Out-of-network Insurance Practices Face Scrutiny

April 1, 2009April 1, 2009 Doug

Great article from The Washington Post about the investigation into deliberate low-balling of out of network reimbursements for consumers. Accountability and transparency is needed in how insurance companies determine out-of-network rates, and patients need to understand how it’s done to avoid sticker shock when they get their medical bills.

By ERICA WERNER

The Associated Press

Saturday, March 28, 2009; 10:01 PM

WASHINGTON — Ever wonder how that bill was calculated if you had to pay to see a doctor outside your insurance network?

Might be a scam, says a senator investigating the issue.

Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, wants answers at a hearing Tuesday from the chief executives of UnitedHealth Group Inc. and its subsidiary Ingenix Inc., a claims database used by insurers nationwide to calculate out-of-network rates.

The inquiry follows lawsuits and an investigation by New York Attorney General Andrew Cuomo alleging that UnitedHealth and Ingenix manipulated rate data so insurers had to pay less and patients more for out-of-network services.

“They’re lowballing deliberately. They deliberately cut the numbers so the consumer has to pay more of the cost,” Rockefeller, D-W.Va., said in an interview with The Associated Press on Friday.

“It’s scamming. It’s fraud,” he said.

In January, UnitedHealth agreed to pay $350 million to settle a suit by the American Medical Association and others over the issue. UnitedHealth did not admit wrongdoing. But, under pressure from Cuomo, the company agreed to pay $50 million toward creation of an independent claims database and eventually close down the Ingenix databases.

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Bargaining Down the Medical Bills

March 13, 2009March 16, 2009 Doug

Below is a recent New York Times article suggesting that consumers take responsibility for lowering the cost of their health care bills. Most consumers find it difficult to negotiate with health care providers because they don’t have the experience or don’t feel comfortable discussing finances with their physician. We recommend using experts like Medical Cost Advocate, which leverage health care market data and use experienced negotiators to reduce consumers medical bills.

By LESLEY ALDERMAN

When money is tight, everything is negotiable — including your health care bills.

As the economy sheds jobs and more people lose their health insurance or are forced to switch to less generous plans, doctors and hospitals are becoming accustomed to patients who are struggling financially. According to the American Hospital Association, half of their members reported an increase in the number of patients needing help with their bills. And that was in November, before the national unemployment rate hit 8.1 percent.

“It’s rough out there,” said Dr. Jacques Moritz, the director of gynecology at St. Luke’s-Roosevelt Hospital Center in New York, who also has a private practice in Manhattan. (Full disclosure: He delivered my son five years ago, but my insurance at the time covered me in full.)

Lately, Dr. Moritz said, “The first thing I say to my long-term patients is, ‘Do you still have a job?’ ” If patients say no, or otherwise indicate that paying will not be easy, Dr. Moritz says he assures them that bills are negotiable.

And keep in mind that doctors, hospitals and medical labs are accustomed to negotiating. After all, they do it all the time with insurers. A hospital may have a dozen or more rates for one procedure, depending on whether Medicare, Medicaid or a private insurer is paying the bill, said Ruth Levin, corporate senior vice president for managed care of Continuum Health Partners, a nonprofit hospital system in New York. Your request for a special arrangement will hardly confound their accounting department.

And it is usually in everyone’s interest to avoid dealing with a bill collector.

If you recently lost your insurance or have a plan with minimal benefits, here is what you need to know if you want to seek a price break from the doctor, hospital or lab.

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For Uninsured Young Adults, Do-It-Yourself Health Care

February 26, 2009October 16, 2009 Doug

This is an excellent article in the New York Times about young people who avoid purchasing health insurance because their age makes them feel invulnerable or because health insurance policies are too expensive. While there are clinics set up to handle routine care for the uninsured, if an uninsured individual needs treatment for a major illness it will likely cost them a large amount of money. Medical Cost Advocate can achieve significant savings for uninsured families by professionally negotiating their bills.

The New York Times, By Cara Buckley

They borrow leftover prescription drugs from friends, attempt to self-diagnose ailments online, stretch their diabetes and asthma medicines for as long as possible and set their own broken bones. When emergencies strike, they rarely can afford the bills that follow.

“My first reaction was to start laughing — I just kept saying, ‘No way, no way,’ ” Alanna Boyd, a 28-year-old receptionist, recalled of the $17,398 — including $13 for the use of a television — that she was charged after spending 46 hours in October at Beth Israel Medical Center in Manhattan with diverticulitis, a digestive illness. “I could have gone to a major university for a year. Instead, I went to the hospital for two days.”

In the parlance of the health care industry, Ms. Boyd, whose case remains unresolved, is among the “young invincibles” — people in their 20s who shun insurance either because their age makes them feel invulnerable or because expensive policies are out of reach. Young adults are the nation’s largest group of uninsured — there were 13.2 million of them nationally in 2007, or 29 percent, according to the latest figures from the Commonwealth Fund, a nonprofit research group in New York.

Gov. David A. Paterson of New York has proposed allowing parents to claim these young adults as dependents for insurance purposes up to age 29, as more than two dozen other states have done in the past decade. Community Catalyst, a Boston-based health care consumer advocacy group, released a report this month urging states to ease eligibility requirements to allow adult children access to their parents’ coverage.

“There’s a big sense of urgency,” said Susan Sherry, the deputy director of Community Catalyst. She described uninsured young adults as especially vulnerable. “People are losing their jobs, and a lot of jobs don’t carry health insurance. They’re new to the work force, they’ve been covered under their parents or school plans, and then they drop off the cliff.”

If Governor Paterson’s proposal is approved, an estimated 80,000 of the 775,000 uninsured young adults across New York Statewould be covered under their parents’ insurance plans. That would leave hundreds of thousands to continue relying on a scattershot network of improvised and often haphazard health care remedies.

In dozens of interviews around the city, these so-called young invincibles described the challenge of living in a high-priced city on low-paying jobs, where staying healthy is one part scavenger hunt and one part balancing act, with high stakes and no safety net.

“For a lot of people, it’s a choice between being able to survive in New York and getting health insurance,” said Hogan Gorman, an actress who was hit by a car five years ago and chronicled her misadventures in “Hot Cripple,” a one-woman show that was a hit at last summer’s Fringe Festival. “There was no way that I could pay my rent, buy insurance and eat.”

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Health Care Costs Increase Strain, Studies Find

January 19, 2009January 29, 2009 admin 1 Comment

In a recent article by New York Times reporter Reed Abelson, she highlights findings of two studies describing the financial toll that health care is placing on working families – even those with health insurance. The studies, by the Kaiser Family Foundation and the Center for Studying Health System Change, were completed earlier in 2008 before the economy and financial markets reached their current state of crisis. It is clear that many Americans are struggling with medical costs including those that are insured, under-insured or uninsured. With the continuing degradation of the economy, these financial struggles are only getting worse, necessitating that consumers take steps to control costs themselves

By REED ABELSON

Even as Washington and Wall Street debate the best way to avert an economic disaster, increasing numbers of Americans are struggling with another financial crisis: the growing burden of unpaid medical bills.

Two studies released Wednesday provide further evidence of the toll that health care is increasingly placing on working families, even for those with health insurance. And as employees are paying more medical expenses out of their own pockets, they are having a harder time coming up with the money.

The studies, by the Kaiser Family Foundation and the Center for Studying Health System Change, were completed earlier this year before the financial markets reached their current state of crisis. But policy analysts say the findings underscore the mounting additional strain that medical care is placing on working Americans.

“The problems people are having paying for health care and health insurance are a central dimension of the economic and pocketbook concerns right now,” said Drew E. Altman, the president of the Kaiser Family Foundation, a nonprofit health research group that conducts an annual survey of employer medical benefits.

The studies, policy analysts say, underscore the need for the government to address the growing unaffordability of care, despite the distraction — and cost to taxpayers — of a proposed $700 billion bailout of the financial sector.

“This makes clear the cost of doing nothing is high and growing,” said Len Nichols, a health economist at the New America Foundation, a nonpartisan policy group in Washington that advocates universal medical coverage.

While policy analysts acknowledge that finding any new money to expand coverage may prove difficult, some also say the terms of the debate may be changing as policy makers and the public rethink their positions on the need for regulation and the role of the government in industry — including the health care system.

“We can now imagine a government takeover that we could not imagine before,” Mr. Nichols said.

Although inflation in insurance premiums has moderated in recent years, the Kaiser survey found that employees were continuing to spend more in medical costs, including their share of yearly insurance premiums. Employees are paying an average of $3,354 in premiums for family coverage, more than double the amount they paid in 1999. The total cost for family coverage now averages $12,680 a year, up 5 percent from 2007.

And as people are paying more, they are finding the higher expense less affordable. In the study by the nonpartisan Center for Studying Health System Change, based on its national survey of households, nearly one of every five families had problems paying medical bills last year. More than half of these families said they borrowed money to pay these expenses, and nearly 20 percent of those having difficulty said they contemplated declaring personal bankruptcy as a result of their medical bills.

The study estimates that 57 million Americans live in families struggling with medical bills, and 43 million of those have insurance coverage. “It’s hitting both the insured and the uninsured, and it’s hitting middle-class families,” said Karen Davis, the president of the Commonwealth Fund, a nonprofit research organization that financed the study.

Because they are already in debt over their medical care, some families start forgoing treatments, even for serious or chronic conditions, Ms. Davis said. By deciding not to fill a prescription for high blood pressure medication or failing to go to the doctor for diabetes, they are at risk of incurring more serious and costly problems that can land them in the emergency room.

“It’s a serious health problem and it’s a serious economic problem,” she said.

As the nation has moved toward greater cost-sharing of medical expenses, “what we’re seeing is families are not in a position to shoulder that financial risk,” Ms. Davis said.

While large employers remain a strong and generous source of coverage, the Kaiser study pointed to the widening divide between employees working for big companies and those at companies with fewer than 200 employees.

Virtually all large employers offered coverage, but only 62 percent of small companies did. People working for big companies were also paying less — about $3,000 a year for family coverage — compared with $4,100 for those in small companies.

Faced with the choice of dropping coverage altogether, many small companies have opted for health plans that ask employees to pay much more in the form of deductibles and out-of-pocket expenses. One in three workers in small businesses has annual deductibles of $1,000 or more, in contrast to one in five in the previous year’s survey.

“We still strongly believe health care is an economic issue for small business, not only to the owners but to their employees; they are both paying for it,” said Amanda Austin, a lobbyist for the National Federation of Independent Business, a Washington group that represents small employers.