Medical billing advocates

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.

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Hospital Bills Disputed by Patients

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As the Health Care Reform Act is implemented over the next two years there will continue to be disputes between Insurers and providers regarding payment. Providers often take large discounts to be in network in return for a greater volume of patients through networks with insurers. It’s a  price for volume trade-off familiar to those who are economics minded. There are often problems in the interpretation and execution of agreements and the associated health care billing practices. Sometimes this results in balance bills being sent to consumers. This article profiles a dispute in New Jersey. Be prepared for other similar disputes across the country.

Meadowlands Hospital bills disputed by patients, Aetna

By  LINDY WASHBURN -The Record, Wednesday, August 15, 2012

Meadowlands Hospital Medical Center has billed hundreds of patients in the last few weeks for care they thought was covered by their Aetna insurance ­policies. The bills — some for thousands of dollars — demand payment within five days.

Aetna’s advice to the recipients: Don’t pay.

Aetna customers who receive bills from Meadowlands Hospital Medical Center are urged to contact the Department of Banking and Insurance at 800-446-7467, or file a complaint online at state.nj.us/dobi/consumer.htm

The dispute shines a light on the complicated terrain that underlies relationships between hospitals and insurers. When new owners bought the Secaucus medical center in December 2010, the state required that the for-profit company make “a reasonable attempt to continue the ­current commercial insurance contracts” for at least a year.

As a result, Aetna says, its contract with the hospital was in force in 2011 — when the bills were incurred — and so the hospital must accept the lower rate it had negotiated as payment in full.

The hospital, however, has told patients they must pay the difference between that contract rate and its regular, higher charges. The letters to those patients state clearly, “You remain obligated to pay all outstanding invoices.” They ask for payment by credit card, certified check or money order.

Meadowlands President Lynn McVey declined through a spokesman to address the contract question.

“Regrettably,” she said in a prepared statement, “a national health insurer is withholding some payments for its plan members who have previously utilized our services. Until this matter is clarified and resolved through negotiations, our reluctant recourse is to follow standard procedure … and seek payment from individuals who were previously treated by [the hospital] and still have an outstanding balance.”

Eileen O’Donnell of North Arlington was told she owed $4,745 for an emergency-room visit in May 2011 to treat a foot injury. That was more than 20 times Aetna’s member rate of $204. Her total responsibility, according to Aetna’s explanation of benefits, was $68.40.

And Kaarin Varon of East Rutherford received a demand from Meadowlands for $13,004 for the care of her son, who was hospitalized with pneumonia last year. Aetna already had paid $1,596 as its contracted rate for his stay.

“I have to admit, I was not sure how a contract dispute had me involved in all this,” said Varon. “But the [Meadowlands billing] representative basically told me it was now my responsibility.”

The state Department of Banking and Insurance is working with the health department to resolve the issue, according to Marshall McKnight, an insurance department spokesman. “Our goal is to protect consumers as much as possible through this process,” he said. Patients who receive the bills are urged to contact the department, he said.

The dispute comes at a time when questions are being raised about finances at the hospital. An independent draft audit for 2011 showed a 10 percent profit margin — four times the state average. A year after MHA LLC, a private investment group, bought Meadowlands in December 2010, the new owners had reversed the $10.4 million operating loss reported for 2010 and posted a $9 million profit, according to the draft submitted to the state.

The dispute also highlights the vast difference between a hospital’s customary charges and the rates negotiated with insurance companies for hospital care. The negotiated rates are often a fraction — 5 percent or 10 percent — of those customary charges.

Some hospitals opt to stay out of insurance contracts as a strategy to increase revenues.

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A Guide Through a Medical Wilderness

Doug

 

As the government churns through health care reform, the media has realized that consumers can negotiate their health care with doctors and hospitals.  The article indicates that it is best to choose an advocate with a successful track record in health care cost reduction.  Medical Cost Advocate is a leader in health care cost reduction through expert negotiation.

 

 

 

New York Times

 

By WALECIA KONRAD

 

THESE days, dealing with medical bills and insurance claims makes April 15 look easy. The medical jargon and inscrutable coding on invoices and explanations of benefits are indecipherable for most lay people. Worse, seriously ill patients may simply be too sick or too broke to deal with the mountains of red tape. That can lead to unpaid medical debts and even bankruptcy.

 

It’s no wonder that a cottage industry has sprung up to fill this void. Known as medical billing advocates, these middlemen and women help patients deal with the paperwork and haggling often associated with medical costs.

 

 

In general, medical billing advocates help you find errors in your bills, negotiate with your insurer to appeal coverage denials, or negotiate lower fees with your medical care providers. Some advocates do all three tasks equally well. But others, because of their training or background, may specialize in one area or another.

 

Still others give the client the ammunition he or she needs to negotiate. That’s what happened to Susan Redstone, a freelance fashion stylist and author. When she broke her back in a horseback riding accident last summer, she held only a bare-bones insurance policy. So Ms. Redstone, who has since recovered, knew that she would be responsible for the bulk of her medical expenses.

 

 

Five months after the accident, just when she thought she had paid everything off, she got a bill for $16,000 from the helicopter ambulance service that ferried her from the remote location in Colorado where the accident occurred to a large medical facility 75 miles away. “I was completely taken by surprise to get this bill so long after the accident happened,” Ms. Redstone said. She consulted with Victoria Caras, a medical advocate in Aspen, Colo., who coached her on how best to approach the medical transportation company to lower her bill. With Ms. Caras’s advice, Ms. Redstone was able to negotiate a 25 percent discount in exchange for paying the bill in full. (more…)

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Health Groups Give Obama Details on Cost-Cutting Measures

J Roberts

 An interesting letter to President Obama by industry trade groups proposing to reduce cost and achieve greater efficacy within the healthcare system. It is very high level and simply points out categories of spend that need to be attacked. The question remains – Can a fragmented group of doctors, hospitals, insurers and pharmacuetical associations come together to self impose cross entity discipline? The proof will be in the pudding.

Health Care Financial Management Association

 

In a letter to President Obama today, six healthcare groups outlined specific initiatives they said would fulfill the pledge they made a month ago to help “achieve your Administration’s goal of decreasing by 1.5 percentage points the annual health care spending growth rate—saving $2 trillion or more.” The six organizations—the American Hospital Association, American Medical Association, America’s Health Insurance Plans, Advanced Medical Technology Association, Pharmaceutical Research and Manufacturers of America, and Service Employees International Union—said that their proposed system-wide cost reductions, which “will require collaboration and good public policy,” have the potential to save $150 to $180 billion on utilization of care; $350 to $850 billion on chronic care; and $500 to $700 billion on administrative simplification and cost of doing business.

Each group presented its own initiatives to contribute to the overall cost savings. The American Hospital Association said it was committed to designing and implementing a national “Hospitals in Pursuit of Excellence” campaign, which would focus on hospital performance improvements that “have meaningful quality improvement and associated cost savings.” Immediate cost savings could be achieved, according to the AHA, by promulgating best practices that would reduce surgical infections and complications, central line-associated blood stream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, adverse drug events, and pressure ulcers. The AHA also listed longer-term goals that hospitals would work towards, including “improving care coordination, implementing health information technology, promoting efficiency resource utilization, preventing patient falls, improving perinatal care, and reducing supply costs.”

The AHA said it would work with “other stakeholders to achieve a more efficient, effective and coordinated health care system. The future vision of such as system includes simplified and standardized public and commercial insurance processing systems, reducing the need to practice defensive medicine and enhancing the ability of practitioners and providers to integrate clinically to improve quality of care.”

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