medical bill help

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 Hospital Bills – The Debate Continues

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The debate continues in New Jersey and New York regarding what to do about out-of-network charges and balance bills when the consumer has no opportunity to choose or shop for care. Several State Legislatures are trying to tackle this problem in order to protect the consumer from large unexpected medical bills. Another related challenge is who should take the financial burden of these bills: the insurance company – by paying out of network bills, or the medical provider – by accepting less payment.

Restarting N.J. hospital billing debate

By Lindy Washburn, The Record

Michael Young, a 24-year-old college student, thought he was going to die a year ago May when he called 911 while visiting his father in Paramus.

It turned out he had appendicitis. The ambulance took him to The Valley Hospital in Ridgewood, where a surgeon performed an emergency appendectomy.

Now Young faces a different kind of crisis: The anesthesiologist that night at The Valley Hospital is suing him for $2,200 — after his insurer paid $726.

Surprise medical bills just keep coming for patients in New Jersey, five months after the Legislature’s effort to fix the problem died. Some come from hospital-based doctors who don’t accept the same insurance plans as the hospital where they work. Others are received by patients with out-of-state or federally regulated coverage who go to out-of-network emergency rooms — New Jersey regulations that require the insurer to protect its members from balance billing in such cases don’t apply to their plans.

Young gets his coverage through a family insurance plan for retired New York City employees; it is outside the jurisdiction of New Jersey regulations.

His anesthesiologist was part of Bergen Anesthesia group, which does not participate in his insurance plan. There were no other choices when the ambulance took him to Valley because it is the sole provider of anesthesia services there.

The insurer — GHI/EmblemHealth — paid about a quarter of the $2,900 he was charged for anesthesiology for lower abdominal surgery under emergency conditions. GHI used its own fee schedule to determine what they considered appropriate; Bergen Anesthesia billed Young for the remainder.

Now Young is stuck with the charges. He has no income of his own.

Other recent examples include:

–At one hospital, the father of a 3-year-old who needed emergency stitches was surprised when the plastic surgeon billed him $2,000, on top of the $3,800 he received from the insurer. When the father took it up with a hospital executive, the executive said his options were limited because the plastic surgeon did not participate in any insurance plans. But he called the surgeon, who agreed to waive the rest of his fee after the child’s father paid $900 — his remaining deductible — toward the balance.

–Another couple chose a Bergen County hospital as their baby’s birthplace because it was in their insurer’s network. They were surprised to learn — when the bills came — that the anesthesiologist, surgeon and neonatologist at the hospital did not participate in their insurance plan. The plan, purchased through the Affordable Care Act on HealthCare.gov, provides no out-of-network coverage.

–In Hudson County, all three hospitals owned by for-profit CarePoint Health no longer participate in the network of the state’s largest insurer, Horizon Blue Cross Blue Shield of New Jersey. Hoboken University Medical Center was the last to opt out, as of Wednesday, when its contract ended. The three, including hospitals in Bayonne and Jersey City, are also out-of-network for Aetna, Cigna, Health Republic of New Jersey, Oscar Health Insurance and UnitedHealthcare. The vast majority of CarePoint’s patients enter through the facilities’ emergency rooms, which enables the hospitals to demand payment from insurers for their charges, among the highest in the nation, while leaving the patient’s obligation the same as it would have been at an in-network facility.

Ward Sanders, president of the state Association of Health Plans, condemned that business model on Thursday, when he renewed his industry’s call for legislative reforms. “New Jersey has become a hotbed for unconscionable out-of-network billing practices,” he said. “Certain facilities and providers … engage in predatory pricing, surprising consumers with unexpected bills, and creating exorbitant costs for consumers, employers and unions.”

“It’s time for the Legislature to step in,” he said.

Now that the logjam over Atlantic City has been broken, lawmakers say they are gearing up to try again on what Democrats and Republicans agree is a pocketbook issue. But recent developments affecting the state’s hospitals may make it more difficult. Legislation that could reduce hospital revenues or diminish their leverage with insurers will be seen as a problem, and lawmakers with hospitals in their districts are likely to hear about it.

Hospitals take a hit

The launch of the Omnia health plan by Horizon Blue Cross Blue Shield of New Jersey alienated half of the state’s 62 hospitals by labeling them as Tier 2, a non-preferred status expected to lead fewer patients to seek care at their facilities, and thus lower revenues. In addition, 30 non-profit hospitals face lawsuits — and the potential loss of their property-tax exemptions — after a precedent-setting state Tax Court decision and Governor Christie’s veto of legislation that would have protected them. And hospitals are fighting additional cuts in state charity care funding this year.

Nevertheless, Sen. Gerald Cardinale, a Demarest Republican and health professional himself — he’s a dentist — has begun circulating his own version of the “Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act” first introduced last year by three Assembly Democrats and the chairman of the Senate Health Committee, Sen. Joseph Vitale, D-Middlesex.

Cardinale’s version is somewhat friendlier to doctors and hospitals, because it would rely on peer review — one panel for doctors and one for hospitals — to settle disputes when insurers and out-of-network providers disagree over how much should be paid for a service. The original version relied on “baseball arbitration” — a choice of one side’s final offer — by outside professional arbitrators.

The Democratic sponsors of the measure that failed last session — Assemblyman Craig Coughlin of Middlesex, and Assemblymen Gary S. Schaer of Passaic and Troy Singleton of Burlington, along with Vitale — have met with interest groups and say they plan to meet again to see what changes might help the bill win passage. And Citizen Action, the consumer advocacy group, plans to call attention to the problem of surprise medical bills at an event in mid-June.

All aim to take the consumer out of the middle of such disputes.

And that’s a goal with which the state hospital association, which did not support the measure last year, can agree. It has suggested changes that would give hospitals a bigger role in preventing staff anesthesiologists and other hospital-based specialists from billing patients beyond their in-network financial obligation after the insurer has paid.

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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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How to Charge $546 for Six Liters of Saltwater

Doug

This article exposes some of the ways medical product suppliers and hospitals mark up products, sometimes 1,000 times, to capture profitable revenue from sick patients and their insurance companies.  Another example of all of the players getting caught with their hand in the cookie jar.  Will it ever change?

By NINA BERNSTEIN for the NY TImes
It is one of the most common components of emergency medicine: an intravenous bag of sterile saltwater.

Luckily for anyone who has ever needed an IV bag to replenish lost fluids or to receive medication, it is also one of the least expensive. The average manufacturer’s price, according to government data, has fluctuated in recent years from 44 cents to $1.

Yet there is nothing either cheap or simple about its ultimate cost, as I learned when I tried to trace the commercial path of IV bags from the factory to the veins of more than 100 patients struck by a May 2012 outbreak of food poisoning in upstate New York.

 Some of the patients’ bills would later include markups of 100 to 200 times the manufacturer’s price, not counting separate charges for “IV administration.” And on other bills, a bundled charge for “IV therapy” was almost 1,000 times the official cost of the solution.

It is no secret that medical care in the United States is overpriced. But as the tale of the humble IV bag shows all too clearly, it is secrecy that helps keep prices high: hidden in the underbrush of transactions among multiple buyers and sellers, and in the hieroglyphics of hospital bills.
At every step from manufacturer to patient, there are confidential deals among the major players, including drug companies, purchasing organizations and distributors, and insurers. These deals so obscure prices and profits that even participants cannot say what the simplest component of care actually costs, let alone what it should cost.

And that leaves taxpayers and patients alike with an inflated bottom line and little or no way to challenge it.

A Price in Flux

In the food-poisoning case, some of the stricken were affluent, and others barely made ends meet. Some had private insurance; some were covered by government programs like Medicare and Medicaid; and some were uninsured.

In the end, those factors strongly (and sometimes perversely) affected overall charges for treatment, including how much patients were expected to pay out of pocket. But at the beginning, there was the cost of an IV bag of normal saline, one of more than a billion units used in the United States each year.

“People are shocked when they hear that a bag of saline solution costs far less than their cup of coffee in the morning,” said Deborah Spak, a spokeswoman for Baxter International, one of three global pharmaceutical companies that make nearly all the IV solutions used in the United States.

It was a rare unguarded comment. Ms. Spak — like a spokesman for Hospira, another giant in the field — later insisted that all information about saline solution prices was private.

In fact, manufacturers are required to report such prices annually to the federal government, which bases Medicare payments on the average national price plus 6 percent. The limit for one liter of normal saline (a little more than a quart) went to $1.07 this year from 46 cents in 2010, an increase manufacturers linked to the cost of raw materials, fuel and transportation. That would seem to make it the rare medical item that is cheaper in the United States than in France, where the price at a typical hospital in Paris last year was 3.62 euros, or $4.73.

Middlemen at the Fore

One-liter IV bags normally contain nine grams of salt, less than two teaspoons. Much of it comes from a major Morton Salt operation in Rittman, Ohio, which uses a subterranean salt deposit formed millions of years ago. The water is local to places like Round Lake, Ill., or Rocky Mount, N.C., where Baxter and Hospira, respectively, run their biggest automated production plants under sterility standards set by the Food and Drug Administration.

But even before the finished product is sold by the case or the truckload, the real cost of a bag of normal saline, like the true cost of medical supplies from gauze to heart implants, disappears into an opaque realm of byzantine contracts, confidential rebates and fees that would be considered illegal kickbacks in many other industries.

IV bags can function like cheap milk and eggs in a high-priced grocery store, or like the one-cent cellphone locked into an expensive service contract. They serve as loss leaders in exclusive contracts with “preferred manufacturers” that bundle together expensive drugs and basics, or throw in “free” medical equipment with costly consequences.

Few hospitals negotiate these deals themselves. Instead, they rely on two formidable sets of middlemen: a few giant group-purchasing organizations that negotiate high-volume contracts, and a few giant distributors that buy and store medical supplies and deliver them to hospitals.

Proponents of this system say it saves hospitals billions in economies of scale. Critics say the middlemen not only take their cut, but they have a strong interest in keeping most prices high and competition minimal.

The top three group-purchasing organizations now handle contracts for more than half of all institutional medical supplies sold in the United States, including the IVs used in the food-poisoning case, which were bought and taken by truck to regional warehouses by big distributors.
These contracts proved to be another black box. Debbie Mitchell, a spokeswoman for Cardinal Health, one of the three largest distributors, said she could not discuss costs or prices under “disclosure rules relative to our investor relations.”

Distributors match different confidential prices for the same product with each hospital’s contract, she said, and sell information on the buyers back to manufacturers.

A huge Cardinal distribution center is in Montgomery, N.Y. — only 30 miles, as it happens, from the landscaped grounds of the Buddhist monastery in Carmel, N.Y., where many of the food-poisoning victims fell ill on Mother’s Day 2012.

Among them were families on 10 tour buses that had left Chinatown in Manhattan that morning to watch dragon dances at the monastery. After eating lunch from food stalls there, some traveled on to the designer outlet stores at Woodbury Common, about 30 miles away, before falling sick.

The symptoms were vicious. “Within two hours of eating that rice that I had bought, I was lying on the ground barely conscious,” said Dr. Elizabeth Frost, 73, an anesthesiologist from Purchase in Westchester County who was visiting the monastery gardens with two friends. “I can’t believe no one died.”

About 100 people were taken to hospitals in the region by ambulance; five were admitted and the rest released the same day. The New York State Department of Health later found the cause was a common bacterium, Staphylococcus aureus, from improperly cooked or stored food sold in the stalls.

Mysterious Charges

The sick entered a health care ecosystem under strain, swept by consolidation and past efforts at cost containment.
For more than a decade, hospitals in the Hudson Valley, like those across the country, have scrambled for mergers and alliances to offset economic pressures from all sides. The five hospitals where most of the victims were treated are all part of merged entities jockeying for bargaining power and market share — or worrying that other players will leave them struggling to survive.

The Affordable Care Act encourages these developments as it drives toward a reimbursement system that strives to keep people out of hospitals through more coordinated, cost-efficient care paid on the basis of results, not services. But the billing mysteries in the food poisoning case show how easily cost-cutting can turn into cost-shifting.

A Chinese-American toddler from Brooklyn and her 56-year-old grandmother, treated and released within hours from the emergency room at St. Luke’s Cornwall Hospital, ran up charges of more than $4,000 and were billed for $1,400 — the hospital’s rate for the uninsured, even though the family is covered by a health maintenance organization under Medicaid, the federal-state program for poor people.
The charges included “IV therapy,” billed at $787 for the adult and $393 for the child, which suggests that the difference in the amount of saline infused, typically less than a liter, could alone account for several hundred dollars.

Tricia O’Malley, a spokeswoman for the hospital, would not disclose the price it pays per IV bag or break down the therapy charge, which she called the hospital’s “private pay rate,” or the sticker price charged to people without insurance. She said she could not explain why patients covered by Medicaid were billed at all.

Eventually the head of the family, an electrician’s helper who speaks little English, complained to HealthFirst, the Medicaid H.M.O. It paid $119 to settle the grandmother’s $2,168 bill, without specifying how much of the payment was for the IV. It paid $66.50 to the doctor, who had billed $606.

At White Plains Hospital, a patient with private insurance from Aetna was charged $91 for one unit of Hospira IV that cost the hospital 86 cents, according to a hospital spokeswoman, Eliza O’Neill.

Ms. O’Neill defended the markup as “consistent with industry standards.” She said it reflected “not only the cost of the solution but a variety of related services and processes,” like procurement, biomedical handling and storage, apparently not included in a charge of $127 for administering the IV and $893 for emergency-room services.

The patient, a financial services professional in her 50s, ended up paying $100 for her visit. “Honestly, I don’t understand the system at all,” said the woman, who shared the information on the condition that she not be named.

Dr. Frost, the anesthesiologist, spent three days in the same hospital and owed only $8, thanks to insurance coverage by United HealthCare. Still, she was baffled by the charges: $6,844, including $546 for six liters of saline that cost the hospital $5.16.
“It’s just absolutely absurd.” she said. “That’s saltwater.”

Last fall, I appealed to the New York State Department of Health for help in mapping the charges for rehydrating patients in the food poisoning episode. Deploying software normally used to detect Medicaid fraud, a team compiled a chart of what Medicaid and Medicare were billed in six of the cases.

But the department has yet to release the chart. It is under indefinite review, Bill Schwarz, a department spokesman, said, “to ensure confidential information is not compromised.”

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For Obamacare, Some Hurdles Still Ahead

Doug

President Obama and his advisers hope the healthcare overhaul will do two things. The first is to extend coverage to tens of millions of Americans who today lack health insurance. The second is to hold the line on rising health care costs. This article describes some hurdles to achieving those two goals. While you are enjoying a vacation this summer, hopefully you will have time to ponder the impacts Health Care Reform will have on you and your family.

By Eduardo Porter, NY Times

Like other big employers, in the mid-1990s Harvard University was struggling with the ballooning cost of providing health insurance.
It chose what was a novel solution for the time. It dropped its standard deal — a subsidy that rose in line with the price of the insurance policy — and switched some 10,000 workers on its payroll to a fixed subsidy that encouraged them to shop around for care.

For Harvard’s accountants, the change worked wonders. A study a couple of years later by David M. Cutler, a Harvard economist, and Sarah Reber, a Harvard graduate, concluded that competition among insurers cut the university’s health bill by 5 to 8 percent.
But not everybody was equally pleased. Families of workers who chose the Preferred Provider Organization offered by Blue Cross/Blue Shield — the most comprehensive plan, with lots of doctors and hospitals on its network — faced a $500-a-year jump in their out-of-pocket spending on health care.

Younger and healthier workers canceled their P.P.O. plans, enrolling in cheaper H.M.O. options or dropping Harvard insurance altogether. Left with a sicker patient base, the P.P.O. raised its premiums further, which prompted the next layer of relatively healthy customers to leave.
And so on. In 1997, Blue Cross/Blue Shield withdrew its P.P.O. from the market, making it a victim of what economists call the death spiral of adverse selection.

In a couple of months the nation is set to experience a similar shock on a very large scale: the greatest change in how Americans pay for health care since the advent of Medicare nearly half a century ago.

Come October, millions of uninsured people will be able to choose one of several health plans, offered at four different tiers of service and cost through new health exchanges coming onstream in every state.

Cheap “bronze” plans will shoulder some 60 percent of patients’ medical expenses. Pricey “platinum” plans will cover at least 90 percent. But insurers will not be allowed to exclude people with pre-existing conditions, or charge more for the sick, or put a lifetime cap on medical costs. Their policies will have to cover a minimum standard of medical care. And the government will subsidize those who cannot afford to buy the policies.

President Obama and his advisers hope the overhaul will do two things. The first is to extend coverage to tens of millions of Americans who today lack health insurance. The second is to hold the line on rising health care costs.

“Over time, success will depend on what happens to the cost curve,” Professor Cutler told me. “If we don’t bend the cost curve, everything will fail. The government won’t be able to afford it. Nobody will be able to afford it.”

In theory, the overhaul could meet both goals. Millions of new Americans armed with a subsidy and shopping among plans would bring consumer choice to bear, finally, on the health care industry. Insurers would compete to create policies that offered the most value for money, pressuring hospitals and doctors on behalf of all of us.

Yet despite the care the administration took in establishing incentives and safeguards, even some of Obamacare’s most committed backers are wondering whether the experiment will work as advertised — or, like Harvard’s P.P.O., go off the rails along the way.

Adverse selection is perhaps the direst threat. For Obamacare to work, millions of healthy, young, uninsured Americans must join a health plan to counterbalance the sicker millions who are most likely to buy insurance. Otherwise, health plans on the exchanges will have to raise premiums to shoulder the higher costs.

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Tips for Lowering Your Medical Bills

J Roberts

Don’t be intimidated by high medical bills. What patients don’t realize is a review to find errors and working with the provider can often enable you to reduce medical bills. To enhance your outcome, enlist the services of a medical bill negotiation expert. With the help of a professional who can provide data, most providers will negotiate and offer some type of discount on out-of-pocket medical expenses. Here are some excellent tips that every health care consumer should know when faced with large and expensive medical bills.

By Alice Park, Time Magazine Online

It doesn’t happen often, but occasionally you can catch a mistake on a restaurant check or a miscalculated receipt from the grocery store. Hospital bills, however, are another matter: as many as 8 out of 10 bills for health care services contain errors, according to Medical Billing Advocates of America. Since Americans spend nearly $7,000 per capita on health care every year — and since these expenses climb steadily, at an average annual rate of 6.5% — it’s probably worth scrutinizing the remittance from your last hospital visit. It just might save you hundreds, if not thousands, of dollars.

According to medical-billing advocates, who are the health care world’s equivalent of tax-refund specialists, there are ways to protect yourself from huge health care expenditures both before you’re seen by a doctor and after you receive your bill. “When you are in the hospital, you should concentrate on getting better,” says Kevin Flynn, president of HealthCare Associations, a company that helps patients decipher their medical bills. “Do what is best medically first, then worry about the finances second.”

At the emergency room or in the hospital:

If you are insured, ask to be seen by a doctor who participates in your insurance plan. Just because a hospital is considered in-network by your plan doesn’t mean that all the physicians who work there are as well. This may not always be possible, but if your preference is noted in your file, once you receive your bill, you may be able to negotiate with the hospital to accept your insurer’s higher in-network reimbursement rate, leaving you with a smaller financial responsibility, even if you are seen by an out-of-network doctor.

For the same reason, if you are able to, ask to have any lab testing that is sent outside the hospital to be sent to facilities that participate in your insurer’s plan.

If possible, ask about the tests the doctor or nurses are ordering. If a less expensive test can provide the same information, then request that option. In some cases, for example, less expensive ultrasound tests are just as effective as costly CT scans.

Once you get your bill:

Always ask for an itemized bill so you can see every charge.

Ask for an explanation, in writing, from the hospital’s billing department for any disputed charges.

If you go to the hospital at night and end up being admitted after midnight, make sure your charges for the room start on the day you start occupying the room.

Check the level of room for which you were charged. Hospitals charge for ER services by level, depending on the amount of equipment and supplies needed, with Level 1 requiring the fewest (e.g., a nosebleed) and Level 5 representing an emergency (trauma, heart attack). Question the level indicated on your bill and ask for a written explanation of why that level was billed. Hospitals have their own criteria for determining levels and should make this available upon request. “They don’t freely hand this information out, but they will send it to you if you ask for a written response,” says Pat Palmer, founder of Medical Billing Advocates of America.

Doctors also charge for ER services by level, also ranging from 1 to 5. Their levels are standardized, and physicians are required to meet three criteria to justify billing at each level. Question the level listed on your bill and ask for a written explanation of why that level was billed by your physician.

The hospital level should be equal to or lower than that of the doctor-billed level; if it’s higher, that’s a red flag that there may be a billing error.

Question charges for what seem like routine items, such as warm blankets, gloves and lights. These should be included as part of the facility fee.

Question any additional readings of tests or scans. You should be charged only once for one doctor’s reading of a scan, unless it is a second opinion or consultation.

If you received anesthesia, check that you were charged for only one anesthesiologist. Some hospitals use certified registered nurse anesthetists (CRNAs) but require that an anesthesiologist supervise the procedure, so some bills will contain charges from both, which amounts to double billing.

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Health Care Reform Rules Give Patients A New Bill Of Rights

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Health Care Reform initiatives have yielded a new “Patient Bill of Rights” since November. There will be a great number of changes enacted in 2013 leading up to 2014 when coverage mandates, state insurance exchanges and tax changes take effect for health care. Sound confusing?, It certainly will be. In the meantime, “Know your rights” and check back with us periodically to learn how to navigate health care cost and confusion.

Jeffrey Young – Huff Post Business – 11/20/2012

Health insurance consumers won’t be discriminated against because of pre-existing conditions, can’t be charged more because of gender and will be guaranteed a basic set of benefits under historic new federal regulations published Tuesday.

Think of them as the Patients’ Bill of Rights that eluded former President Bill Clinton more than a decade ago. The regulations carry out the promises of President Barack Obama’s health care reform law, which will extend health insurance coverage to 30 million people over a decade and outlaw some of the industry’s most notorious practices.

Health insurance companies, state regulators and consumer advocates have eagerly awaited these rules since Obama enacted the health care overhaul in March 2010.

The details contained within the 331 pages of regulations are crucial for health insurance companies and states preparing for the new options that will be available to uninsured people and small businesses starting in 2014. The health insurance exchanges, online marketplaces where consumers can shop for plans and determine whether they qualify for tax credits to pay for private insurance coverage or Medicaid benefits, are slated to be open for business on Oct. 1, 2013.

“Americans in all 50 states will have access to an exchange and the benefits of the new law,” Health and Human Services Secretary Kathleen Sebelius said on a conference call with reporters Tuesday. “Beginning in October next year, families and small-business owners everywhere will be able to shop for affordable, quality health coverage.”

The Department of Health and Human Services published three separate regulations Tuesday. Broadly, the rules restate the health insurance market reforms in Obama’s health care law. But health insurance companies and state officials that aren’t actively resisting the implementation of Obamacare need the details to ensure that health insurance exchanges are ready, and health plans available for sale on time.

One lays out the rules requiring health insurance companies to sell coverage to anyone who applies, prohibits charging women more than men, limits how much people must pay additionally based on age, where they live, family size and whether they use tobacco, and guarantees renewal of health coverage every year.

A second set of regulations spells out which benefits all health insurance plans sold on the exchanges must cover — 10 categories of medical care, including emergency services, hospital stays, maternity care, prescription drugs and preventive medicine. In addition, the rule explains how states must designate an insurance product already on the market as a “benchmark plan” to serve as a model for what the new insurance products will cover starting in 2014. This regulation also sets up how health insurance companies must prove their plans will cover at least 60 percent of a consumer’s average annual medical expenses.

The cost of health insurance on the exchanges will be subsidized using tax credits for people with incomes up to 400 percent of the federal poverty level, which is $44,680 this year. People who make up to 133 percent of poverty, $14,856 in 2012, will qualify for Medicaid in states that opt into an expansion of the health program for the poor.

The Obama administration published a third rule on “wellness” programs that employers include in workers’ health benefits, such as discounts to employees who quit smoking, lose weight or lower their cholesterol. The new regulations are designed, in part, to prevent companies from using the programs to set prices to discriminate against workers who don’t meet the wellness programs’ standards.

Publishing these regulations is just one small step toward 2014, however, and major obstacles remain. As of Monday, just 17 states and the District of Columbia had committed to creating a health insurance exchange themselves as the law sets out, according to a tally by the Henry J. Kaiser Family Foundation. The federal government will have to step in, and partially or completely establish these exchanges in the rest of the states, including those run by Republican governors like Rick Perry of Texas who have vowed continued opposition to the law.

“Now that the law is here to stay, I’m hopeful that states and other partners will continue to work with us to implement the law,” said Sebelius, who offered to meet with governors who have outstanding questions about states’ role in carrying out the health care reform law. Florida Gov. Rick Scott (R), an ardent opponent of Obamacare, last week wrote Sebelius requesting a sit-down.

(more…)

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Sixteen percent of Americans unable to pay medical bills, according to Consumer Reports’ Trouble Tracker Index

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Medical Cost Advocate recently appeared in the September issue of Consumer Reports. One of the key points of this article is the assertion that consumers should line up a medical billing advocate or their own alternatives proactively. Don’t wait until its too late to do your research and find a health care negotiator.

Consumer Reports: How to Haggle With Your Doctor or Hospital

YONKERS, NY — When we visit our doctors, we don’t typically think of ourselves as “consumers” or buyers of health care, but in these tough times, that is precisely the role a patient needs to play to avoid drowning in a sea of medical bills. What are the best strategies for haggling with your doctor or hospital? A new report in the October issue of Consumer Reports and online at www.ConsumerReportsHealth.org features advice from Consumer Reports’ medical expert and M.D., John Santa.

According to the latest Consumer Reports Index, which gauges the health of the economy from the consumer perspective, 16.3 percent of Americans are unable to afford medical bills.

“Americans are overwhelmed by health costs and many people simply can’t pay their bills, can’t afford their medications,” says John Santa, M.D., M.P.H., director of the Consumer Reports Health Ratings Center. “The last thing most patients want to do is haggle with their doctors, but a little bit of negotiating can go a long way. It’s also important to know that there are tremendous variations in health care costs—knowing this can help a consumer get a hand up and politely insist on the fairest possible price.”

Here’s Consumer Reports’ advice for three possible scenarios:

You’re healthy.The optimal time for patients to talk with their healthcare providers about costs is before any have been incurred. While doctors have a professional obligation to take a patient’s financial resources into account, patients should raise the issue with their doctors to let them know that costs are important to them. “For a variety of reasons, doctors are likely to suggest the most expensive options first. But you might be surprised by your doctor’s willingness to change course, for example prescribing fewer expensive brand name drugs or choosing watchful waiting over a costly diagnostic test,” says Santa.

The unexpected occurs. A patient lands in the hospital without the benefit of any planning and gets slammed with a huge bill, say $15,000 for a coronary angiogram, and insurance ends up covering only a fraction of the bill. Consumer Reports recommends these approaches to get the greatest reduction to their bill:

  • Sit down with the doctor who ordered or performed the hospital services to find out how the hospital costs ran so high. Were all the services needed and reasonably priced? Consumers can judge for themselves by checking www.healthcarebluebook.com which lists the going rates for many medical services for free. Closely examine each bill to identify errors, which are common.
  • Consumers should not assume the price on their bill is set in stone. Providers often discount rates substantially to insurers and others, so why shouldn’t a consumer ask for the same rate reduction? Consumers should dispute any charges they think their insurance company ought to cover.
  • Patients should not pay their bill until they have exhausted all of their options, but they should make clear to the hospital’s billing department that reaching a resolution is important to them. They might consider making a discounted offer they think would be manageable within a set time period. Consumers can consult one of the reputable groups that, for a fee, can help reduce the size of medical bills, such as Medical Cost Advocate (localhost/wp1).

You’re having an elective surgery. This situation allows for more planning and research into the best procedure, doctor, hospital, drug or other option. “Use your time wisely to do the research because variations in health-care costs can be significant, and providers will gladly let you overpay for a service that you could get for less,” says Santa. Keep in mind the following advice:

  • Consumers should shop around, talk to different providers, and bargain for what they think is a fair price.
  • Consumers shouldn’t hesitate to ask for the price upfront and get it in writing. Request an itemized list of all potential charges.
  • As with any purchase, consumers should beware of any offer that sounds too good to be true. If a provider suggests a shortcut, be wary and ask a lot of questions, and check out providers that are unfamiliar.

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Care costs continue brisk growth in 2011

J Roberts

Another study revealing the ever increasing rise in healthcare costs. Tell us something we don’t know. Will costs ever level off and maybe even decrease or is that just wishful thinking? At this point, I’ll take no increase over the double digit rise in premiums and the greater out-of-pocket expense. Americans continue to pay more and get less. What’s wrong with this picture?

By Tom Murphy

AP Business Writer

Health care costs have more than doubled for some American families over the past nine years, and they show few signs of dropping, according to a

The employee portion of costs paid for a family of four covered by the most common form of employer-sponsored health insurance will climb to a projected $8,008 this year from $3,634 in 2002. That amounts to an additional $84 a week from household budgets for health care.

Preferred provider organization plans are the most common form of employer-sponsored coverage.

The rise in health care costs is slower in 2011 compared to recent years, but they are still rising much higher than costs in other consumer areas, said consulting actuary Lorraine Mayne, one of the report’s authors.

“We don’t see anything on the near-term horizon that’s going to bend that downward,” she said.

The consulting firm compiled its annual health care cost measurement, known as the Milliman Medical Index, by studying provider fees, benefits and average health care use in all 50 states. Health care costs include insurance premiums for health care and other costs that come out of an employee’s pocket like co-payments, deductibles and co-insurance payments.

Employers still pay most of the total health care cost for families, but Milliman said the portion paid by the worker reached an all-time high of almost 40 percent this year.

Counting employers’ contributions, this year’s total health care cost for a family of four more than doubled to $19,393 from $9,235 in 2002. The 2011 figure represents a 7 percent increase compared to 2010.

Health care costs are rising mainly due to price increases in categories like pharmacy, inpatient or outpatient hospital care and doctors’ office visits. Mayne said these charge increases are a bigger factor than changes in health care use.

The national health care overhaul, which started unfolding last year and aims to eventually cover millions of uninsured people, had virtually no impact on health care costs for this year, Mayne said. She also doesn’t see the new law having any “direct, immediate impact” on the trend.

The Milliman report revealed nothing surprising to Helen Darling, CEO of the National Business Group on Health, a non-profit organization that represents large employers on health care issues. Darling, who was not involved in the study, said it offers more evidence of the “serious economic and financial dysfunction of the health care system.”

“The health care system continues to outstrip everything in its growth,” she said, noting that the economy “simply can’t support this kind of expense.”

Milliman said the total for health care costs varies around the country and doesn’t represent the total for all health care plans. Variables like costs and use can differ for government-sponsored Medicare and Medicaid coverage or other forms of commercial health insurance.

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Rising Cost Tops Employees’ Health Care Worries

J Roberts


Employers are still concerned about the rising cost of healthcare. Will there be any end in sight?

By Stephen Miller

U.S. employees’ greatest concerns about health care are rising costs, canceled coverage and new taxes on medical benefits. Their employers are most concerned about the lack of federal guidance on what requirements must be communicated to employees, according to a December 2010 survey by HighRoads, a benefits administration service provider.

“There appears to be a healthy skepticism on the employer’s part about the content and timing of guidance from the federal government on how to administer and communicate future plan changes,” said Kim Buckey, practice lead at HighRoads. “While most employers increased their communications efforts during the fall 2010 open enrollment period to communicate changes required by health care reform, there are still doubts about how effective those communications were.”

Buckey advised, “There is clearly an opportunity to do some follow-up communications—based on the actual employee elections during open enrollment—or employee sensing (surveys or focus groups) midyear to determine whether employees truly understood the impact of the year’s plan changes.”

Employees’ Concerns

The biggest concerns HR professionals and benefits managers are hearing from employees about how health care reform affects them, HighRoads found, include:

• Increased cost of coverage (noted by 50 percent of respondents).

• Cancellation of benefits (13 percent).

• Government taxation of medical benefits (13 percent).

• Ability to add adult dependents (12 percent).

• No real concerns (12 percent).

Increased Communications

While 88 percent of employers reported that they had increased their employee communications to address health care reform, many still worried that the communications might not have been enough. The biggest communications concerns employers had around health care reform for the year ahead include:

• Lack of federal guidance on what the requirements are or how any changes in guidance during the year might change what has been communicated to employees (25 percent).

• The disconnect on cost and existing plans, because the law is predicated on being cost neutral to taxpayers and allowing employees to not lose the coverage they have (13 percent).

• Making sure that employees are told everything that is changing under their plans (13 percent).

• Employee understanding of changes and how the changes affect them (12 percent).

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