used to (more on that below)
  • Weight loss was much less than the first week. I believe my assertion that most of the weight was water weight in the first 3 days was incorrect, and that I continued to shed water weight for most of the week.
  • I’m really at a “new normal” now as far as preparing food, making lunches, eating food, etc is concerned. It’s easy to say no to most foods, and I cook without thinking.
  • My allergies seem to be gone. (Weird!) I don’t breathe heavily, nor have I been congested. This doesn’t seem connected to the air quality, so I don’t have any idea why this is true.

The most illustrative thing, though, is the bike ride I went on. I hadn’t been on a bike in a month, and I decided to go on one about 2 hours after lunch. Up until that point, I’d had breakfast (two eggs, lentils, half a thick sausage patty) and lunch (cereal-bowl-sized bowl of chili with melted cheddar). I knew I’d be hungry by the end, so I brought some carrots with me to eat when I was done.

About halfway through, I got hungry. In the past, this would have meant I would have hit the wall, unable to bike with any appreciable energy. I did not have this problem. I had no problem sustaining 18-20mph, and when I turned back, I was sustaining 20-22mph, despite being hungry. In fact, these are the fastest speeds I have ever sustained on this course… even though I hadn’t been on a bike in a month, and my weight loss wasn’t much as a percentage of my starting weight.

It was very strange to have my energy levels largely decoupled from my hunger. Similarly, my leg strength was the limiting factor, not my cardiovascular system. This hasn’t been the case since I was in high school, so this is A Very Good Thing.

Slow carb week 1 foods

Health, Personal

I’ve been asked what I ate during week 1. The answer: pretty boring stuff, mostly. I actually took pictures of most of the food I was eating to send to Laurel, because she was planning on doing the diet, but was away in Israel when I started.

The trick is to cook more than one serving at a time, even for things like cooked vegetables. I don’t like frozen veggies, so I generally buy fresh and make 2-4 servings at a time because it saves time and energy. Hooray for dishwashers.

Things cooked in bulk:

  • Lentils: one package tends to last me about a week. I like them a little softer, so I boil them for close to 30 minutes.
  • Bacon: one package of center cut bacon at a time. I save the bacon rendering for later. Haven’t used it for anything yet.

Breakfast tends to be the same thing every day:

  • Lentils (often fried in some oil; the texture is nicer)
  • 3 scrambled eggs, Gordon Ramsay style
  • 3 strips of bacon (microwave them for 20 seconds, and they taste like they’re right out of the pan!)
  • 1 serving (8oz) of V8 juice. This was my savior at the beginning, as it the thing with the “loudest” flavor, and until I adjusted to the subtleties of the other things I was eating, it was the most interesting thing on a daily basis
  • 2 cups coffee with 1 tablespoon of cream per cup

Lunches and dinners are generally a meat with a legume and vegetables–often 2 or more. Sometimes cooked, sometimes raw. If you need rubs for your meats, I recommend Penzeys market (online or retail).

Meats:

  • Steak spiced with a rub or seasoning
  • Chicken spiced with a rub
  • Boneless pork chops spiced with a rub
  • Breadless cheeseburger, using aged swiss cheese, and often topped with salsa
  • Tuna (usually wrapped in lettuce like a lettuce+tuna roll)
  • Chicken sausage (grilled or broiled)

Sides:

  • Black beans or lentils
  • Raw cucumbers and carrots
  • Nathan’s dill pickles

Vegetables:

  • Asparagus (sauteed in olive oil with spices, or steamed)
  • Green beans (steam a bunch, and eat them over the next 2-3 days)

Other dishes I make regularly or would make again:

  • Spaghetti squash + slow carb tomato sauce + turkey meatballs, and shredded parmesan on top. Surprisingly good. Make the turkey meatballs with almond meal instead of breadcrumbs.
  • Two slices of Thin n trim chicken from the deli with a slice of aged swiss in between. Brown it up in a pan (no oil needed!), which melts the cheese. Top with salsa, and eat with a knife and fork like a thick slice of ham.
  • Lentils mixed with salsa.

Things I’d like to try:

  • Grilled kabobs with meat and veggies
  • A cooked black bean salad/stir fry thing with meat and veggies and beans
  • A stir fry over lentils or beans.

I eat the same things over and over again, which is what most people do (and certainly what I did before the diet). The only real difference is that I’ve changed the things that I repeat.

Slow carb: week 1

Health, Personal

Last Saturday, I sat down in the morning, and planned out my strategy for eating for the weekend. I knew I’d essentially be by myself, so if I was going to be miserable, I wouldn’t be bothering anyone. Ideally I need to lose about 40lbs; I’m at 230lbs now and 190lbs would put me at about 5lbs more than my high school weight.

My initial goals for the weekend experiment were modest:

  • Eating entirely slow carb, where the biggest change was replacing starches with beans and lentils
  • Seeing how I would feel during my first two days: how bad would the transition be?
  • Putting together some slow carb meals to see if they were palatable

Knowing that I’d be doing at least a full month of it at some point, I figured I would just stick with the diet if:

  • The transition was miserable, but I got through it in the two days (why repeat it?)
  • I was satisfied with the meals I’d created

This is how I approached the experiment:

  • I didn’t treat “Tim’s word” as received wisdom, which is fairly unusual in the slow carb world where explanations are often prefaced with “Well, Tim says…” whenever a newbie asks a question.
    • I haven’t read 4 Hour Body (and probably won’t)
    • I skipped the supplements; “toxins being released” and “flushing the body” and other pseudosciency hand-waving is nothing but woo and appeals to magical thinking
    • When in doubt, I looked at the glycemic index of the food before eating
    • I deferred to Gary Taubes more often than Tim Ferriss, as Gary’s work is incredibly well sourced
    • I followed the diet pretty strictly, though I did add a slice of aged swiss cheese to make breadless cheeseburgers and tuna melts
  • I ate any time I felt hungry
  • I did not count calories
  • I deferred to sustainability if I was particularly unhappy with something (adding in cheese, for example)
  • I didn’t exercise any more than usual

To make it easy, I planned out all of my meals for the next two days, and made enough inputs to more than last for that time. (I batch cooked all of my legumes, because cooking them is time consuming and generally sucky.) I also bought a bunch of vegetables to have as snacks, as most of my normal snack foods aren’t allowed.

Yesterday (Saturday) was my cheat day. Now for the results…

Quantitative

  • Down 7lbs (230 -> 223)
  • Two inches off my waist (42″ -> 40″)
  • I spent about $40 on food this week, way less than normal

Qualitative

  • I got a headache the first day, but 800mg ibuprofen cleared it up
  • I felt a little light headed and dizzy on the first day; this may’ve been psychosomatic.
  • Day 2 was substantially better, and I didn’t need to approach my routine in a “defensive” fashion; I just went about my life as normal
  • It was going so well by the end of day 2, I decided to just roll with it indefinitely
  • I was pissing like a racehorse for the first couple of days (most of the weight loss occurred after this period, oddly enough)
  • I could not wait for my cheat day for the first 3 days. This urge disappeared almost completely by day 5, and when I added in aged swiss cheese and made a breadless cheeseburger, the results were even better
  • I stopped getting hungry after 2-3 days. (Not that I don’t get hungry, but if you were to graph hunger over time, it’d look like a slow wave with no sharp spikes. Except on cheat day(!).
  • I did not get tired in the afternoons the way I normally do. This happened around day 3; I didn’t notice until day 6. Even trying to take a nap was useless; I couldn’t stay asleep for more than 15 minutes.
  • My energy was quite high this whole week, even after playing frisbee. Normally I’m depleted afterwards, but not this week.

Cheat day
My cheat day was not nearly as excellent as I thought it imagined it would be during the first few days. By the end, I was anxious to get back to the slow carb eating. My energy was lower; I had severe hunger spikes.

The strangest thing I noticed?

Unhealthy food is very loud. The tastes are overpowering, and there isn’t much subtlety. It’s like a food version of the loudness war: there’s not a lot of dynamic range in processed foods. Even “boring” foods like honey bunches of oats are incredibly sweet. The foods I ended up enjoying the most were fruits, and apple pie. I ate 1/4 of a 12″ pie for dinner last night, and I have no regrets for having done so.

I also thoroughly enjoyed the small Hawaiian pizza I ordered, and my normal grape fizzies (grape juice + seltzer). On my next cheat day, I will probably eat a buttload of fruit: strawberries, blueberries, pineapples, apples, and apple pie. Maybe another pizza. That’s about it.

How does this compare to counting calories?
I dieted the “normal” way back in 2010, for about 3 months; eating balanced meals, maintaining a calorie deficit of at least 500 under maintenance load every day except one cheat day per week. I lost 3lbs during that time. On the slow carb diet, I never felt hungry or deprived–which is more than I can say for my experience in 2010.

There’s an argument to be made that my weight loss is purely do to with releasing water weight by depleting the glycogen stores in my liver–which theoretically happens whenever you restrict caloric intake. That said, I did not lose any water weight when I was counting calories, and most of my weight loss occurred after the first three days.

Open questions
How sustainable is this? I don’t know. I don’t have an end game right now, and I’m just going with it. I’ve spent a little bit of time thinking about “What comes after”, and I think a longer-term diet plan might look less slow carb and a little more paleo. One thing it won’t be is full of white carbs like it has been; I feel so much better eating this way. My breathing isn’t labored, I don’t get tired during the day, and generally have more energy. As a random aside: I wrote a fair bit of code this week, and it’s the best code I’ve ever written, and my thinking has felt clearer, but it could be placebo.

I’ve also been toying with the idea of going ketogenic, just to see what it’s like (but I probably won’t).

Pigouvian taxes on soda

Economics, Health

The Center for Science in the Public Interest — an organization I’ve wanted to work for — is pondering a soda tax. It’s not a new plan… I first had the idea in the fall of last year, though I didn’t write about it, and Ezra Klein has written about it twice. (1, 2) Quite a few people in a Kaiser Family Foundation/NPR poll (PDF) are in favor of it as well:

 
I don’t see a problem with it, really. It’s not a bad idea to take the negative externalities associated with a given activity and force the market to internalize them. I have a paper sitting on my hard drive that I’ve been meaning to adapt for the web for a while, but I’ll share a snippet here:

Money that would have greater marginal utility upstream is instead being spent downstream, because measuring the downstream effects are easier than measuring upstream effects. We spent an estimated $91.3 billion in diabetes care in 2002. How much money could be saved not just in diabetes but on healthcare in general if we combated the upstream problem of obesity instead of throwing money at its downstream consequences? Drastic expenditures on things like adverse cardiovascular events? In 1995, the economic cost of obesity was estimated at $99.2 billion. In 1997, an estimated 19.4% of the US population was obese (PDF). In 2007, that number jumped to 26.6% (PDF). Converting 1995 dollars to 2007 dollars, assuming that real per capita obesity costs did not increase over time (very unlikely) gives us this chart:

 
Obesity is probably the main public health concern in the United States these days. Communicable diseases have largely been eliminated through public health efforts, leaving lifestyle diseases as the main cause of morbidity in this country. If we cut our obesity rates in half, we could eliminate quite a lot of spending further down the line.

That adds up to about $240 billion a year spent on obesity care.

Pigouvian taxes work. By making the market account for the negative effects of its activity, it modifies consumer behavior — if not on an individual level, then certainly on a macro level. A 3 cent tax on soda doesn’t sound like much, but I’d put a significant chunk of change on it having a measurable effect on obesity. Of course it would only be one step in a real comprehensive public health strategy, but certainly not a bad step.

Before we go taxing soda, however, I would also humbly suggest that we get rid of the corn subsidies that make high fructose corn syrup so cheap, and eliminate sugar tariffs as well. Not that sugar is any healthier than HFCS from a public health standpoint, but it’s not generally good policy to layer a tax on an already-distorted market. If we stopped subsidizing corn production, we might not even need to have a soda tax… the increase in price might well take care of the over-consumption problem by itself.