Wednesday, June 7, 2017

Using Refinancing to Maximize Benefit from the NHSC or State Loan Repayment Programs

I'm going to share how I figured out how to effectively put your student loans into a grace period while you work towards paying them off via the NHSC or state loan repayment programs.

Loan repayment programs, whether through the NHSC or the state, can be a tremendous boon for medical or dental providers with student loans. The NHSC Loan Repayment Program (LRP) provides $50k/$30k (depending on the HPSA score of your community health center) for a two-year commitment, $20k/$10k per year for the next two years (extended one year at a time), then $10k/$5k per year after that.

Unlike with Public Service Loan Forgiveness (PLFS) where there are pretty specific criteria for how payments must be made leading to loan forgiveness, loan repayment programs give you the money which you then pay towards your loans. These programs are also pretty hands-off regarding what you can do with your loans in the meantime. As long as you don't consolidate eligible loans with ineligible loans, you can refinance or consolidate at will, picking any type of repayment plan available.

The financial strategy for someone using a loan repayment program to pay off their remaining student loans differs markedly from the strategy used when you are paying them off by yourself. Instead of the normal goal of securing a low interest rate and paying off the loan as quickly as possible, you instead want to pay as little as possible towards the loan until the loan repayment funds are received. This way, you've maximized your use of the loan repayment funds while minimizing your out-of-pocket cost. Interest rate only matters in that 1) it may dictate your monthly payment if you are on an interest-only repayment plan, 2) your loan repayment plans could fall through leaving you to pay the accumulated interest, and 3) it may cause your loans to exceed the amount covered by the loan repayment program if your loan amounts are about equal the maximum benefit of your program. Basically, the most ideal situation possible would be if you could lower your interest rate and put your loans into another grace period while you wait for loan repayment funds. Note, that this strategy assumes your loans will be covered in full by the loan repayment program. If your program will only cover a portion of your remaining loans, you want to use the normal strategy on the excess, but pay as little as possible on the portion to be covered by the program.

After I finished my two-year commitment for the NHSC Scholarship Program, I transitioned into the LRP. I hadn't done anything with my federal loans beside consolidating them and picking the 30-year graduated repayment plan. However, this still left me accumulating 6.5% interest with a significant monthly payment. I searched for a way to minimize my interest rate while also minimizing my monthly payment, but SoFi, CommonBond, DRB, and Earnest all would result in me paying more as they are geared to give you the maximum benefit with short loan terms and their high monthly payments. Eventually, I was able to refinance my loan with College Ave Student Loans using Credible (a middle man that connects you with offers from several smaller name lenders) to effectively put my loans into a bonus grace period. This unique strategy works by leveraging a few principles in your favor:

1) Interest-only repayment period - College Ave is one of the only student loan refinancers that I could find that offered an interest-only repayment period. Their 5-year loans start with 2 years of interest-only payments. Short of qualifying for a grace period or forbearance, this is the next smallest loan payment you could hope for.

2) Low interest rates - This isn't unique to College Ave, but I was able to get a 3% variable interest rate, which is less than half of my previous 6.5% rate. Since my monthly payments are going to be interest-only, this again helps me pay as little as possible on my balance. I'm not too worried about it being variable because this won't be a long-term loan, and as you will see next, I won't be paying monthly payments for long.

3) "Paid Ahead" status - This is the key to this strategy, without which it would fall apart. Loan servicers do one of two things which you pay a lump sum. They either 1) shorten the term of the loan but go on requiring the same monthly payment or 2) put you in "Paid Ahead" status where your payment covers your next X number of months, and a monthly payment is not required again until those X months have elapsed. I checked with CommonBond, SoFi, etc. and all the big players seemed to do option 1. College Ave uses Navient as their servicer, and they do option 2. Why is this such a huge deal? Remember that loan repayment programs give you a lump sum of money that you then pay towards your loan. So, when you take your $50k and use it to make a lump sum payment on your refinanced loan, Navient is going to give you credit for covering however many monthly payments that would cover, and won't require a monthly payment until that lump sum has "run out." With any of the servicers that do option 1, you'd have to keep making your monthly payment!

So, here is the strategy. First, figure out if you are going to have a loan repayment program cover your remaining student loans, or if you think it is likely enough that it is worth minimizing the amount you pay on your loans now. Before you use your lump sum from the loan repayment program to pay towards your loan, refinance. Use Credible to get your loan refinanced with College Ave Student Loans, picking their 5-year loan with a 2-year interest-only period. Next, if you have your lump sum already, pay it towards your loan. If not, pay your interest-only monthly payment until you can make your lump sum payment. Once you make this payment, you will have to disable autopay (unfortunately losing your .25% interest rate deduction, but it won't really matter because you likely won't be paying another monthly payment again), otherwise Navient will keep auto-debiting your monthly payment. Then sit back and enjoy paying nothing on your loan since you will put in "Paid Ahead" status. Now, where you go from here depends on the balance of your loans and the nature of your specific loan repayment program. But with the NHSC your initial $50k/$30k in "Paid Ahead" status will keep you payment free by the time your $20k/$10k comes two years later, and so forth.

A few notes: I couldn't find any other lender that would work with this strategy other than College Ave Student Loans, mainly because of their "Paid Ahead" status. I confirmed twice with the servicer Navient that their "Paid Ahead" status worked like this, but I suppose it could change at any time, so you may want to confirm yourself. You can always refinance again with another lender if terms change. To refinance, you could go directly with College Ave to refinance, but if you use my Credible link at the end, you get $200 if you refinance over $30,000 or $100 for less, plus I get a referral bonus from Credible. The process refinancing with Credible and College Ave was painless. I didn't have to upload any documents. The process from start to finish took about two weeks rather than the months it took to refinance with CommonBond (did that for my wife's loans last year) or the months just to get a rate from DRB. Also, you'll want to read the fine print with your loan repayment program to make sure it works like the NHSC (that they are fine with privately refinanced student loans as long as they don't include ineligible loans, and that they pay you the lump sum that you apply to your loan). Finally, I am not a financial advisor, so you should check with your financial advisor before making large financial decisions.

Anyway, I was pretty excited to find this method, which will end up saving me a few thousand dollars. Utilizing the unique characteristics of College Ave Student Loans along with a loan repayment program makes for a killer combo that is about as close as you can get to putting your loans into a permanent grace period.

Well, here is my link to get you started with a $200 bonus for refinancing over $30,000 and $100 for less than $30,000: Credible

Let me know in the comments below if you have any questions or suggestions. Thanks!

3/24/19 Update: College Ave now uses University Account Service (UAS) to service their student loans instead of Navient, but College Ave's website states that they still treat excess payments by putting you in a "paid ahead" status and not requiring a payment until the lump sump payment is used up. Also, I'm now almost 2 years into this, and it's worked out perfectly. I wasn't aware of this strategy until after I received my initial lump sum of $50k, so I had to pay interest-only payments until I received my next lump sum of $20k, but haven't paid a monthly payment since!

Wednesday, March 22, 2017

How to get Insurance to Cover a Home Birth

Introduction

After more than six months and over 20 hours on the phone with insurance (regarding home birth coverage and a prescription coverage related to the pregnancy), I have succeeded in getting our insurance to cover our home birth. Well, they still owe us $87.89, and I’m working on that, but I’ll still count this as a hard-fought win.

I say hard-fought, because at every step of the way, either through incompetence, a lack of familiarity with the process, or intentional obstruction, our insurance repeatedly failed to fulfill their contractual obligation. They failed in a multitude of ways. I was promised multiple call backs that didn’t happen. I was told several times that things would be taken care of when they weren’t. I was given misinformation. Even when I did take a couple steps forward to get another step approved, insurance would usually make mistakes in the reprocessing of claims. Only through sheer persistence was I able to get anywhere. As a dentist, I see many of these same issues with dental claims. The more that an insurance can obstruct either willfully, or by having poorly trained employees, the less insurance has to pay out for claims.

I’m writing this post because I feel that these tactics are an unethical way to treat members and providers and because I feel that members shouldn’t have to spend over 20 hours on the phone over six months to get insurance to pay for a covered service. If it took me, as a healthcare provider with a decent working knowledge of billing, coding, and insurance terminology, this much work to get our home birth covered, I know there are many who have been bulldozed by insurance and given up.

I’ll first go over some terminology important to understand in our situation and with insurance in general, then explain the background for our case, then go through a detailed account of how we got insurance to cover our home birth, and then finally cover general recommendations on getting insurance to cover a home birth.

Glossary

Before I start, it’s important to understand some terminology so that you understand what insurance representatives or providers are telling you, and also so you know what to ask for.

NPI – National Provider Identifier. A number that identifies medical providers.

CPT code – The medical billing code that defines what procedure was done.

ICD 10 diagnosis code – A medical code that defines a medical condition.

Gap exception – Some online sites, and the NY attorney general’s office, refer to a gap exception, although Excellus never used this term. Basically it refers to when an insurance company does not have a participating provider for a covered service and an exception is made to cover an out-of-network provider. This doesn’t insure that they full charged amount will be covered, or whether they will just cover the allowed amount.

Allowed amount – Each insurance has what they call a Usual and Customary Rate (UCR), although these rates are neither usual or customary. Basically, the insurance says that $X is the amount they think should be paid for a procedure. If you see an out-of-network provider, they will only process the claim based on that amount. You would be responsible or “balance billed” for the remainder. In-network providers agree to accept the allowed amount as payment in full, whether from you, your insurance, or a combination. They agree not to “balance bill” you for the difference between the allowed amount and their fee schedule. They agree to this tradeoff so that they get the increased number of patients from insurance.

Up-to-charge – Excellus (and maybe other insurances) used this term to refer to covering something up to the amount charged by the provider. This is in contrast to the allowed amount.

Balance billing – When a provider bills you for the difference between what insurance pays or the allowed amount, and what the provider’s charged amount is. Most or all insurance contracts do not allow in-network providers to balance bill.

Adjust a claim – Reprocess a claim with new information (corrected amounts, as in-network versus out-of-network, etc.).

Insurance adjustment – In-network providers will write off or adjust off the difference between their full fee and the allowed amount since they are contractually required to accept the allowed amount as payment in full. So, on your bill it will often say “Excellus adjustment” on a line and will show how much the office is writing off, or not collecting.

Authorization/Preauthorization/Preauth/Predetermination/PreD/Prior Approval – A request to insurance to approve a procedure, made before the procedure is performed. In this case, requesting an out-of-network provider be covered at an in-network rate was referred to by Excellus as an authorization, or “Pre Service Review for Out of Network Service.”

Member contract/subscriber contract – The terms of your insurance. The contract has important information about the process to get out-of-network providers covered, about deductibles, etc.

Deductible – The amount the insured has to pay before insurance starts paying. Even when you haven’t met your deductible, you get significant savings if you go to an in-network provider because you are only paying the allowed amount instead of the fee schedule amount. Insurances often have a separate in-network and out-of-network deductible. So even if you have met your in-network deductible, if you go to an out-of-network provider, you will be paying out of pocket, and be paying the full fee schedule amount.

Coinsurance – The percentage the insured pays. So if insurance pays 80% after the deductible is met, the insured patient’s coinsurance is 20%.

Background

Now, some background so that you can understand our situation and how it may apply to yours. We had a high deductible plan through Excellus BlueCross BlueShield based out of Rochester, NY, with a $2,600 in-network deductible and a $2,600 out-of-network deductible. After meeting the deductible for in-network providers, our plan covered 85% of remaining costs. After meeting the out-of-network deductible, insurance covered 70% of remaining costs of the allowed amount. Our insurance contract specifically stated that home birth and midwives were covered.

Our home birth fees were $4,640 billed for my wife which covered all prenatal and postpartum care with the exception of Rhogam injections, ultrasounds, and labs, and $660 billed for our newborn which included delivery and two subsequent home visits. Our midwives did not participate with our insurance, and I think they only participate with Medicaid. Despite it being listed as a covered service, there were no in-network midwives that performed home births in the area, or likely anywhere with Excellus. However, I have seen forum posts stating that there are a couple home birth midwives that do participate with insurances in some metropolitan areas like New York City.

Our Experience

What follows is a very detailed and lengthy account of what we went through to get our home birth covered. You can skip ahead to the next section where I explain how I recommend proceeding to get insurance to cover a home birth, but most of those recommendations stem from my experience. Reading through this account, though long, will likely help you understand what you will likely be up against, and will probably save you time in the long run.

We didn’t seek out a home birth, but ended up with a home birth because the providers my wife felt most confident would provide the care she wanted, ended up being home birth midwives. Were there a birthing center nearby, we would have seriously considered that option. In the end, the home birth went extremely well and we have no regrets.

Our midwives gave us some direction on how to start the process to get insurance to cover them as in-network because there are no in-network home birth midwives. They also let us know that it was a difficult process, that insurance typically fights paying, and that often when they pay, it is a small amount. We were given receipts for the care that we could submit to insurance listing the CPT billing codes, the diagnosis, and the amount we paid. Our midwives submitted the requested information to insurance to process the authorization for the birth. However, as a small midwifery practice without a billing person, we were on our own. Given that each insurance is different, that they midwives don’t participate with most insurances, and that insurance is notoriously difficult to deal with, the midwives were understandably not obligated or equipped to help us further through the process. The more time a healthcare provider has to commit to fighting with insurance and the more compromises they make in terms of reimbursement rates, the less they are able to practice the way they feel best.

So, the first step I took was to follow the midwives' instructions to call Excellus’ Medical Authorization Intake team (1-800-363-4658) a month or so before the birth and request a “Level 1 Pre Service Review for Out of Network Service,” specifically a home birth with a certified nurse midwife. I had the NPI (identification number for healthcare providers) and the practice name, but my instructions didn’t tell me what ICD (diagnosis) or CPT (billing) codes were going to be used. The representative wanted those codes, so I had to get those codes from the midwives and call back.

The midwives gave us the ICD code Z34.00 (which is specific for normal first pregnancies) and the CPT code 59400 (global maternity care for a vaginal birth). CPT 59400 is one code that covers all prenatal care (outside of injections, labs, ultrasounds), the delivery, and postpartum care. They also gave us the ICD codes Z38.1 (single liveborn infant born outside of hospital) and Z13.228 (encounter for screening for metabolic disorders) along with CPT codes 99345, 99348, 99349 (home medical visits). Now, I don’t remember exactly what happened here, but I think all the representative wanted was the ICD (Z34.00) and CPT codes (59400) that applied to my wife. After all, this was an authorization that was being submitted to get Excellus to consider covering treatment for my wife by an out-of-network provider. I didn’t end up giving her the ICD and CPT codes that would be billed for our newborn, and this ended up being a problem that I will describe later. Once I gave her this information, she said she would reach out to request information from the midwives. Basically insurance needed to verify the midwives’ credentials, that they have an OB they work with, and that they have liability insurance. The representative was a little surprised that I was initiating the authorization request rather than the provider, which also comes into play later. Anyway, from my understanding this process was both to 1) preauthorize the maternity care by an out-of-network provider (basic medial preauthorization for a major medical procedure), and also to 2) evaluate an out-of-network for coverage at in-network rates since there was no in-network participating provider. At one point a representative told me that those two processes were separate and that after authorization, I would then need to request consideration for the in-network coverage, but other representatives told me it was one process.

Weeks passed and the authorization still showed as pending. So, we called Excellus and a representative stated they were waiting to hear back for more information from the midwives. We then called the midwives who didn’t seem to be aware insurance was waiting for further information. There may have been some miscommunication, but eventually things got rolling again. Insurance apparently wanted to verify one of my wife’s allergic reactions to a medication that was on her medical history, although irrelevant to an un-medicated childbirth, and would not approve it until that happened. Eventually the authorization got approved a couple weeks after the birth. This timing was also significant later.

Somewhere around this time, I had submitted a claim for a Rhogam injection the midwives gave my wife. I was confused to see that even though the midwives charged $122 for the injection, insurance only considered $93 of the charge as the “Allowed Amount.” At this point I realized that this was going to be an entirely separate battle. Even if insurance decided to cover the midwives as in-network, they would likely just consider the allowed amount, which has no relation to the actual charge. Participating providers agree not to bill patients for the difference between their actual charge and the lesser allowed amount that insurance covers. It’s a trade off for providers, but they get the benefit that participating in insurance gives, namely that patients are driven to their practice. Since the midwives are not participating providers, they are not bound by the same rules that a participating provider is, nor should they be, since they derive none of the benefits that the participating provider does.

I spent several phone calls trying to find out what the allowed amount would be for the CPT 59400 code. A couple representatives tried to obstruct saying that they couldn’t get that information (someone has to have it, because Excellus uses it every time the process a claim for that code), that we couldn’t be sure that that was the code that would be billed if the birth had complications and needed to be transferred to a hospital (sure, but I still wanted the allowed amount for that code), and that the reimbursement rates change monthly (fine, but they aren’t going to change that drastically). Eventually I reached someone who was able to do some research and told me that the allowed amount for CPT 59400 was around $1,700. Specifically, she left me a voicemail saying that the estimated amount I would have to pay was $1,700, which couldn’t be further from the case. What she didn’t understand was that because that allowed amount is so low, Excellus would likely only try to pay 85% of $1,700 after the deductible was met, leaving them paying little to nothing. We, on the other hand, would be paying out of pocket for the balance of the CPT 59400 charge ($4,640 - $1,700).

Once I found out how low the allowed amount was, I called Excellus to discuss the matter. I explained to them that it was not our fault that Excellus does not have any in-network providers to perform a covered service, which is largely a result of their low reimbursement rate. As such, we should not be the ones to bear the financial responsibility of Excellus’ inadequate network. The representative at first claimed that the midwives had requested consideration to be covered as in-network providers and therefore would have to accept the allowed amount. I explained that I had been the one to request the midwives to be covered at the in-network rate, not the midwives, and that they had no obligation to accept anything less than payment in full, which we had already paid. Another representative suggested that the midwives could bill more charges to us so that we could submit them to insurance to maximize our reimbursement. When I explained that this was being coded as a global maternity charge that shouldn’t be unbundled, she clarified she was referring to other charges like lactation counseling, etc. I explained that given how low the allowed amount for the global maternity charge was, I was doubtful that additional codes would significantly change the reimbursement. Additionally, the midwives would have to charge for these procedures, which would either have increased our bill from the midwives, or required them to restructure their fee schedule to keep the total amount the same but accommodate these additional charges. I wasn’t able to get a satisfactory resolution at this point, and it sounded like I just had to wait until the claim was processed to fight the low allowed amount.

Meanwhile, the birth had happened on October 20th. At the birth, the midwives gave us two receipts. One was for $4,640 covering CPT code 59400 for my wife and the other for $660 covering CPT codes 99345, 99348, and 99349 for our newborn for the birth and two subsequent home visits for a follow up exam and the genetic screening visit. The $660 receipt had the date of service for the first code, but not for the other two codes because they hadn’t happened yet. These missing dates also became significant later on.

A couple days after the birth, I manually submitted claims for the birth to my insurance using their claim forms. I accidentally submitted our newborn’s claim under my wife’s name, as I overlooked the fact that some of the charges were for my wife, and some were for our newborn. This mistaken submission ended up causing some problems later, even though I resubmitted it correctly a few days later when I realized my error.

At this point, the procedure was done, insurance had the submitted receipts, the authorization was in process, and the procedure should have been covered at an in-network rate, with insurance covering 85% after our deductible was met. Unfortunately, the process was far from over.

A couple days after submission, insurance processed the claim. Since the authorization had not been approved yet, it was processed as an out-of-network provider. Out of the full $4640 for CPT 59400, $1723.47 was the allowed amount. The full $1723.47 was applied to the out-of-network deductible, which is completely separate from the in-network deductible, and insurance paid nothing. Out-of-network providers are not contractually obligated to accept an allowed amount, yet the claim was incorrectly processed to indicate that the provider could only bill us $1723.47.

The newborn charges, which were three home visit codes totaling $660, processed out-of-network with an allowed amount of $178.16. Insurance paid nothing as this was again applied to our out-of-network deductible. The claim also incorrectly stated that the provider could only bill us $178.16 out of the $660. As mentioned earlier, I submitted the receipt which did not have the dates of the second and third home visit since the receipt was given before those happened. So, the claim was actually processed with all three visits on the same date of service, and the second and third home visits had a $0 allowed amount, without an explanation on the claim as to why. It was only on a later call to a representative where I was explained that they were denied because all three were processed on same date of service, so only one was considered. I was told to resubmit with the dates of the second and third visit and the claim would be reprocessed. I resubmitted the claim on November 8th but for some reason that resubmitted claim was not processed until three months later. Several representatives in the meantime were able to see the resubmitted claim and told me that it would be reprocessed, only to have it stay unprocessed.

At this point, the next step was to wait until the authorization was approved and then have the claims reprocessed as in-network claims. When I inquired at this time about the allowed amount versus the charged amount, I was told that the authorization determination would also decide whether the claims were processed at the allowed amount or “up to charge” which meant using the provider’s charged amount as the allowed amount. A couple weeks after the birth, the authorization was approved. I was told on a call November 8th that it was approved to cover the midwives in-network and that claims would be processed up to charge. Given what representatives had told me about the allowed amount, I’m pretty sure that had I not brought up this concern before the authorization was approved, the authorization would be approved using Excellus’ allowed amount. I was told that adjusting the claims and receiving a check from Excellus would take up to 30 days, but no further action was needed on my end.

I was also told that the authorization was only for my wife’s care and not for any of the newborn charges. So, the $660 that was billed for our son for the home visits (including the delivery and stabilization) would not be considered for in-network coverage. I explained that when I originally requested the authorization, the representative processing it said she was familiar with this process and had performed these before, so she should have told me at that time that I not only needed to request an authorization for my wife, but also for our son. I also explained that at the time the authorization was requested, my son was neither born nor had insurance coverage, so I technically was unable to request an authorization for someone who didn’t exist. I explained that I wasn’t positive, but I thought that I had tried to give the original representative more than the global maternity CPT code, but was told that that was the only one needed. Finally, I explained that it would make no sense for Excellus to approve an out-of-network midwife to be covered as in-network to provide care for my wife since there was none participating, but to deny an out-of-network midwife to be covered as in-network to provide care for the resulting newborn. She told me there was nothing she could do, that they would have somehow noted the authorization had I requested the newborn charges to be covered, and that all I could do now was file a grievance for reconsideration.

On November 16th I called in and was told by another representative that the claim for my wife needed to be sent for adjustment, despite being told earlier that it was being processed and nothing was needed on my end.

Finally the claim for my wife got reprocessed about a month later, only to be denied with some error about the authorization. I called that day or a day later on December 12th and talked to a supervisor who said that they had made a mistake and that she was adjusting the claim while I was on the phone, that the full $4640 was the allowed amount, and that I would be receiving a check in a few days for 85% of the balance after the in-network deductible was met. I had her look at the newborn charges, and she said that I should hold off submitting a grievance, but that she would try to escalate things internally to get the newborn charges added to the authorization to be covered in-network. I also explained the issue with the dates missing for two out of the three visits. She was able to pull up my resubmitted claim, which had not been processed despite being submitted over a month ago, and said she would send it to be reprocessed. Finally, I let her know my concern about these charges being covered up to charge and not with Excellus’ allowed amount. She said she’d get back to me. A few days later I received the check covering the proper amount of the CPT 59400 code for my wife. At this point the charges for my wife had finally been processed correctly, two and a half months after being submitted.

Two weeks passed without word from the supervisor regarding the newborn charges. I called on December 27th and was told by her that the resubmitted claim with the dates had still not been processed, and that that had to be done before she requested it to be covered on the authorization. She asked me to call back early to mid January. I called back at that time and the claim had still not been reprocessed. Eventually on January 30th I called in and was told that the supervisor had submitted a grievance that was approved, and that the newborn charges would be covered in-network. The representative wasn’t sure if it was to be covered up to charge or the allowed amount. She assured me that the charges to be considered were the three separate dates of home visits totaling $660, and not all three visits on the same date of service. However, on my end, I had not still not seen any indication that the claim was reprocessed with the correct dates. She told me she would have the supervisor call me back regarding whether the claim would be covered up to charge.

After receiving no call from the supervisor, I saw online that the claim for the newborn charges had been adjusted as in-network. However, Excellus was still using an allowed amount instead of the charged amount, and all three visits were still showing the same date of service and the second and third codes were therefore denied. I called in February 2nd and spoke to a representative who did some research and later called me back assuring me that things had been resolved. She told me that I would be receiving the check for the first home visit up to charge, but then later I would receive a check later for the second and third home visits up to charge also. Additionally, she informed me that the supervisor had reprocessed the newborn charges that I incorrectly submitted under my wife’s name, and that claim was being paid out in an $87 check to me. She told me that I should send that check back to Excellus. I was told that nothing else needed to be done on my end.

I called in February 6th and talked to a representative who routinely would cut me off and explain that he knew exactly how the process worked and that he could resolve any issues for me. I asked him to confirm that I would be receiving a check for the second and third home visit. He told me that those were denied because those charges did not meet clinical guidelines, and that they had to be sent to a different department to be reviewed. I explained that I was told everything was resolved with those charges, but he insisted they were being denied. Eventually I realized that the clinical guidelines he was talking about were that the charges were still all showing the same date of service. He was finally able to manually look up the updated submission from November 8th that had still not been processed three months later. He told me that the updated claim had not been sent to be adjusted as in-network and up to charge (despite being told less than a week earlier that it was all taken care of), and that he would submit it. I asked him about the $87 sent in error, and whether I really needed to send this back or if I could destroy the check. He said I could shred the check. I asked how long it would take for the second and third home visit checks to be processed. He told me it would take 30 days. I advised him that I was not interested in waiting 30 days after waiting for over three months to get this far, and that I would give them some time but would be considering filing a complaint with the Department of Financial Services. At the end of the call he tried to explain to me that when I call in to Excellus, there is no reason to give a long explanation of the problem, because they know how to resolve issues and are able to look up in the documentation to see everything that has happened with the case. I let him know that after three months and almost 20 hours on the phone with Excellus resolving this and a pregnancy prescription issue, I wasn’t confident that was true.

A day later I received a check for 85% of the allowed amount of the first home visit (the date of delivery).

The next day, on February 8th, I called and spoke to the original supervisor who had submitted the internal grievance. She thought that she had resolved the issue. I explained to her that the second and third home visits were never entered in with the correct date despite my resubmission, and that the first home visit was only adjusted to the allowed amount. She adjusted the claims while I was on the phone and told me I would be getting a check for 85% of the charged amount of all three home visits, minus what I had already received.

Finally, it was resolved.

Or not. I received the check a few days later with all that she had told me I would receive, minus the $87.89 that Excellus had mistakenly sent me and then told me I could shred. It was deducted as an “Overpayment Recovery Amount.” I called and spoke to different supervisor on February 15th, explained the situation, and he said that he would send this to the finance department to correct. On February 25th I emailed him to let him know that I still have received no word on a resolution. On February 28th, he emailed back saying he was reviewing my issue. On March 6th I submitted a grievance regarding this outstanding amount. As of March 22nd the issue has still not been resolved, and I’ve had no follow-up from Excellus.

Overall, it took around six months from start to mostly finished. I spent over 20 hours on the phone with Excellus resolving this issue and a prescription drug issue that was related to the pregnancy. Let me share what I’ve learned.

Recommended Steps (roughly in order)

  • Know your insurance contract
    • As you can see from my story, the more prepared you are, the better able you are to anticipate pitfalls and avoid mistakes. Any mistakes that you may make could extend the process significantly.
    • The first part of this involves knowing your insurance contract. Request it from your insurance, or you are likely able to download it from your insurance website after logging in. Find out the following:
      • Is home birth specifically listed as a covered service? Are midwives specifically listed as covered providers? If not, this does not mean you are out of luck, but it certainly makes it easier if they are. Some states may have legislation dictating that home births or midwives are covered, making it a moot point as to whether it is spelled out in your contract. More on that below.
      • What is your deductible? Is there a separate in-network and out-of-network deductible?
      • What is your coinsurance for maternity/prenatal care for in-network and out-of-network providers?
      • What stipulations does your contract have regarding situations when there is not an in-network provider for a covered service. My contract with Excellus had the following under “Access to Care and Transitional Care”:
        • “Authorization to a Non-Participating Provider. If We determine that We do not have a Participating Provider that has the appropriate training and experience to treat Your condition, We will approve an authorization to an appropriate Non-Participating Provider. Your Participating Provider or You must request prior approval of the authorization to a specific Non-Participating Provider. Approvals of authorizations to Non-Participating Providers will not be made for the convenience of You or another treating Provider and may not necessarily be to the specific Non-Participating Provider You requested. If We approve the authorization, all services performed by the Non-Participating Provider are subject to a treatment plan approved by Us in consultation with Your PCP, the Non-Participating Provider and You. Covered Services rendered by the Non-Participating Provider will be paid as if they were provided by a Participating Provider. You will be responsible only for any applicable in-network Cost-Sharing. In the event an authorization is not approved, any services rendered by a Non-Participating Provider will be Covered as an out-of-network benefit if available.”
        • This is an important paragraph to become familiar with. It says that if there is no in-network provider, insurance will approve an authorization to an out-of-network provider. If your insurance benefits specifically list home birth and midwives, you can make the argument that there is no in-network midwife for home births (as long as there isn’t) and that the contract requires they cover an out-of-network midwife for you. If it doesn’t specifically list those benefits, you may need to research if there are laws in your state that require midwives or home births to be covered. New York has such a law, and I’ll cover it below.
        • Note that this paragraph is somewhat ambiguous. Insurance could and will likely interpret covering an out-of-network provider as an in-network provider differently than you will. They will likely try to pay the in-network percentage of the allowed amount for that service. In my case, this would have been 80% of $1723 for the global maternity fee (after the deductible was met), leaving me on the hook not only for the 20% but also anything above the allowed amount, i.e. $4640-$1723. You need to make the argument that the lack of a participating provider in their network is not any fault of you, the subscriber (it is likely due to their low allowed amount), and therefore you should not bear the resulting financial burden. They should treat the entire billed amount as the allowed amount and cover it at the in-network percentage after applying it to the in-network deductible.
      • Does your insurance cover house calls? Our midwives billed the newborn charges as home visits, and our Excellus insurance contract stated:
        • “Office Visits. 
We cover office visits for the diagnosis and treatment of injury, disease and medical conditions. Office visits may include house calls."
  • Know your laws
    • I heard our midwives and our doula state that New York state has a law stating that insurance cannot dictate where you give birth, but I wasn’t able to find out where that was stated. After doing a bit of research on my own, I found the following related paragraph in New York Insurance Law § 4303(c)(1) which I believe applies to managed care organizations, including HMOs and PPOs, but may not apply to employer funded insurances, and may not apply if the insurance is managed outside of New York or covers people in multiple states, but I’m not sure of the specifics (underlining is my own):
      • "(A) Every contract issued by a corporation subject to the provisions of this article which provides hospital service, medical expense indemnity or both shall provide coverage for maternity care including hospital, surgical or medical care to the same extent that hospital service, medical expense indemnity or both are provided for illness or disease under the contract. Such maternity care coverage, other than coverage for perinatal complications, shall include inpatient hospital coverage for mother and for newborn for at least forty-eight hours after childbirth for any delivery other than a caesarean section, and for at least ninety-six hours following a caesarean section. Such coverage for maternity care shall include the services of a midwife licensed pursuant to article one hundred forty of the education law, practicing consistent with a written agreement pursuant to section sixty-nine hundred fifty-one of the education law and affiliated or practicing in conjunction with a facility licensed pursuant to article twenty-eight of the public health law, but no insurer shall be required to pay for duplicative routine services actually provided by both a licensed midwife and a physician."
    • I also found that the Department of Financial Services website has a page with an opinion issued April 13, 2005 by the Office of General Counsel at http://www.dfs.ny.gov/insurance/ogco2005/rg050409.htm. Granted, this is a legal opinion or interpretation of the previous law, but is not itself law. One section reads:
      • "While home births are not specifically mentioned in New York Insurance Law § 4303(c)(1), if supervision of a home birth is within the scope of practice of a midwife, the HMO would have to provide coverage for such services."
      • The rest of the opinion deals with Healthy New York, which is a program to provide affordable health insurance, and may not apply to you.
    • Other states may have laws that work in your favor. New York also may have additional laws, but I was unable to find any beyond what is quoted above. During this process, I reached out to the New York State Association of Licensed Midwives and also to the Health Care Bureau (under the New York Attorney General’s office), but didn’t find that either of them had much more information than I was able to find myself. Had I hit a dead end, I would have worked more with the Health Care Bureau, because I think I would have eventually been directed to someone more familiar with the laws on maternity coverage.
  • Know your area's providers 
    • At one point during this process, an Excellus representative mentioned that they had midwives that participated. I asked if any of them performed home births, because if they did, Excellus would not need to cover our midwives. The representative did not know. Unfortunately, while insurance will have a list of participating midwives, they will likely not know if they perform home births. Most won’t, but the onus may be on you to prove that none of them do. I never got much pushback on this, because I think Excellus knew that there were no home birth midwives that participated. Your home birth midwives will probably know the other midwives in the area that perform home births, and should know if any participate with insurance. But to cover my bases, I looked up all the participating midwives on the Excellus website within a reasonable 50 miles or so and called. It took a couple hours, and I got a bunch of No’s as expected, but at least I had done my due diligence and verified that their were no home birth midwives in-network. You may be fine going off of your midwife’s word that none participate, and if insurance gives you pushback, try putting the ball in their court to find you an in-network home birth midwife.
  • Know your midwife
    • See what recommendations your midwife has in regards to your insurance. Some midwives have a billing person that can handle a lot of this work, many will not. Some midwives may be familiar with insurance and what hoops to jump through, but often providers are as much in the dark with insurance as you are, and many times you as a subscriber can get more done, having more time and motivation, dealing insurance than a provider.
  • Contact your insurance to request home birth coverage in-network
    • Get the CPT and ICD codes that your midwife will be using for both the pregnant mother and the newborn, along with the midwife’s office address, fax number, and NPI. Approximately two months before the due date, contact your insurance and let them know you are planning on having a home birth, that there are no in-network providers (if that is the case), and that you would like to request an out-of-network provider to be covered in-network. This may be called a gap exception, depending on the terminology used by your insurance. Some midwives may start this process for you, but we initiated this request, and because we did, I was able to counter an insurance representative who at one point argued that since the midwives were requesting to be covered in-network, they were agreeing to accept the allowed amount. Since I had requested the authorization, I explained this wasn’t the case, and the midwives had no obligation to accept less than their fee schedule. I’m not even sure if what the representative said would be true if the midwives initiated the request.
    • Make sure that you are requesting the CPT codes for both the pregnant mother AND the baby. This may be difficult, because the baby doesn’t legally exist yet and is not covered by insurance. Be clear with insurance that you are requesting both the charges for the mother and newborn to be covered in-network. If you know there will be any other procedures outside of the birth, for instance a Rhogam injection, you might as well include the CPT code for this.
    • When you are making this request, specify that you are requesting the charges to be covered at the provider’s fee schedule rates, not at the insurance’s allowed amount. Excellus called referred to this as being covered “up to charge.” The person you are initiating this request with may not know anything about this, or how this is handled. They may give you pushback as they did me. You may also have to wait until the approval is granted to find out whether insurance has decided to cover at the allowed amount or the fee schedule amount. If they tell you they are using an allowed amount, explain that you should not bear the financial responsibility for the fact that the insurance does not have a robust enough network to have an in-network home birth midwife. It is not your fault, therefore you should not have to pay the difference between the allowed amount and the billed amount. The strength of your argument will depend on your state laws, if home birth is listed in the contract as a covered service, and the wording of your contract’s stipulation on what happens when there is not an in-network provider. You want to get this issue of allowed amount versus billed amount sorted out before you submit the claim. 
    • With Excellus, this authorization step consisted of calling the Medical Authorization Intake Resource Team at 1-800-363-4658 and requesting a “Level 1 Pre Service Review for Out of Network Service.” You will need the CPT codes and ICD diagnosis codes for mother and child, as well as the midwife’s name, office address, fax number, and NPI number.
  • Get insurance coverage for the newborn
    • Once the birth happens, contact your HR department at work or contact insurance to get your newborn active on your insurance. Submit the paperwork that work or insurance requires to get your newborn covered added to your plan. You have 30 days to enroll your baby under your insurance, but once he is active it gets backdated to when he was born. Make sure he is covered before submitting your claim, or it will be denied and will need to be reprocessed/adjusted later.
  • Submit your claims
    • Download or obtain the form to manually submit your claims to insurance. The form should tell you what is required on the receipt, including ICD and CPT codes, dates of service, name, address, NPI, etc. Make sure everything is in order before you submit:
      • Are the ICD diagnosis codes and CPT codes on the receipt?
      • Is the midwife’s name, address, NPI on the receipt?
      • Is there a date of service on the receipt? Are all dates of service filled in? Our midwives gave us a receipt at birth for the newborn that had the dates of service blank for the 2nd and 3rd home visit, because they hadn’t yet happened. I submitted this to insurance without catching this, and three CPT codes were all incorrectly processed on the same date of service, leading two of the three to be denied. Make sure these are all filled in. Preferably, ask the midwives for the receipt after the home visits are completed so that the date of the receipt is after all the dates of service. One representative I talked to said that it may be a problem that my receipt had the date of the bill as being before the dates of the 2nd and 3rd home visit. She told me providers are not able to bill before a procedure is performed. This didn’t end up being a problem, and I didn’t need to request a new receipt, but it could be for you.
      • Is the newborn active under the insurance?
      • Are you submitting two separate claims, one under the mother and one under the newborn? I accidentally submitted both under my wife, and it resulted in denials and other unforeseen problems. 
      • Is your gap exception or authorization approved? I submitted while ours was still pending, so the claim got processed as out-of-network and had to be adjusted when the authorization was approved.
      • Have you confirmed that insurance is going to be covering up to the billed amount and not using an allowed amount? Otherwise the claim will get processed and you may have a harder time fighting once you’ve been paid. It is better to have this issue squared away before the claim is submitted.
    • The goal is to submit the claims once, and have them processed once. 
    • Excellus’ claim form is on the website under Claims > Submit a Claim, and can be uploaded electronically.
  • Wait
    • It may take days to a whole month for the claim to get processed after submitting online. When the claim is processed, make sure it is processed correctly:
      • Did the claim get processed up to charge, or to an allowed amount?
      • Did the claim get processed in-network with the correct coinsurance (i.e. 15% coinsurance rather than the 30% that an out-of-network charge would be, or whatever your specific plan’s numbers are) and did the correct amount get applied to the correct deductible (in-network, not out-of-network)?
  • Call to resolve problems
    • If, or rather when your insurance gives you pushback or incorrectly processes something, call. You can try to be nice and give the 1st tier representative a chance to resolve your issue, but often times they don’t deal with cases this complicated and don’t have the authority to get things done. So, it may be better off just asking to speak to a supervisor.
    • With Excellus, I had to walk them through every step of this process. More often than not, when something happened to the claim, it happened incorrectly. So I needed to stay on top of what was happening. I did not get callbacks, nor did things get resolved when I was told that everything was resolved. When representatives told me that no further action was needed on my part, I often found that further action was needed on my part. I found that supervisors (I believe they call them lead representatives with) were able to process claims while you were on the phone, whereas the 1st tier representatives could not, and usually told you things would take up to 30 days. So, if you don’t need to use a supervisor, great, but you probably will.
Notes:
  • Document every call to insurance. Ask for the representative’s name and the call reference number. Excellus representatives will only give you their first name and first initial of their last name. Keep a log of when you called, who you talked to, and the call reference number. You will likely have to refer to these in future calls. These are also helpful if you need to file a grievance. If you forget to get a call reference number, you can call back and ask for the call reference number of a previous call.
  • If you need to, file a grievance with your insurance. With Excellus, you can even file a pre-service grievance before the birth takes place (but wait until the authorization is approved or denied), which may be helpful if you get stonewalled about the allowed amount versus billed amount issue. The grievance process is outlined in your contract. There are specific timeframes depending on what type of grievance or plan, but with Excellus they make a decision within 15 days of receipt of your grievance for pre-service grievances, and within 30 days for post-service grievances. You’ll want to confirm the address if you have Excellus, but for me the process was to send a letter to:
    • Customer Advocate Unit
      PO Box 4717
      Syracuse NY 13221
    • Make sure you include documentation of representative names, call reference numbers, dates, specifics of your contract, and applicable laws, etc. If your grievance gets denied, you can file a grievance appeal to take it one step higher within your insurance. If that gets denied, you can file for an external appeal.
  • If needed, enlist help. This issue falls under a couple different governmental departments. You will likely have to have had something denied or processed unfavorably to get someone external to help. I tried contacting some of these numbers before the birth and before the authorization was approved because I was getting a lot of pushback from Excellus, but was told that I needed to have the claim filed and processed before anything could be done. Here are some contacts for New York. There is also a whole page of contacts for New York state residents at https://www.health.ny.gov/health_care/managed_care/complaints/:
    • Health Care Bureau under the New York Attorney General’s office
      1-800-428-9071
    • New York State Department of Health’s Bureau of Managed Care Certification and Surveillance
      1-800-206-8125
      managedcarecomplaint@health.state.ny.us
    • New York State Department of Financial Services’ Customer Assistance Unit
      1-800-342-3736
    • You may also contact your employer’s benefits department and ask them to advocate for you with their representative from the insurance company. Your company pays insurance to cover its employees, and wants to know they are getting their money’s worth.
    • You may also tweet at your insurance company. Many companies have dedicated social media teams that can escalate issues if you contact them. Towards the end, I sent a tweet at Excellus, and they responded back asking me to send them an email. However, I ended getting things to move forward again over the phone, so I didn’t end up emailing them.

Conclusion

As both a healthcare provider and a healthcare consumer, I’ve unfortunately seen a fair amount of obstruction from insurance companies as a measure of cost control. I’ve also seen a lot of human error, and poorly trained representatives.

On the one hand, our home birth was expensive for insurance to cover at the fee schedule amount of $5,300 when compared to the roughly $2,000 that would have been considered for a participating provider. So it’s logical that insurance would not be thrilled covering this amount. However, their low reimbursement rate for participating providers is one of the main reasons there are little to no home birth midwives that participate. The financial burden of the tradeoffs that stem from their low reimbursement rate should not be shifted to the member, particularly when home birth is listed as a covered service. Insurance cannot have their cake and eat it too.

On the other hand, given the significantly higher percentage of births performed by Cesarean when you compare hospital deliveries to home births and control for risk levels, combined with the substantially higher cost of such deliveries, and considering that a home birth requires no facility fees, homebirths likely save insurance companies money. When you consider this, you could say insurance companies want to 1) reimburse participating providers at a very low rate, 2) have members who decide to pursue home births cover any additional cost beyond their low reimbursement rate, and 3) benefit from the cost savings of less expensive vaginal deliveries and non-existent facility charges. Basically, they want to have their cake, and then eat it twice.

Hopefully this lengthy account of our experience and my recommendations is helpful to others pursuing a home birth, whether you are in upstate New York and covered by Excellus, or across the country with another insurance provider. Feel free to comment or ask questions.

Friday, May 3, 2013

Healthcare and Billing Practices


I just got my tonsils out two days ago and will be graduating dental school in a couple weeks, so I've been thinking a bit about healthcare lately. I just got a bill today from an ENT. I had gone to the ENT to have her look at my tonsils. In the process of the exam, she checked my ears (not my chief complaint). She said something along the lines of "Hold on, I'm going to just get a bit of earwax out," swung some sort of scope over, and within a minute the earwax was removed and the exam continued.

At the time I thought to myself, "That's a nice gesture. She saw something that needed taken care of that I wasn't really aware of, and she did it." Then the skeptic in me thought, "I wonder if I am going to be billed for that." Sure enough today I got a bill showing that $179 was billed to the insurance, while only $55.03 was allowed. Since I hadn't met my deductible, my portion was $55.03.

Alexia and I were just talking the other day about how odd it is that providers bill a large amount and then it always seems to be adjusted to a "contractual discount." So is the insurance shortchanging the provider by reimbursing less or only allowing a lower amount to be billed? Or is there fee inflation going on causing uninsured people to subsidize the contractual "discounts" insurance companies have?

Furthermore, should you as a provider inform patients of every fee they are going to get charged with? I struggle with this as a dental student. Do you inform the patient about the cost for radiographs and give them an option as to whether they want to get them or hold off for another six months, or do you make your opinion and perform the procedure? Will you be stuck with indecisive patients, who may be unable to understand and weigh the cost/benefit of a preventative radiograph vs. a possible cavity? Should a patient be financially counseled before all billable procedures? And what about billing not for service, but for complexity/time spent plus materials like a mechanic? My procedure to me did not seem like a $55 ear wax removal, certainly not a $179, but then again, I can't judge ENTs, the cost of equipment, cost of schooling, and complexity of procedures.

I guess overall the question is, what level of autonomy and trust should patients be given in their health care? As a patient, I feel capable with my medical knowledge, and the resources available to me, to be fairly autonomous in my cost/benefit analyses and to largely decide what I should and shouldn't have done if given the appropriate diagnoses and professional opinion. Many others may feel differently and may prefer to have the provider take the wheel. However, overall I am in favor of more transparency on pricing, procedures to be performed, potential risks, and especially complications that happened during the procedure, so that the power is in the patient's hands. If the patient decides that they would like to be less involved in the process, at least they were informed.

The difficulty with this is the implementation. I've heard of providers posting prices online, which sounds like a good idea. I feel like there needs to be some informed consent from a financial aspect where the patient either agrees that he or she will either not be aware of every billable procedure before it is performed, or where they are provided with prices and indicate that they would like to be informed of what procedures will be happening and that the onus is on them to get involved if they have a concern. Ultimately, providers shouldn't be expected to unreasonably compromise care because a patient wants to apply their Slickdeals mindset to their healthcare, but I think patients are currently losing a battle against autonomy, confusing medical codes, and convoluted insurance practices. What do you think?

Sunday, January 8, 2012

Free Insulated Chicken Coop Plans

My big project of the year, actually of my lifetime (at least in the building category so far), was to build a chicken coop. Alexia talked about wanting chickens last year; I wasn't as thrilled. But, eventually I realized she really wanted them, and so I got on board. She called our borough, and they said we could have 5 animals. So, now we have one dog and four chickens.


Our first step was designing the project. I suggested we design it on the computer before putting it together in real life. Honestly, I wouldn't have a clue where to start otherwise. I also wanted to put together a design we could share with others, since most of the designs we found online weren't free. Alexia started working in Google SketchUp and got the frame together. Since I'd be doing most of the building, I took it from there. She was the one who had checked out and read several chicken raising books from the library, so she served as my advisor for the project. I'd tell her what I was planning, and she would tell me about insulation, ventilation, height of roosts, etc. Designing the project took a while since we had to learn SketchUp, but I was happy with it. It is based on a popular design called the playhouse coop, which has plans available online. Making our own plans allowed us to customize the design. Our plans appear to result in a more costly and complicated coop, but the coop includes insulation, gives the chickens more room in the actual coop itself, and is customized for our automated feeding, door opening, and watering. We designed the coop to house 4 chickens comfortably. Besides those two plans, there are several other plans available online if you look in the right places. There are also plenty of pictures of chicken coops on BackyardChickens.com to at least give you some idea of the possibilities out there.

Alexia did some scrounging online and found some free wood. We borrowed a truck, broke the wood down enough to fit it in the bed, and brought it home. It saved us quite a bit of money since plywood is expensive, but we still needed to buy a lot of 2x4s. Then Alexia spent a lot of time sanding the wood to prepare it for sealing. Eventually I had a 3 week break from school and started to hit this project full time. It wasn't long before I got the frame together. That was the easy part.


After putting the frame together, I sealed it with a natural sealer. We wanted to go non-toxic since chickens have the tendency to peck indiscriminately and we'd be eating their eggs, however, in the end I'm not so certain this was necessary. All the surfaces available to the chickens (all 2x4s and the inside of the plywood when I put them on) were sealed with AFM Naturals Clear Penetrating Oil. The rest of the plywood surfaces I coated with generic clear sealer from Lowe's. I like the non-toxic sealer, but it required a lot, and it was rather expensive (over $70 a gallon). I think I used over 2 gallons.


Then I started to cut the plywood and screw it on. This part was tricky since I had to do two of the walls in parts because my plywood pieces were not big enough. It was also a lot trickier because we were double-walling the sides and insulating. Some say this isn't necessary, but since we weren't planning on having a heat lamp out there and it gets pretty cold here, we wanted to play it safe. Alexia found some free insulation on Freecycle that did the job nicely.



After the plywood and insulation was placed (I sealed the plywood as I put it up) and the removable plywood floor was installed (works better in theory, as it's a little difficult to get it to slide out without scraping it clean first), I installed the roof. Our landlady had some corrugated fiberglass material that worked wonderfully. I secured it with screws that included rubber washers and caulked the seams. Then I improvised and made a roof cap.

As for the enclosure, everyone up to snuff on chicken keeping seems to advise against poultry fencing and recommend hardware cloth. The problem is that poultry fencing doesn't keep predators out, hardware cloth does. Unfortunately, it is expensive. However, I designed the coop dimensions just right so I was able to get it done with one 50' roll. I then placed a larger mesh apron around the coop that I stapled down to stop digging predators.



That's basically the bulk of the coop. As for the chickens' amenities, here's how they are living. They've got plenty of roosting area in the coop. The feeder is designed to hold a lot of food and is filled from a hatch on the outside. Once we gave away the rest of the chickens we raised from chicks to get down to the 4 we kept, I only needed to refill it once a month. The side of the feeder has a clear plastic window to indicate the level. The waterer is a 6 gallon bucket with nipples screwed in to the bottom (used some teflon tape). For the winter I dropped a thermostatically controlled birdbath deicer. So far, it's been working beautifully. I also only need to refill this once a month. The chickens have two nesting boxes accessible from the outside for egg collecting. Oddly enough, I've noticed

that they are segregating themselves by color of eggs. Blue egg layers on the left, brown egg layers on the right. We've got latches on all the accesses, two windows that are secured with hardware cloth put have plexiglass windows you can slide in for winter. The coop has plenty of ventilation that comes out underneath the sides of the roof. We also have a solar panel which charges a marine battery. This powers a timer that opens a plexiglass door every morning closes it every night. The panel, timer, and battery are available here, and the motor is available here. Finally, I installed a hanging CFL on a timer to extend the days in the winter by coming on at 3AM to keep the chickens laying through the winter. Unfortunately the solar panel and battery only have enough power to run the automatic door, while the CFL and birdbath deicer run off an extension cord. I couldn't find any suitable solar solutions to prevent water from freezing. Solar powered lighting was a bit more feasible, but since we ended up running an extension cord out to the coop for the light during the winter, I figured there was no point in investing in a solar powered lighting which would only be necessary in the winter.























This project took about 10 times longer than I thought it would. However, getting our first eggs was so rewarding. I think a lot of that had to do with all the work I put into it. Which is probably why I am the one that collects the eggs each day out of excitement (sometimes checking multiple times a day). We get 3-4 eggs a day, and the chickens seem happy.



















You can download the model from Google SketchUp's 3D warehouse. You will need SketchUp to view it. Let me know if you end up building it or have any comments, questions, or suggestions. Thanks!

Wednesday, November 23, 2011

Eliminate Fast User Switching by Using an Applescript to Toggle Preferences

Alexia was a PC. I'm a Mac. However, when moving into our house after getting married, her PC bit the dust. So, eager to spread the gospel of Apple, I transferred her stuff over to my Macbook Pro.

However, as productive as Hot Corners can be when you are familiar with them (me), they can be equally frustrating to someone who is not familiar with them, nor has any intention of becoming so (Alexia). I like to tap to click sometimes, she doesn't. I have switched over to the natural scrolling of Lion, she is still using the unnatural(?) scrolling of Snow Leopard.

So, to make it work, I set up different profiles. While these allowed us to keep our individualized settings, it also had its drawbacks. Fast user switching is still not fast enough. You have to click on the name, select your name, type your password, and then wait for the cube to rotate to your profile. It was also a pain when restarting, because you were prompted for your password to confirm that the other user's programs would be terminated (also a problem if they had something open they didn't save). I also had a background program that would often crash while switching profiles. Finally, I have yet to figure the best way to share an iTunes library (and iPhoto is even worse). Permissions would always get wonky and the iTunes library file would be locked.

So today I made all that change. I had never Applescripted before, so I relied heavily on piecing code together from here and there. The Frankenstein that I ended up with was exactly what I wanted. I have a quick application called Switch that toggles back between my "preference profile" and my lovely wife's profile simply by switching the individual preferences back and forth. Run it once, and it turns off Hot Corners, tap to click, and natural scrolling, while displaying a Growl notification that Alexia's profile is now activated. Run it again, and you're back to mine.



The Hot Corners are toggled using some code that edits the plist files. I borrowed this code from a script called Lava Corners Switch. The Growl notification code is adapted from the Growl website (which I just noticed the other day is now in the Mac App Store. I declined to buy it because... how much more can Growl be improved? It gives me messages, that's great.). The toggling of the natural scrolling is implemented with UI scripting (so you have to enable access for assistive devices) and comes from commenter fireshadow52 on stackoverflow.com. I added the tap to click toggling. And finally, the method testing to see if an app is running came from CodeSnippets. Then I just grabbed a nice icon from the web and slapped it on there.

To get this running, copy the code into a new Applescript. Save it as an application and throw it on your dock. Set all your settings, and then run the application to toggle all of your Hot Corners off, and switch those other two trackpad settings. Obviously individuals will need to tweak the settings they want changed, and that will take some digging online. If you use it, let me know how it works. And if there is a better way to do any of this, feel free to enlighten me.

As a side note, it amazes me how much some people know out there. I'd like to think of myself as pretty computer savvy, especially compared to those I interact with daily, but my progress to this point can best be described as blindly stumbling for hours. The knowledge of some out there is very impressive. Anyway, I hope this helps. To me, this will be so much better than multiple logins.


-- List of properties for hot corners. Just set your hot corners and it will toggle back and forth between those settings and being disabled
property tl : 1
property tr : 1
property br : 1
property bl : 1
property runs : 0

if appIsRunning("GrowlHelperApp") then
tell application id "com.Growl.GrowlHelperApp"
-- Make a list of all the notification types
-- that this script will ever send:
set the allNotificationsList to ¬
{"Switch Notification"}

-- Make a list of the notifications
-- that will be enabled by default.
-- Those not enabled by default can be enabled later
-- in the 'Applications' tab of the Growl preferences.
set the enabledNotificationsList to ¬
{"Switch Notification"}

-- Register our script with growl.
-- You can optionally (as here) set a default icon
-- for this script's notifications.
register as application ¬
"Switch" all notifications allNotificationsList ¬
default notifications enabledNotificationsList ¬
icon of application "Switch.app"

-- Indicate which user or profile is now running
if runs = 1 then
notify with name ¬
"Switch Notification" title ¬
"Profile Activated:" description ¬
"User 1" application name "Switch"

else
notify with name ¬
"Switch Notification" title ¬
"Profile Activated:" description ¬
"User 2" application name "Switch"
end if

end tell
end if

-- Stores existing hot corners as properties for next toggle
if runs is 0 then
set tl to do shell script "defaults read com.apple.dock wvous-tl-corner"
set tr to do shell script "defaults read com.apple.dock wvous-tr-corner"
set bl to do shell script "defaults read com.apple.dock wvous-bl-corner"
set br to do shell script "defaults read com.apple.dock wvous-br-corner"

-- Disables hot corners
do shell script "defaults write com.apple.dock wvous-tl-corner -int 1; defaults write com.apple.dock wvous-br-corner -int 1; defaults write com.apple.dock wvous-bl-corner -int 1; defaults write com.apple.dock wvous-tr-corner -int 1; killall Dock"
set runs_A to 1
end if

-- Sets hot corners back to existing values
if runs is 1 then
do shell script ("defaults write com.apple.dock wvous-tl-corner -int " & tl & "; defaults write com.apple.dock wvous-br-corner -int " & br & "; defaults write com.apple.dock wvous-bl-corner -int " & bl & "; defaults write com.apple.dock wvous-tr-corner -int " & tr & "; killall Dock")
set runs_A to 0
end if

-- Initializes the trackpad preference pane
tell application "System Preferences"
set current pane to pane "com.apple.preference.trackpad"
end tell

tell application "System Events"
tell process "System Preferences"
-- Toggles between natural scrolling and unnatural(?) scrolling
click radio button "Scroll & Zoom" of tab group 1 of window "Trackpad"
click checkbox 1 of tab group 1 of window "Trackpad"
-- Toggles tap to click on
click radio button "Point & Click" of tab group 1 of window "Trackpad"
click checkbox 1 of tab group 1 of window "Trackpad"
end tell
end tell

quit application "System Preferences"

-- Keeps track of where you are at in the toggle
set runs to runs_A

-- Call to make sure growl is running
on appIsRunning(appName)
tell application "System Events" to (name of processes) contains appName
end appIsRunning

Thursday, September 1, 2011

How to re-web your own Chacos

My 5 year old Chacos which I purchased for 40 bucks had seen better days. The soles were peeling off. So I sent them in and got them resoled under the warranty for free. Yipee! It was then that I realized that the webbing was fraying through. I called to see if this was covered under the warranty, but they said it most likely wasn't. They needed to see them first.

Not wanting to spend another $8 to ship them off, certainly not wanting to pay $36 bucks to have them re-webbed, and knowing that my brother had successfully re-webbed his own Chacos, I started my project.

You will need:
  • A torch, or matches, or some heat source to melt the ends of your webbing
  • About 10' 3/4" wide tubular webbing (costed me a little over a quarter a foot)
  • A medium sized needle
  • Strong thread (I had to go to Jo-Ann Fabric and Craft for upholstery thread)
  • A knife
  • Scissors
  • A few hours
Here are pictures of the beginning and the end, and then how I did it.



1. Remove the bar tack stitching that connects the main strap to the inside heel riser (the ones between your feet, not on the outside). I just replaced the main strap as my heel strap and buckle straps were fine, as I assume most are. But those seem replaceable too, you just need to take off the chaco logo.

The bar tack stitch also has a straight stitch underneath. So I took a knife and cut the side to side bar tack stitch, and then pulled the thread out with my leatherman. Be very careful that you don't cut any of the heel riser webbing. Take your time so you are just cutting stitches. After the bar tack is gone, you need to cut the straight line of stitches holding the strap in.


2. Cut the end of the webbing you just removed from the heel riser at an angle and fuse it with a torch. Cut the end of your new webbing complementary and fuse it as well.


3. Thread your needle and sew the two ends together well. You want to butt the ends together, not overlap. Make sure it is very secure. Otherwise the connection may break while it is being threaded through, and then you will need to cut through your sole to finish the repair.

To sew it together, I took 10 inches of thread, and threaded 2 inches through the eye of the needle. Don't tie a knot anywhere in the thread. Just sew 4 or 5 times through the smallest bite of webbing on a corner of one of the pieces. Once you have this anchor, just keep looping over that seam between the pieces. I went from one end to the other, and then back and anchored again like I did at the start. Then snip the pieces. You may want to double this if you aren't sure it is strong enough or if you don't have heavy duty thread (I'd recommend upholstery thread, which is 100% nylon and doesn't fray). Trim any protruding corners that may impede threading this seam through your sole.


4. Now pull, and pull hard. You need to pull your new webbing through the whole webbing pattern. You may need to find the right angle of pull so that the webbing moves and you don't tear your foot bed apart. Check your stitching after each pass so it doesn't fall apart on you.


5. Now that it is all the way through, snip off the old webbing by cutting your new webbing at a right angle right after the seam. Fuse the end. You can now cut the other end of your old webbing and disconnect it from the buckle. Note how it is attached, because you will be replicating that.

6. Sew your new webbing on the buckle like the old webbing was sewn. Again, thread the needle, pass through the same bite (as much as you can, you just want to concentrate your stitching on the smallest possible piece of webbing) several times, and do your best to replicate a bar tack stitch (what was there originally). With all the stitches in this project, I did it twice, with about two passes each. So I would anchor, go from one side to the other and back, anchor again, and trim the thread. Then I repeated the process. That way if one stitch breaks, you have a backup.


7. Now, put the sandal on your foot and adjust all the straps just like you normally would. Mark about where you should cut the other end of your new webbing, and cut it at an angle (it comes out of the heel riser at about a 45 degree angle). Fuse the end.

8. Slide the end into the heal riser, thread your needle, anchor, stitch two passes, anchor, trim. Repeat. You've finished repairing one sandal, now do the other.


9. Enjoy the re-webbing job that cost you under $10

I was pretty pleased with the result. My only complaint is that my new webbing is a little softer and floppier than my original webbing so it takes a bit more effort to put them on. The original webbing is tubular, but it looks like it may be stitched flat. It may stiffen up it time, or perhaps wax or a rosin could help it out.

Let me know if you have any questions.


Tuesday, July 19, 2011

2 Seconds

-- The amount of time it took me to pause at the trashcan and decide that feeding the chickens my leftover chicken was not right. I threw it away.

Monday, July 11, 2011

Drone

....and I got a Parrot AR Drone for our anniversary. It is pretty much awesome. Except for the fact that it is a little out of commission while I wait for repair parts:-).

Chickens

I'd say two posts in one day, but technically my last post was started yesterday. Alexia and I currently have 17 chicks living in our basement bathroom. There are 5 Cuckoo Maran pullets that lay a dark brown egg, 4 Ameraucana pullets that lay blue/green eggs, and 8 Rhode Island Red (we think) roosters that were included in the box to keep the girls warm during the shipping process.

I spent my three week school break working non-stop building a chicken coop. I'll put up some pictures when it is finished. But the end goal is a 5x8 coop to keep 4 hens in for egg laying. The funny thing is we don't eat many eggs, but I guess we will learn to. You can blame this all on my wife to, she's from Portland:-). No, it has been fun. I originally wrote "really" before "fun" but took it away because it has been hard work too. But fun hard work.