Uninsured

Trump and Congress Tried to Make Coronavirus Testing and Treatment Free, but People are Still Getting Big Bills when They Go to the Hospital

Maria Montecillo Leave a comment

In the early stages of the pandemic, the rules regarding insurance and patient billing for a suspected or confirmed COVID-19 diagnosis were not very clear. One must do his/her due diligence in asking your own insurance company how they will be processing a claim. Many provider billing departments send out invoices automatically via computer. Make sure you check your invoices carefully, as Coronavirus testing and treatment should be “free.” What this truly means is “no out-of-pocket costs or cost-sharing” for the patient.

Kimberly Leonard – Businessinsider.com – 5/21/20

The Trump administration set up a fund for the uninsured. But Imad Khachan, a coronavirus patient who is uninsured, received a large medical bill after a hospital stay.
– Congress and the Trump administration tried to protect coronavirus patients from getting large medical bills, but problems are popping up.
– Two patients who tried to get treatment for coronavirus symptoms didn’t get tested, but still received large medical bills.
– One uninsured patient living in New York City got a nearly $50,000 bill after a three-night hospital stay for coronavirus care.
David Anthony in New Jersey received a $1,528.43 bill for a chest X-ray.
Lindsay Hill in Milwaukee spent 30 minutes in a triage tent and later received a $1,186 bill in the mail.
Imad Khachan from New York City received a bill for nearly $50,000 after a three-night hospital stay.
Patients who seek medical attention for COVID-19, the disease caused by the coronavirus, are not supposed to be getting large charges like these.
President Donald Trump signed two measures into law to protect patients with the coronavirus — and those who seek help because they fear they have it — from having to pay for testing and treatment. His administration is also letting hospitals bill the government directly for coronavirus testing and treatment for the uninsured, instead of charging patients.
But the changes aren’t happening seamlessly. Whether because of bad timing, an incorrect billing code, or being unable to get tested, documents sent to Business Insider show patients who sought medical help for the coronavirus are still facing big bills.
Business Insider previously reported on loopholes in the laws that were passed to protect patients from big medical bills related to the coronavirus. Michael Santos, for instance, received a $1,689.21 bill after unsuccessfully seeking a coronavirus test and getting a flu test and X-ray instead. His insurer decided to cover the cost of his emergency department visit after Business Insider inquired about it.
Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, said part of the reason patients are still getting large medical bills is that healthcare providers are “dealing with a whole bunch of new payment options.” On top of that, she said, there are loopholes in the new laws and regulations.
“It’s going to result in a significant amount of confusion on the consumer end,” she said, adding that “people’s fear of bills could deter them from seeking care.”

Uninsured small businesman in NYC gets COVID-19

Khachan, 56, the patient in New York City, spent three nights at the end of March in the hospital being treated for the coronavirus.
Khachan owns a chess shop called the Chess Forum in Greenwich Village that has been shut down since March 20. He had been covered by private health insurance until Dec. 31, 2019, but had foregone coverage for 2020 because of cost.
On March 24, while still in the hospital, Khachan paid the hospital $5,000 out of pocket for care, according to a receipt he received from Northwell Health, the health system the hospital belongs to.
“Everyone in the hospital was extremely kind and nice and wonderful and the hospital itself is a great medical facility that offers great medical care,” Khachan said in an email to Business Insider.
A couple of weeks after he was discharged, he was stunned to receive a bill for $47,915.20. He also received several other smaller bills for treatment and tests, as well as a $788.50 ambulance bill. He said he couldn’t afford the bills and had expected to pay roughly another $5,000.
In a later email from the hospital that Khachan shared with Business Insider, Lenox Hill said he owed a lower amount of $32,864.20.
Khachan appeared to be a victim of bad timing. He received his bill before the Department of Health and Human Services set up a website where hospitals can request reimbursement for coronavirus testing and care for the uninsured.
The administration announced the fund for the uninsured on April 22 and the website wasn’t up until May 6, which was after Khachan received medical care and his first bill. Payments from the federal government to hospitals started going out May 18, according to the Trump administration.
Under the fund’s rules, hospitals can get paid for anyone who is uninsured who received testing or care for the coronavirus starting on Feb. 4. Hospitals aren’t obligated to use the fund, and it is not yet clear how many will choose to participate.
Terry Lynam, a spokesman for Northwell Health, said the hospital first had to enroll to use the online portal, which took a few days, and then started filing claims for uninsured coronavirus patients on May 14.
Khachan’s claims would be included, meaning he won’t have to pay for the medical care and will be refunded his $5,000 deposit, Lynam said. Northwell plans to call Khachan to double check his information and will send the check before the end of this week, Lynam said.
Hundreds more patients were uninsured and treated for the coronavirus at Northwell’s hospitals alone. Bill Fuchs, who oversees billing at Northwell, said so far its hospital system filed coronavirus claims to the government for roughly 800 uninsured patients.
The hospital system said it’s also instituting a 60-day hold on all patient bills, which prevents them from being turned over to collections. The hold can be renewed depending on financial hardship.
As for the bill for the ambulance, which was provided through the New York City Fire Department, that won’t be covered by the federal uninsured fund, because the department isn’t eligible to use it, a spokesman for the department said.
Federal health officials won’t say how much money they set aside for the uninsured and it’s not clear whether the funding will be adequate at a time when nearly 39 million people have lost their jobs — and, many of them, the insurance that came with them. The Kaiser Family Foundation estimated that the cost of treating uninsured patients with the coronavirus could land between $13.9 billion and $41.8 billion.
Linke Young from Brookings said people with the coronavirus who have smaller bills were likely to pay them rather than contest them under the new rules because they don’t know about the federal fund for the uninsured.
She said she would advise patients to call the hospital or doctor’s office and explain why they believe the provider is entitled to reimbursement from the federal government, and for the patient to ask the provider to pursue that option.
“There is nothing that tells providers they can’t bill the consumer first,” she said.
“These funds didn’t use to exist and providers were just doing what they have always done — sending bills,” she added.
Patients sought help for coronavirus but ended up with no answers and big bills.

Patients are getting billed in other instances
Anthony, 34 — who asked to use his middle name for this story to protect his family’s privacy — did a video visit on March 23 because he feared he had the coronavirus after he had chest pain that lasted several weeks and spread to his abdomen. His doctor recommended he get an X-ray, so he did.
He didn’t receive a coronavirus test and, after examining the X-ray, the doctor told him he likely had inflammation in the lungs and advised he take Advil.
A couple of weeks later, Anthony got a $52.94 bill for the online consultation. A couple of days later he received a bill for $1,528.43 for the X-ray. He was confused about the telehealth bill because he had understood all virtual visits were supposed to be covered without a copay — a change his insurer, United HealthCare, announced March 18.
He received the bill because he hadn’t yet met the deductible for his insurance plan, Anthony told Business Insider. His insurer told him the healthcare provider billed for pleurodynia, a lung infection that causes chest pain.
Anthony paid the bill with money from a health savings account.

‘Textbook COVID’ and a $1,186 bill
Hill, 39, the patient from Wisconsin, on April 5 visited a triage tent at St. Luke’s Medical Center because she worried she had the coronavirus.
Nurses measured her temperature, her pulse, and her oxygen levels, and listened to her lungs. Over a video inside the tent, Hill spoke to a nurse practitioner who told her that her symptoms were “textbook COVID.”
But, the nurse told Hill, she wouldn’t be admitted to the hospital because her oxygen levels were healthy. And because she wasn’t being admitted, the hospital wouldn’t be performing a coronavirus test.
“She told me that I ‘most likely’ had it, told me to quarantine myself for two weeks, take extra cleaning precautions around my family, and come back to the ER if my breathing became even more labored,” Hill told Business Insider in an email. “I was in and out of the triage tent in about 30 minutes. No tests were run on me, but my discharge papers read, ‘suspected COVID-19.’”
At the end of April, she received a $1,186 bill.
“It was my understanding from what I had read and what I had heard that there would not be a bill for it,” she told Business Insider.
Anthony and Hill both sought care because they worried they had the coronavirus. Under Trump administration rules, “presumed cases” of coronavirus are supposed to be covered, but it’s left up to healthcare providers to bill an insurance company for COVID-19.
“A presumptive case of COVID-19 is a case where a patient’s medical record documentation supports a diagnosis of COVID-19, even if the patient does not have a positive in vitro diagnostic test result in his or her medical record,” said a Health Resources and Services Administration spokesperson.
When patients see doctors, they sometimes order other tests to rule out similar conditions. That means patients can still get charged for those tests even if they only went to a provider in the first place because they feared they had the coronavirus.
Linke Young from Brookings pointed out that other patients could end up in similar situations. For instance, patients could get big bills after getting checked out at a hospital that didn’t have coronavirus testing, or after going to a clinic and finding out they didn’t have the coronavirus after all.
“There is nothing to protect them from getting those bills,” she said.

Health insurers revisited the medical bills
When Business Insider asked about Anthony’s charges, United HealthCare said that it was waiving all out of pocket charges for him after reviewing the services he received, and said it would refund his payments. The company is waiving charges for coronavirus treatment from February 4 to May 31, and providers have to bill the visit as related to COVID-19.
Hill is appealing her bill. She called her insurance provider, Blue Cross Blue Shield of Illinois, which told her that its billing practices had changed since the beginning of April because of the pandemic. The insurer called St. Luke’s to re-code the diagnosis so that it would be covered.
Hill said her insurer was helpful, and she will find out the result of her appeal within 30 days. BCBS Illinois told her that if for some reason the hospital doesn’t recode the bill, then she can appeal to the insurer and submit her discharge papers that read “suspected COVID-19.”
Asked about company’s practices, Katherine Wojtecki, spokeswoman for BCBS of Illinois, didn’t comment specifically on Hill’s case but said in an email that “our focus is on helping our members access medically necessary care amid the coronavirus public health emergency and ease the burden of individuals who may be facing challenging circumstances, so they can focus on their health and well-being.”
LeeAnn Betz, spokeswoman for Advocate Aurora Health, the health system St. Luke’s belongs to, also didn’t comment on Hill’s case but said in an email that patients who arrive at facilities with symptoms of coronavirus will get tested.
“We’ve had to react quickly to changes that insurance companies made in how they wanted services billed during this pandemic, but it’s a priority that our patients are informed on what services they are receiving and why they are being performed,” she said. “In most cases, insurance companies are paying for COVID¬-related services without any remaining patient financial responsibility.”

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New Proposal Aims to Address Rising Out-of-pocket Health Care Costs: Prospect for Bipartisanship?

Maria Montecillo Leave a comment

Republicans and Democrats have an opportunity to work together to come up with reforms to address the high cost of health care. A draft discussion was recently released addressing surprise billing and the rising cost of prescription drugs, two of the most common problems for patients. We are hoping that this draft bill will be passed soon to help reduce out-of-pocket health care costs for everyone.

New Proposal Aims to Address Rising Out-of-pocket Health Care Costs: Prospect for Bipartisanship?

by Kara Jones

 

Blog photo 061219

Republicans and Democrats have an opportunity to work together to come up with reforms to address the high cost of health care. There are some areas of agreement on this issue. The Senate Health, Education, Labor, and Pensions (HELP) Committee, led by Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) released a draft discussion of nearly three dozen specific proposals to reduce out-of-pocket health care costs and increase health care price transparency.

The five main parts of the draft bill, the Lower Health Care Costs Act of 2019, include:

1. Tackle surprise medical billing: The bill would make sure that patients are not held responsible for surprise medical bills received when they see an out-of-network doctor that they didn’t choose. The bill lists three different approaches that health care providers and insurance companies could take to resolve payment for these surprise bills.

2. Lower the price of prescription drugs: The bill would ensure that pharmaceutical companies don’t game the system to prevent new and lower-cost generic drugs from coming to market. It would also help generic drug and biosimilar companies to speed drug development and avoid patent infringement by providing a searchable patent database. These actions would get lifesaving drugs into the hands of patients more quickly.

3. Increase transparency in the health care market: The bill would set up a non-profit entity to create an all-payer claims database, which would house anonymous patient health care data that patients, states, and employers could use to better understand their health care costs. The bill would also ban certain anti-competitive hospital contracts, such as those that prevent insurers from sharing pricing information with patients.

4. Improve public health: The bill would authorize grants to address important public health issues such as increasing vaccination rates and reducing maternal mortality. It would also give states an evidence-based guide to develop programs to prevent obesity and other chronic health conditions.

5. Enhance health information technology: The bill would give patients full, electronic access to their own health care claims information and would incentivize health care systems to keep patients’ personal health information private and secure.

Health care reform is a polarizing issue between Republicans and Democrats, and with current gridlock in Congress, it is not possible for either party to pass its own comprehensive reform. However, rising health care costs continually rank in the top three issues that voters are most concerned about. This presents an opportunity for the two parties to come together and compromise on ways to reduce health care costs for all Americans.

Two areas where we are most likely to see movement in Congress are on surprise billing and prescription drug costs. Large surprise medical bills have become a growing problem for patients who unknowingly visit health care providers that are out-of-network. And as insurance deductibles continue to rise year after year, patients are feeling high prescription drug costs more acutely.

There have been numerous bills introduced to address these two issues, and both Republicans and Democrats agree that patients need relief. The Lower Health Care Costs Act of 2019 would directly address these issues, as well as the others listed above, in its aim to reduce out-of-pocket health care costs.

The Senate HELP committee is requesting input on the draft to be submitted to LowerHealthCareCosts@help.senate.gov.The committee plans to hold hearings on the legislation by the end of June and put the bill to a vote later this summer.

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States Are Cleared to Allow Less-Comprehensive Health Plans

Maria Montecillo Leave a comment

Many families are searching for options in the individual insurance markets. This year we are seeing more non-traditional options added to the mix. This article describes how the US Government may start allowing subsidies on nontraditional plans. The saying “buyer beware” applies in healthcare. If a plan seems very inexpensive or too good to be true, look at the details and ensure there are valid networks and adequate coverage if you have a serious or costly health issue. With deductibles and coinsurance rising so high for most families, small procedures are usually paid out of pocket. So make sure your insurance is there for the large and catastrophic issues to ensure you can afford to get care.

States Are Cleared to Allow Less-Comprehensive Health Plans
Trump administration would let federal subsidies cover plans that don’t meet ACA rules
By WSJ Michelle Hackman

WASHINGTON—States will be allowed to offer less-comprehensive health plans yet still qualify for federal subsidies under a new Trump administration policy that will let them skirt key regulations under the Affordable Care Act.
The change, announced by the Department of Health and Human Services on Monday, marks a fundamental shift in how the federal government enforces the states’ administration of the ACA, accelerating a trend in which red and blue states can craft significantly different health-care policies under the same federal law.
Under the guidelines, the administration will consider state ACA waiver requests that would allow federal subsidies to cover skimpier, less-expensive plans that don’t meet the law’s requirements. Such plans can be cheaper for consumers and might be preferable for younger and healthier Americans, but many health-care analysts say they could end up siphoning healthy customers out of the ACA market, resulting in higher premiums for older people and others with pre-existing medical conditions who need fuller plans.
Seema Verma, who heads the Centers for Medicare and Medicaid Services, which oversees the ACA, described the move as a major step in lowering health-care prices.
“Premiums are still much too high, and choice is still too limited,” she said in a statement. “This is a new day—this is a new approach to empower states to provide relief.”
Democrats said the move contradicted Republicans’ claims that they want to protect people with pre-existing medical conditions from high premiums.
“The American people should look at what Republicans are doing, rather than what they’re saying, when it comes to health care,” said Senate Minority Leader Chuck Schumer (D., N.Y.). “Just weeks before the election, Republicans are once again undermining protections for people with pre-existing conditions and sabotaging our health-care system.”
The Obama administration also allowed states to submit proposals to waive ACA requirements, but with far more limitations.
Obama officials required that under any waivers, individuals still must have health plans that were at least as expansive and affordable as those required by the health law. The current administration will instead require that those plans simply be available, along with the less-regulated options.
Since Republicans in Congress failed last year to repeal the ACA, the Trump administration has steadily pursued policies giving individual states the option of weakening the law’s provisions.
The administration has moved, for example, to permit the sale of short-term health policies and let businesses and some individuals band together in “associations” to obtain plans that don’t comply with the ACA. Congress last year also successfully repealed the ACA’s requirement that individuals purchase health care or pay a penalty. That repeal will take effect in 2019.
“This was the plan from the start,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy think tank. “If the ACA couldn’t be repealed outright, then the next best thing is to let states do it one by one.”
The latest guidelines respond to requests from conservative-leaning states whose leaders have expressed interest in rolling back ACA rules they say inflate consumers’ health costs, such as a requirement that all insurance plans cover certain benefits.
Iowa and Oklahoma, for example, submitted plans last year that would have erased key ACA regulations. The administration rejected those proposals under the stricter Obama-era guidelines.
The administration in the new guidelines encouraged states to bolster “private” insurance plans, suggesting it might not approve state plans that propose putting federal ACA money toward systems that use more government funding.
Some Democratic-leaning states have signaled an interest in adopting such systems. Gavin Newsom, a Democratic candidate for California governor, has vowed to move toward such an arrangement should he be elected in November.
Separately, the administration will propose a new rule on Tuesday allowing employers to allot their workers money to purchase health plans on the individual market, according to a senior administration official. The Obama administration had prohibited employers from doing so, in part fearing that employers would push only their older and sicker employees onto the individual market, where consumers buy insurance on their own.
Under the new rule, employers wouldn’t be able to choose which workers to offer money rather than an employer-sponsored health plan, limiting the possibility that business owners would take advantage of the new rules to direct only their most expensive workers to the individual market, the official said.
Write to Michelle Hackman at Michelle.Hackman@wsj.com

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Medical Cost Advocate was featured in a documentary by a French journalist

Maria Montecillo Leave a comment

A French journalist from CAPA TV (the equivalent of 60 Minutes in the US) came to our office and interviewed our CEO Derek Fitteron regarding our advocacy services. The interview was also about our client Stella who is featured on the previous blog. Watch how Stella was very stressed over the thousands of dollars in medical bills that she received when her triplets were born prematurely, and how her Advocate helped her in resolving these bills.

To watch it subtitled in English, go to settings➡️subtitles➡️auto translate➡️English.

You will see Stella, Stella’s advocate Maria, and Derek beginning at the 7:20 mark.

 

 

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Surprise Medical Bills

Doug Leave a comment

This is an excellent article published by the Kaiser Family Foundation reporting on a survey finding that 7 in 10 individuals with out-of-network bills didn’t know their health care provider was not participating in their plan. Surprise medical bills can contribute significantly to financial burden and medical debt among insured individuals.

By Karen Pollitz, KFF

A Kaiser Family Foundation survey finds that among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time. Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers. Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network. These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others. In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network. In these non-emergency situations, too, the in-network provider or facility generally arranges for the other treating providers, not the patient.

For insured patients, the surprise medical bill can involve two components. The first component reflects the difference in patient cost-sharing between in-network and out-of-network providers. For example, in a managed care plan that provides coverage in- and out-of-network (sometimes called a PPO plan), a patient might owe 20% of allowed charges for in-network services and 40% of allowed charges for out-of-network services. A second component of surprise medical bills is due to “balance billing.” Typically health plans negotiate fee schedules, or allowed charges, with network providers that reflect a discount from providers’ full charges. Network contracts also typically prohibit providers from billing patients the difference between the allowed charge and the full charge. Because out-of-network providers have no such contractual obligation, however, patients can be liable for the balance bill in addition to any cost-sharing that might otherwise apply.

Data on the prevalence of surprise medical bills and costs to consumers are limited. The Affordable Care Act (ACA) requires health plans in and out of the Marketplace to report data on out-of-network costs to enrollees, though this provision has not yet been implemented. Research studies offer some clues as to the prevalence and cost to patients due to surprise medical bills:

• One national survey found that 8% of privately insured individuals used out-of-network care in 2011; 40% of those claims involved surprise (involuntary) out-of-network claims. This survey found that most surprise medical bills were related to emergency care.

• In 2011, the New York Department of Financial Services studied more than 2,000 complaints involving surprise medical bills, and found the average out-of-network emergency bill was $7,006. Insurers paid an average of $3,228 leaving consumers, on average, “to pay $3,778 for an emergency in which they had no choice.”

• The same New York study found that 90% of surprise medical bills were not for emergency services, but for other in-hospital care. The specialty areas of physicians most often submitting such bills were anesthesiology, lab services, surgery, and radiology. Out-of-network assistant surgeons, who often were called in without the patient’s knowledge, on average billed $13,914, while insurers paid $1,794 on average. Surprise bills by out-of-network radiologists averaged $5,406, of which insurers paid $2,497 on average.

• A private study of data reported by health insurers in 2013 to the Texas Department of Insurance suggest that emergency room physicians often do not participate in the same health plan networks as the hospitals in which they work. Three Texas insurers with the largest market share reported that between 41% and 68% of dollars billed by for emergency physician care at in-network hospitals were submitted by out-of-network emergency physicians. Analysis of provider directories of these three insurers found that between 21% and 45% of in-network hospitals had no in-network emergency room physicians.

Federal and State protections against surprise medical bills

Policymakers at the federal and state level have expressed concern that surprise medical bills can pose significant financial burdens and are beyond the control of patients to prevent since, by definition, they cannot choose the treating provider. Various policy proposals have been advanced, and some implemented, to address the problem. These include hold harmless provisions that protect consumers from the added cost of surprise medical bills, including limits or prohibitions on balance billing. Others include disclosure requirements that require health plans and/or providers to notify patients in advance that surprise balance billing may occur, potentially giving them an opportunity to choose other providers.

Federal policy responses

Several federal standards have been adopted or proposed to address the problem of surprise medical bills in private health plans generally, in qualified health plans offered through the Marketplace, and in Medicare. These standards vary in scope and applicability:

• Out-of-network emergency services (all private health plans) – The ACA requires non-grandfathered health plans, in and outside of the Marketplace, to provide coverage for out-of-network emergency care services and apply in-network levels of cost sharing for emergency services, even if the plan otherwise provides no out-of-network coverage. For example, if an HMO would normally cover 80% of allowed charges for in-network care and nothing for out-of-network care, the HMO would have to pay 80% of allowed charges for an out-of-network emergency room visit. This provision does not, however, limit balance billing by out-of-network emergency providers.

• Proposed changes to coverage for out-of-network non-emergency services (Marketplace plans) – Recently the Centers for Medicare and Medicaid services proposed changes to address surprise medical bills for non-emergency services for individuals covered by qualified health plans offered through the Marketplace. Proposed standards would apply when an enrollee receives care for essential health benefits from an out-of-network provider in an otherwise in-network setting (for example, anesthesia care for surgery performed in an in-network hospital.) Plans would be required to apply out-of-network cost sharing for such care toward the plan’s annual out-of-pocket limit for in-network cost sharing. The proposed rule would waive this requirement whenever plans notify enrollees in writing at least 10 days in advance (for example, as part of a plan pre-authorization process) that such surprise medical bills might arise. The proposed rule indicates that CMS may consider an alternative under which all out-of-network cost sharing for surprise medical bills would count toward the in-network OOP limit, regardless of whether the plan provides advance notification, but notes the agency is “wary of the impact of such a policy on premiums.” The proposal would not apply to balance billing charges arising from surprise medical bills. In addition, the proposal would seem to not affect enrollees of HMO or EPO plans that do not cover non-emergency out-of-network services at all. Such plans comprise 73% of all QHPs offered in the federal Marketplace in 2016.

• Out-of-network services (Medicare) – Rules governing the traditional Medicare program generally limit patient exposure to balance billing, including surprise medical bills. Providers that do not participate in Medicare are limited in the amount they can balance bill patients to no more than 15% of Medicare’s established fee schedule amount for the service. Since these rules were adopted in 1989, the vast majority of providers accept Medicare assignment, and beneficiary out-of-pocket liability from balance billing has declined from $2.5 billion annually in 1983 ($5.65 billion in 2011 dollars) to $40 million in 2011. The rules are somewhat different for Medicare Advantage plans, which typically have more limited provider networks compared to traditional Medicare and which may not provide any coverage out-of-network. For emergency services, Medicare Advantage plans must apply in-network cost sharing rates even for out-of-network providers. Balance billing limits similar to those under traditional Medicare also apply. For non-emergency services, enrollees in PPO plans in surprise medical bill situations would be liable for out-of-network cost sharing, but Medicare balance billing rules would still apply, while enrollees in HMO plans might not have any coverage for non-emergency out-of-network services.

State policy responses

• New York’s comprehensive approach to surprise medical bills – Last year a new law took effect in New York limiting surprise medical bills from out-of-network providers in emergency situations and in non-emergency situations when patients receive treatment at an in-network hospital or facility. To date, this law stands out as offering the most comprehensive state law protection against surprise medical bills. For emergency services, patients insured by state-regulated health plans (e.g., not including self-funded employer plans) are held harmless for costs beyond the in-network cost sharing amounts that would otherwise apply. For non-emergency care, patients who receive surprise out-of-network bills can submit a form authorizing the provider to bill the insurer directly, and then are held harmless to pay no more than the otherwise applicable in-network cost sharing. In both situations, out-of-network providers are prohibited from balance billing the patient; although providers who dispute the reasonableness of health plan reimbursement may appeal to a state-run arbitration process to determine a binding payment amount. The New York law applies only to state-regulated health plans. However, patients who are uninsured or covered by self-insured group health plans may also apply to the state-run arbitration process to limit balance billing by providers under certain circumstances.

• Limited provisions addressing surprise medical bills – A number of other states have laws limiting balance billing by out-of-network providers in certain circumstances. Some of these laws apply only to certain types of health plans (HMO vs. PPO) or only to certain types of providers or services (for example, for ambulance providers or emergency care services.)

• NAIC model act – This fall, the National Association of Insurance Commissioners (NAIC) proposed changes to its health plan network adequacy model act to address surprise medical bills. NAIC model acts do not have the force of law, but often encourage state legislative action. For example, twenty states had adopted the previous NAIC model act on network adequacy or similar laws for network-based health plans. In addition, federal health insurance laws and regulations sometimes cite NAIC model act standards. The model act revisions would apply new standards for in-network facilities (hospitals and ambulatory care facilities) with non-participating facility based providers (such as anesthesiologists or emergency physicians). For emergency services, state-regulated plans would be required to apply in-network cost sharing rates for surprise medical bills (extending the ACA’s requirement for non-grandfathered plans to grandfathered plans as well). For balance billing amounts, out-of-network facility-based providers would be required to offer patients 3 choices: (1) pay the balance bill, (2) for balance bill amounts greater than $500, submit the claim to a mediation process with the provider to determine an allowed charge amount, or (3) rely on any other rights and remedies that may be available in the state. Similar requirements would apply for non-emergency services. In addition, health plans that require pre-authorization of facility-based care would be required to notify enrollees that surprise medical bills could arise, and plans would be required to provide enrollees with a list of facility-based providers that are participating in the plan network. Finally, plans would be required to keep data on all requests for mediation involving surprise medical bills and, upon request, report it to the state regulator.

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This Could Be the Obamacare Outcome we’ve All Been Waiting For

Doug Leave a comment

This often-overlooked long-term goal of Obamacare may be finding the mark according to this latest study from the American Cancer Society.

The third open enrollment period for the Affordable Care Act, best known as Obamacare, has been ongoing for roughly five weeks now. And as seems to be the trend around this time of year, more questions than answers appear to be swirling around healthcare’s law of the land.

Big changes lead to an uncertain future

Obamacare is facing a number of changes in the 2016 calendar year, and, frankly, no one is certain yet how those changes might affect enrollment or patient mix for insurers.

For example, insurance premiums are rising at about their fastest rate in about a decade. The Great Recession held premium rate inflation in check for years, but the failure of more than half of Obamacare’s health cooperatives, coupled with many low-cost insurers coming to the realization that their rates were unsustainably low, are leading to big premium hikes in the upcoming year.

Data from the Washington Examiner showed that 231 insurers requested double-digit percentage premium price hikes in 2016 compared to just 121 in 2015. Furthermore, the magnitude of these hikes — 61 plans are looking for a minimum premium increase of 30% this year — is much higher than 2015. In short, there’s concern that higher premiums could reduce the affordability of the program for those who don’t qualify for a subsidy, leading to a higher uninsured rate.

Meanwhile, the employer mandate will be fully implemented on Jan. 1, 2016. The employer mandate will require that businesses with 50 or more full-time-equivalent employees (FTE’s) offer eligible health coverage to those FTE’s and their dependents under the age of 26, as well as provide financial assistance in instances where low-income FTE’s would be paying more than 9.5% of their modified adjusted gross income out of pocket toward their premium. If qualifying businesses fail to follow the rules, they could be looking at a $2,000 to $3,000 fine per employee.
The big question here is how businesses will respond. Will bigger companies step up and supply health insurance for their workers or will we see layoffs, hour cutbacks, or a move to private health exchanges? Obamacare’s big changes in 2016 are leading to a seemingly uncertain enrollment outlook in the near term.

Obamacare’s incredibly important goal that you probably overlooked

The easiest way to measure the success of Obamacare has always been by its overall enrollment totals. Obamacare was first and foremost designed to reduce the number of uninsured and to utilize the individual mandate and employer mandate to make that happen. The Centers for Disease Control and Prevention reported in Q1 2015 that just 9.2% of U.S. adults remained uninsured, including Medicare patients, which is the lowest figure on record. By this token, Obamacare would appear to be hitting its primary goal.

But there’s an even more important long-term goal that’s often lost on critics when discussing Obamacare’s success or failure — namely, the impact that preventative (and earlier) medical access could have on reducing long-term medical costs.
For insurers, Obamacare is a bit of a give and take. Insurers are enrolling more people than ever, and they’re also being required to accept members with pre-existing conditions. The result is that some insurers, such as the nation’s largest, UnitedHealth Group, are dealing with adverse selection and losing money on their individual marketplace plans because they’ve enrolled a large number of sicker individuals. Even though some of its large peers such asAnthem are healthfully profitable, the margins most insurers are generating on Obamacare plans (if they’re even profitable in the first place) are relatively small.

Now here’s the catch: In exchange for spending more money on their members up front, it’s possible that chronic and serious diseases that are the primary expense culprit for insurance companies can be caught before they become a serious issue. Thus, while health benefit providers may be spending more now than they would like to, their long-term outlook is also looking brighter presuming the current generation of members is now going to be healthier than the last generation given expanded access to medical care.

This could be the outcome we’ve been waiting for.

This last point sounds great on paper, but it’s difficult to prove that Obamacare is really making a dent in lowering long-term healthcare costs, especially since it’s only been the law of the land for about two years. All that consumers and critics can focus on at the moment are the rapidly rising premium prices.

However, a new study from the American Cancer society that was published online in the Journal of the American Medical Association late last month appears to show that there is a correlation between Obamacare’s expansion and a higher rate of cervical cancer diagnoses in select patients.

Researchers from the Department of Epidemiology at Emory University and from the ACS’ Department of Intramural Research analyzed a large database of cancer cases within the United States, separating cervical cancer diagnoses for women ages 21 to 25 in one group from cervical cancer diagnoses in women ages 26 to 34 in the other cohort. The reasoning behind this split? Persons under the age of 26 are still eligible to be covered under their parents’ health plan under Obamacare, and thus the expansion of this dependent clause should give researchers a reasonable correlation of how well Obamacare is affecting the rate of cervical cancer diagnoses.

After examining cervical cancer diagnosis rates for both cohorts before and after the implementation of Obamacare, researchers noted that there was a substantial increase in the number of cervical cancer diagnoses for women ages 21 to 25, whereas the age 26-34 cohort had a relatively consistent number of diagnoses before and after Obamacare’s implementation.

On the surface, a rising rate of cervical cancer diagnoses may not sound good at all. But, in a different context it could be just the news we’ve been hoping for. The key to beating cervical cancer is discovering it early, and presumably being able to stay on their parents’ health plans until age 26 helped the 21- to 25-year-old cohort gain this vital medical access. It’s possible that this early diagnoses not only saved lives, but for insurers that it kept them from shelling out big bucks in mid- to late-stage cancer treatments.

Keep in mind that this is just one example, and one example does not make a trend. However, it’s long been postulated that reducing the barriers to health insurance would lead to a higher medical utilization rate for consumers and a better chance of discovering potentially serious and chronic conditions at an earlier time, thus saving the patients’ lives and cutting insurers’ long-term medical expenses. It’s possible we could be witnessing the first signs of that.

Understandably, we’ll want to see additional studies emerge that examine disease diagnosis and treatment rates in a pre- and post-Obamacare setting so we can make a conclusive ruling as to whether or not Obamacare could actually lower long-term healthcare costs and improve long-term patient survival rates. The initial signs, though, are very encouraging.

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How 6 key trends are driving the employee benefits landscape

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Interesting report on trends shaping the design and delivery of employee benefits for the Workplace Benefits Summit.

By Melissa Winn, Employee Benefit Advisor

Emerging trends in the health care insurance and benefits landscape threaten to have a lasting impact on the way employers provide and administer employee benefit packages. Benefit advisers hoping to not only remain relevant to their clients, but to thrive during this time of adversity, will need to adjust to the changes ahead, according to Rick Lindquist, president of Zane Benefits.

He told attendees of the Workplace Benefits Summit that his company is focusing product development on 6 key trends in the industry today.

  • First and foremost is a sharp rise in the cost of employer contributions for health care insurance.
    (This trend is driving employers to seek ways to fix the cost of offering benefits so they can sustain them.)
  • Second, employee costs are also rising, and rising faster than wages, causing dissatisfaction.
  • The third trend is shifting more financial responsibility for benefits to consumers.
  • The fourth trend is the increased use of consumer technology, a trend which actually aids employers and advisers in shifting more responsibility to individuals.
  • Trend number five is the decrease in unemployment rates, will increase importance on employers’ compensation and benefit packages.
  • Last, millennials are entering the workforce in droves and will comprise the majority of the workforce by 2025. Millennials want to own their own way when it comes to benefit selection. They demand to operate at their own convenience.

The four characteristics of modern benefit offerings, Lindquist said, include:

  1. They are technology-driven, including through the use of a mobile experience and a Facebook like interface
  2. They offer maximum choice and convenience
  3. They are employer-funded, employee-owned
  4. They offer a better value than cash

For advisers these trends mean they must be able to deliver direct to consumer employee services, or broker a third party service.

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The Hospital-Dependent Patient

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By PAULINE W. CHEN, M.D.

Interesting piece about the unintended cost and consequences of hospital re-admissions.  Spectacular advances in medical science have led to a growing population of patients who are “hospital-dependent” adding great cost to the healthcare system.

“He’s back?” my colleague asked, eyes widening as she passed the patient’s room. “He’s in the hospital again?”
Slender, pale and in his late 60s, the man had first been admitted nearly a year earlier with pressure in his chest so severe he had trouble breathing. When his heart stopped, doctors and nurses revived him by injecting the latest life-saving medicines into his veins and applying the newest electrical defibrillator paddles to his chest.

Within minutes, the cardiology team arrived, but when the blockage in the arteries of his heart proved too extensive for even their state-of-the-art techniques and equipment, they handed him off to the waiting surgeons. The surgeons, in turn, cooled down his heart until it stopped beating, sewed in bypass conduits with threads finer than human hairs, restarted the heart with a few well-placed jolts of electricity and then transferred the patient to the cutting-edge intensive care unit to recover.

The man survived. Sort of.

Weakened by this string of emergencies, he required a breathing machine for several days. When excess fluid in his lungs caused shortness of breath, he needed intravenous diuretics. When his heart began beating erratically, he was obliged to take a finely tuned cocktail of heart medications. And when his chest wound became infected, he had to return to the operating room.

Finally, after nearly two months in the hospital, he was discharged to a skilled nursing center. But then a urinary tract infection made him dizzy and confused, and he went right back to the hospital, beginning a cycle of discharge and re-admittance that would persist for almost a year.
To many of us who had cared for the man, it seemed as if he had spent more days in the hospital than out.

“What kind of life is that?” my colleague asked as we stood in the hallway and watched the man’s wife help him once again put on his hospital gown and pack away his street clothes. “You’ve got to wonder,” she whispered, “did we really do him a favor when we ‘saved’ him?”
I was reminded of the frail man and the many patients like him whom I have known when I read a recent Perspective piece in The New England Journal of Medicine titled “The Hospital-Dependent Patient.”

Over the last 30 years, American hospitals have become a showcase of medical progress, saving lives that not long ago would have been lost.

“Rapid response teams,” drilled in precision teamwork and the latest techniques of critical care, have become commonplace. Cardiac and respiratory monitors, once found only in intensive care units, are now standard equipment on most wards and even in many patient rooms. CAT scanners and M.R.I. machines, once rare, have become de rigueur, with some hospitals boasting duplicates and even triplicates.

But up to one-fifth of patients treated with these new medical advances and then deemed well enough to leave the hospital end up being re-admitted within 30 days of their discharge, at considerable cost. Insurers and third-party payers have begun penalizing health care systems for these quick re-admissions; and hospitals, in response, have begun significant efforts to improve the transition from hospital to home, creating clinics that remain open beyond usual working hours and marshaling teams of care coordinators, post-discharge pharmacists and “care transition coaches.”

The problem persists, though, because our spectacular advances in medical science have led to a growing population of patients who are “hospital-dependent,” according to the authors of the Perspectives article.

Hospital-dependent patients are those who, a generation ago, were doomed to die. Now they are being saved. But they are not like the so-called hot spotters, a group of patients more commonly associated with frequent re-admissions who return to the hospital because of inadequate follow-up care, failure to take prescriptions correctly or difficult socioeconomic circumstances. Instead, hospital-dependent patients come back because they are so fragile, their grasp on health so tenuous, that they easily “decompensate,” or deteriorate under stress, when not in the hospital.

Medical advances can snatch them from the clutches of death, but not necessarily free them from dependence on near-constant high-tech monitoring and treatments.

“They are like a house of cards,” said Dr. David B. Reuben, lead author of the article and chief of the division of geriatrics at the Geffen School of Medicine at the University of California, Los Angeles. “When one thing goes wrong, they collapse.”

Not surprisingly, hospital-dependent patients feel more secure and are happier in the hospital than at home. While clinicians and even family members may judge theirs a diminished existence, these patients find their quality of life acceptable, relishing their time with friends and family or engaged in passive hobbies like watching sports or reading the newspaper, albeit in the hospital.

Over time, however, their recurring presence can result in conflicted feelings among those who were responsible for saving them in the first place. Some clinicians even begin to resent their obligation to continue administering resource-intensive care. “Physicians are socialized to cure patients, then move on,” Dr. Reuben observed. “They want to treat patients, not adopt them.”

Dr. Reuben and his co-author offer potential solutions, such as specialized wards or facilities that would be more intensive than skilled nursing homes yet less costly than a hospital. But they are quick to add that more research must also be done. Their concept of “hospital-dependency” is a new one, so no research is available to help identify patients at risk of becoming hospital-dependent, estimate the percentage of early re-admissions they are responsible for or calculate the costs they incur.

Even without studies, it’s clear that the numbers of these patients are increasing. With every triumphant medical advance, there are patients who are cured but who remain too fragile to live beyond the immediate reach of the technology that saved them. Until we begin making different decisions regarding how we allocate our resources, their presence will be a constant reminder of which medical research and health care we consider worthy and which we do not.

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When Health Costs Harm Your Credit

Doug

By ELISABETH ROSENTHAL New York Times

This is an excellent article outlining the problems people can run into by allowing medical bills to go unpaid. It takes a long time to decipher what you actually owe, but providers can report you to credit agencies for late payment very quickly.  People in these types of situations have reason to worry.

LIKE most people, I am generally vigilant about paying my bills — credit cards, mortgage, cellphone and so on. But medical bills have a different trajectory. I (usually) open the envelopes and peruse the amalgam of codes and charges. I sigh or swear. And set them aside for when I have time to clarify the confusion: An out-of-network charge from a doctor I know is in-network? An un-itemized laboratory bill from a doctor I’ve never heard of? A bill for a huge charge before my insurer has paid its yet unknown portion of a hospital’s unknowable fee?

I would never countenance the phrase “60 days past due” on my Visa card statement. But medical bills? Well… with the complex negotiations that determine my ultimate payment, it often takes months to understand what I actually owe.

Unfortunately, I may be playing a dangerous game. Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.

A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.

A single medical bill reported to a credit agency can easily become a “millstone around your neck” said Mark Rukavina, principal at Community Health Advisors, a health care advisory service. He added: “It will take a long time to make that right, even once the bill is paid. I’ve had mortgage brokers call me and say ‘I have these people with great credit. They’ve refinanced before, but now they’ve got this medical bill and even though they’ve paid it off, I can’t get them a good rate.’ ”

Part of the problem is that there are few standards governing medical debts: One billing office might give you — or your insurer — 60 days to pay before pursuing collection. Another might allow you to pay off a bill slowly over a year. Many will sell the debt to collection companies, which typically take a cut of the proceeds and decide when or whether to report unpaid debt to credit agencies.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.

Both Congress and the protection bureau have been trying to better insulate patient credit scores from the inefficiencies of our market-based medical system. Various proposals have been considered to differentiate medical debt from other forms; it could be erased once it has been paid off or not reported to credit agencies at all, for example. So far, the credit industry has fought successfully against such efforts, noting that they could allow some genuine scofflaws to evade legitimate charges. But it’s also good business, since health care bills are now the largest source of business for collection companies, according to consumer protection agency officials.

Having spent the last year reporting a series on American health costs, I’ve heard plenty about credit casualties.

Gene Cavallo, 61, a New Mexico businessman who put his children through college, had always paid his bills promptly and had an excellent credit rating, until he required surgical excision of a melanoma on his shin two years ago. The more than 60 bills generated for the surgery and six months of follow-up visits — arriving sporadically and ranging from 18 cents to $17,000 — came to $110,000; his insurance covered about $70,000.

When various providers asked him to pay the remaining $40,000, he requested itemized bills and balked at some of the “ridiculously inflated prices,” such as $85 for tweezers and $20 for a box of tissues. He argued the bills point by point, and ultimately agreed to pay $25,000.
But during the negotiations some of the debt was sent to collection. Two years later, he no longer answers the daily robocalls from collection agencies and has had a couple of credit cards canceled because his score has fallen. “It was a scary thing to do because I own a business and dabble in real estate, so the ability to borrow has always been important to me. And now I have no ability, I assume, to borrow for any reason.”
Michael S., who declined to give his full name so as to protect his reputation with business clients, had to declare bankruptcy in Wisconsin more than five years ago after a fraught year in which his toddler was evaluated for what proved to be a benign neurological condition that required no treatment: “You’d get bills for several different doctors’ groups and for tests and M.R.I.s and you don’t know what they are. I was having trouble figuring out who we owed what. And then, if it goes to collection, then suddenly they’re saying we need this paid now.”

With medical expenses, unlike most other purchases, you generally don’t know the price the hospital will charge in advance. And the subsequent bills and insurance statements — so-called explanations of benefits — are often layered in obfuscation and pressure tactics.

Consider Chris Sullivan of Pennsylvania, whose $2,770 bill for an echocardiogram offered a “prompt payment” discount of 20 percent if he wrote a check within 21 days — meaning a discount for not asking questions on a bill for a test he was told would be under $300.

Another “explanation of benefits” statement notified Joe Cotugno of New York City that his two-day hospital stay for a hip replacement was billed at $99,469.70 (doctors’ fees not included). Cigna paid $68,420.53 after knocking off some $28,000 and requiring Mr. Cotugno to pay $3,018.41. So, it informed him, “You saved 96 percent.” Huh?

The Consumer Financial Protection Bureau has been studying the impact of medical billing on credit scores since 2012, acknowledging that unpaid medical bills in collection “frequently end up on consumer credit reports,” as an outgrowth of “very complex and confusing systems of figuring out who owes what after a medical procedure.” Mr. Cordray, the bureau’s director, said it would take appropriate action if harmful practices were identified.

Bills in Congress that would regulate the practices have been stalled for years. The Medical Debt Relief Act was passed by the House in 2010, but never made it to a Senate vote. After a modified version of the bill failed to pass again last year, another act was recently introduced in the Senate and House.

Meanwhile, patients are right to worry. When Matt Meyer, who owns a saddle-fitting company in New Hampshire, set up a monthly payment plan after some surgery, he was distressed to notice that the invoices came from a debt collector. “I had no idea this was considered debt,” he said, and wondered: “Are they reporting that” to a credit agency?

Good question.

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Americans don’t know what’s in Obamacare, do know they don’t like it

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By Sarah Kliff, Washington Post

Fifty percent of Americans now say they oppose the Affordable Care Act. This is the highest number that Kaiser Family Foundation’s poll has seen since October 2011, when Republicans were in the midst of a primary cycle and lots of anti-Obamacare rhetoric was in the air. The easiest explanation for the recent upswing in negative sentiment would be that lots of Americans tried, but failed, to buy insurance through HealthCare.gov. They ran into technical barriers that plagued the site in October and November. But Kaiser’s data don’t really bear out that thesis. There’s actually only been a tiny uptick in the number of Americans who say the health-care law has affected their lives over the past three months. A full 59 percent of Americans still report no personal experience with the law. 

Most Americans don’t know that Obamacare has, at this point, pretty much fully taken effect. When surveyed in January, after the insurance expansion began, 18 percent said they thought “all” or “most” provisions of the Affordable Care Act had been put into place.

There’s lots of confusion, too, about what policies are and aren’t part of the health-care law. Most Americans know there’s a mandate to purchase health insurance. A lot fewer are aware that the law provides financial help for low- to middle-income Americans (the tax subsidies) or gives states the option of expanding Medicaid.

For many Americans – particularly the 68 percent who get coverage through their work, Medicare and Medicaid — the launch of the exchanges probably doesn’t affect their coverage situation. They’ll continue getting insurance in 2014 just the same way they did in 2013. For them, an expansion of Medicaid or an end to the denial of coverage for people with pre-existing conditions isn’t a big change (unless, of course, they lose their current coverage).

So what’s driving the negative opinions of Obamacare? The Kaiser survey does point to one potential culprit: negative news coverage. More Americans say they’ve seen stories about people having bad experiences with the Affordable Care Act than good ones.

Politico’s David Nather had a great line on this recently, in a story about the very high bar for success stories about the Affordable Care Act.

“Here’s the challenge the White House faces in telling Obamacare success stories: Try to picture a headline that says, ‘Obamacare does what it’s supposed to do,’ ” Nather writes. “Somehow, the Obama administration and its allies will have to convince news outlets to run those kinds of stories — and to give the happy newly insured the same kind of attention as the outraged complainers whose health plans were canceled because of the law.”

We don’t have a great sense yet of what type of experience Obamacare’s new enrollees are having — whether they’re disproportionately bad or if the bad stories are just more interesting to cover. But the more negative news coverage does seem to have played some role in the recent uptick in negative opinions about the new law.

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