How Not To Get “Hurt” Giving Birth: Medical Billing Tips for Parents

The Cost of Giving Birth: What Expecting Parents Should Know About Medical Billing

Giving birth in America comes with a lot of costs so disclosed and some not. It is possible to manage the cost of childbirth through informed, careful decision-making. The key is to plan ahead. The below article includes quotes by Medical Cost Advocate and appeared on Fatherly.com on August 16, 2019

By Adam Bulger – Fatherly.com

Giving birth

Moments after my daughter’s birth, I basically had to negotiate the cost of a timeshare.

My first job as a new dad was choosing a recovery room at a Manhattan hospital known for luxury accommodations. It was the dead of night. I was exhausted and unsure about our insurance coverage, so I opted for a lower-tier option. Months later, our insurance covered the room but, because of a billing error that took months to resolve, didn’t cover basic care.
Sorting out the cost of birth was confusing and stressful. But compared to other parents, my family had it pretty easy. Giving birth in America is an expensive, confusing process where parents often feel like they have no choices or negotiating power. But medical billing experts and maternity care advocates say it’s possible to manage the cost of childbirth through informed, careful decision-making.

In a 2013 national study of inpatient care costs, pregnancy and childbirth hospitalizations accounted for five of the 20 most expensive conditions for hospital stays covered by Medicaid and three of the 20 most expensive conditions for hospital stays covered by private insurance. The mean hospital stay expense is $18,000. All told, a standard birth could run you roughly $30,000. If a C-Section is required? It’s considerably more. But despite the price tag, births aren’t big money-makers for hospitals. Sean P. Lillis, founder and CEO of New York City–based medical billing services firm Billing Geeks, notes that the high cost of birth for parents doesn’t translate into enormous profits for hospitals.

Per Lillis, hospitals don’t make money off of obstetrics. Hospitals have to devote considerable time, resources, and staff for labor. Despite the overhead, private insurance pays hospitals according to fee-for-service schedules, meaning insurance pays more to hospitals for some types of patients, like the ones undergoing short stay surgical procedures requiring a battery of tests and procedures, than others, like the ones giving birth. “They can’t make their maximum reimbursement charge rate,” he says.

While the real action of having a kid happens in the delivery room, that’s not what you pay for. Most labor costs happen later, during the mom’s short hospital stay following birth.
“Four out of five of all dollars paid on behalf of the mother and the baby across that full episode from pregnancy through the postpartum and newborn period go into that relatively brief hospital window,” says Carol Sakala, Director of Childbirth Connection Programs at the National Partnership for Women & Families.

Some of the hospital costs, like medical tests for the baby and mother, can’t be avoided. Others you might be able to work around. Some hospitals reportedly impose fees for using their TVs; others can charge as much as $20 for an Ibuprofen. Packing an iPad and a bottle of Advil in your go-bag can defray some of those gotchas. But, honestly, saying no to these add-ons is chump change compared to what you can save by doing a little homework ahead of time.

How to Avoid the High Costs of Child Birth
Maria Montecillo, a healthcare insurance and billing advocate for the New Jersey medical billing advocacy firm Medical Cost Advocate, says parents should get in the weeds of their health plan as soon as they know they’re expecting. Knowing what health care providers are in your network makes a huge cost difference. And if your network’s too small, you may be lucky enough to be able to expand it. While it isn’t easy to time a pregnancy, the months leading up to your company’s health care enrollment period are an ideal time to make informed coverage changes.

“If you know you’re going to be pregnant this year, think about changing your insurance coverage,” Montecillo says. “You’ll pay a higher premium now but it’ll work out later.”
And when you’re getting close to the due date, taking your time can save a lot of money. Hospitals often try to slot births into a timetable that benefits the institution but may harm its patients, as there’s evidence early admission correlates with higher rates of labor induction and C-section births.
“The system is, for its convenience, pushing women into giving birth at weekday, daytime, non-holiday hours,” Sakala says. “A vast number of labor inductions, which add costs, could be avoided, a vast number of Caesarians, which add costs, could be avoided.”

Delayed admission to labor, where the mother doesn’t enter the delivery until they’re in active labor, is a simple way to reduce the cost of birth. Under delayed admission, the mother, ideally with the guidance of a midwife, doula, or other birthing professional, monitors the frequency and intensity of her contractions.

If the expectant mother has a hearty constitution or advanced skills in pain management, forgoing an epidural can avoid billing surprises.
“One of the places where people are getting into trouble with out-of-network providers is with the anesthesiologist,” Sakala says. “You didn’t choose that person, and the person who’s on call at that time could very well be out-of-network and those charges could be sky-high.”

It might be possible to skip the hospital — and its price tag — altogether. Sakala is a big proponent of birth centers, non-hospital labor facilities that offer natural births, without epidurals, inductions, or Caesarians or the high costs associated with those procedures. “They’re avoiding many things that are avoidable and pulling in beneficial practices that might be kind of low-tech, like being up and about, as opposed to staying in bed,” she says. “Or being in a tub or being in a shower. Those kinds of things can make a huge difference.”

The first month after the birth, parents have a small window of opportunity to shuffle around their insurance coverage. If the mother and father have separate insurance coverages, a baby’s birth is automatically billed under the mother’s insurance. They have 30 days to add the newborn to either the mother or father’s policy. Tracking the vagaries of insurance coverage can easily slip down the priorities list when you’re dealing with a newborn but ignoring it can court disaster.
“I once had a case where the parents ‘forgot’ to add the baby into their insurance plan, and they had to wait until open enrollment for the baby to be added,” Montecillo says. “As luck would have it, the baby developed complications and needed surgery. The insurance company stuck to their guns and refused coverage for the baby, as this was clearly stated on the policy and the parents were hit with a huge medical bill.”

When your insurance company’s bill for the birth arrives, don’t rush out to the post office with a check. Take your time and scrutinize the charges. Insurance coverage is complicated, even for insurance professionals. Mistakes happen. An insurer may have calculated a payment on the basis of an incorrect fee schedule for your plan or charged you for something that wasn’t performed.
“Look over the bill carefully,” Montecillo says. “It’s just like at a restaurant. You want to see that if you ordered chicken nuggets that they charged you for chicken nuggets.”

Spotting a costly error can be infuriating. Nonetheless, overt hostility is the wrong approach to the discovery. Montecillo says that everything is negotiable — she chiseled down a $60,000 triplet birth to a $1,300 final bill, for example — but only when the person on the phone wants to negotiate. And that means being not just polite but persuasive. “Start with sweetness but if you’re not getting anywhere, ask to talk to a manager,” she says.

And Montecillo speaks from experience. Before working on behalf of consumers, she spent 14 years as billing manager for a large private medical practice.
“I was on the other end of those calls and I know that I can make changes,” she says. “But if you’re nasty or you’re saying mean things about the doctor, I can say no.”

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

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

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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Why does it cost $32,093 just to give birth in America?

Our company receives many inquiries like this. Stella had approached us last April, emotionally distraught over the thousands of dollars in medical bills she was receiving related to the premature birth of her triplets. One of our expert medical billing advocates was assigned to take her case. She was very happy with the favorable outcome (a reduction in her final balance by an incredible amount), and so were we. Like Stella, we may be able to help you too. 

The US is the most expensive nation in the world in which to have a baby – and it may factor into thousands of bankruptcies each year.

Tue 16 Jan 2018

Jessica Glenza in New York – The Guardian

Stella Apo

Stella Apo Osae-Twum and her husband did everything by the book. They went to a hospital covered by insurance, saw an obstetrician in their plan, but when her three sons – triplets – were born prematurely, bills started rolling in.

The hospital charged her family $877,000 in total.

“When the bills started coming, to be very honest, I was an emotional wreck,” said Apo Osae-Twum. “And this is in the midst of trying to take care of three babies who were premature.”

America is the most expensive nation in the world to give birth. When things go wrong – – from preeclampsia to premature birth – costs can quickly spiral into the hundreds of thousands of dollars. While the data is limited, experts in medical debt say the costs of childbirth factor into thousands of family bankruptcies in America each year.

It’s nearly impossible to put a price tag on giving birth in America, since costs vary dramatically by state and hospital. But one 2013 study by the advocacy group Childbirth Connection found that, on average, hospitals charged $32,093 for an uncomplicated vaginal birth and newborn care, and $51,125 for a standard caesarean section and newborn care. Insurance typically covers a large chunk of those costs, but families are still often on the hook for thousands of dollars.

Another estimate from the International Federation of Health Plans put average charges for vaginal birth in the US at $10,808 in 2015, but that estimate excludes newborn care and other related medical services. That is quintuple the IFHP estimate for another industrialized nation, Spain, where it costs $1,950 to deliver a child, and the cost is covered by the government.

Even the luxurious accommodations provided to the Duchess of Cambridge for the birth of the royal family’s daughter Princess Charlotte – believed to have cost up to $18,000 – were cheaper than many average births in America.

Despite these high costs, the US consistently ranks poorly in health outcomes for mothers and infants. The US rate of infant mortality is 6.1 for every 1,000 live births, higher than Slovakia and Hungary, and nearly three times the rate of Japan and Finland. The US also has the worst rate of maternal mortality in the developed world. That means America is simultaneously the most expensive and one of the riskiest industrialized nations in which to have children.

American families rarely shoulder the full costs of childbirth on their own – but still pay far more than in other industrialized nations. Nearly half of American mothers are covered by Medicaid, a program available to low income households that covers nearly all birth costs. But people with private insurance still regularly pay thousands of dollars in co-pays, deductibles and partially reimbursed services when they give birth. Childbirth Connection put the average out of pocket childbirth costs for mothers with insurance at $3,400 in 2013.

In Apo Osae-Twum’s case, private insurance covered most of the $877,000 bill, but her family was responsible for $51,000.

Apo Osae-Twum was the victim of what is called “surprise billing”. In these cases, patients have no way of knowing whether an ambulance company, emergency room physician, anesthesiologist – or, in her case, a half dozen neonatologists – are members of the patient’s insurance plan.

Even though Apo Osae-Twum went to a hospital covered by her insurance, none of the neonatologists who attended to her sons were “in-network”. Therefore the insurance reimbursed far less of their bills.

There are few studies that estimate the number of families who go bankrupt from this type of unexpected expense. One of the best estimates is now outdated – conducted 10 years ago. But one of the authors of that research, Dr Steffie Woolhandler, estimates as many as 56,000 families each year still go bankrupt from adding a new family member through birth or adoption.

“Why any society should let anyone be bankrupted by medical bills is beyond me, frankly,” said Woolhandler. “It just doesn’t happen in other western democracies.”

Since Woolhandler conducted that research in 2007, 20 million Americans gained health insurance through the Affordable Care Act health reform law, and consumer protections were added for pregnant women. But Republicans and the Trump administration have pledged to repeal these consumer protections.

“People face a double whammy when they’re faced with a medical condition,” said Woolhandler. Bankruptcy is often, “the combined effect of medical bills and the need to take time off work”.

There is no nationwide law that provides paid family leave in the US, meaning most families forego income to have a child.

And although childbirth is one of the most common hospital procedures in the nation, prices are completely opaque. That means Americans don’t know how much a birth will cost in advance.

Dr Renee Hsia, an emergency department physician at the University of California San Francisco and a health policy expert likened the experience to buying a car, but not knowing whether the dealership sells Fords or Lamborghinis. “You don’t know, are you going to have a complication that is a lot more expensive? And is it going to be financially ruinous?”

According to Hsia’s 2013 study, a “California woman could be charged as little as $3,296 or as much as $37,227 for a vaginal delivery, and $8,312 to $70,908 for a caesarean section, depending on which hospital she was admitted to.”

Apo Osae-Twum and her family only found relief after a professional medical billing advocate agreed to take their case. Medical Cost Advocate in New Jersey, where Derek Fitteron is CEO, negotiated with doctors to lower the charges to $1,300.

“This is why people are scared to go to the doctor, why they go bankrupt, and why they forego other things to get care from their kids,” said Hsia. “I find it heartbreaking when patients say… ‘How much does this cost?’

https://www.theguardian.com/us-news/2018/jan/16/why-does-it-cost-32093-just-to-give-birth-in-america?CMP=fb_gu

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Surprise Medical Bills

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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Finding Help for the High Costs of Cancer Care

This article from the Philadelphia Enquirer contains valuable information about the high cost of cancer care and the options people have in managing those costs.

The good news is more Americans are surviving cancer.

The bad news? We pay big bucks to stay free and clear of the disease.

Nearly 14.5 million American cancer survivors remain alive and well as of Jan. 1, 2014, according to the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control and Prevention. By 2024, cancer survivors will number 19 million people.

So how much does it cost to stay cancer-free? Quite a lot, says Zhiyuan Zheng, Ph.D. and senior health services researcher with the American Cancer Society in Atlanta.

For American men, the three most prevalent types of cancer among survivors are prostate (43 percent), colorectal (9 percent), and melanoma (8 percent). Breast (41 percent), uterine (8 percent), and colon and rectum (8 percent) are most common among women who survive cancer.

Prostate, colorectal, and breast cancers account for about 30 percent of all cancer-related health-care costs. The survivors incur higher medical expenses, are at higher risk of secondary cancer, and require more tests and follow-up care.

Total cancer treatment costs in 2004 were $72 billion, about $120 billion in 2014, and will increase to $180 billion by 2024, Zheng adds.

How does that break down per person? In the first 12 months, breast cancer treatment costs roughly $20,000, colorectal cancer $30,000, and prostate $10,000.

Lost workdays add to the total annual economic burden per cancer survivor: $20,238 for colorectal, $14,202 for breast, and $9,278 for prostate, for those under age 64, the researchers found.

Fortunately, cancer patients can now turn to medical bill negotiators who bargain with medical providers.

“We have a number of cancer patients who’ve hired us. Plus we’re also seeing a higher success rate” among cancer patients, says Derek Fitteron, founder and CEO of Medical Cost Advocate in Wyckoff, N.J.

One customer was a family facing $125,000 in bills incurred in a year for treatment of a rare childhood cancer.

“We reviewed the bills for billing accuracy and found comparable pricing negotiating savings of more than $85,000 with several Pennsylvania facilities,” Fitteron said.

Resources Cancer maintains a list of organizations that help patients financially

The Cancer Financial Assistance Coalition is a group of national organizations that provide financial help.

The nonprofit CancerCare provides limited financial assistance to people affected by cancer. It also has a foundation to help fund copays, the CancerCare Patient Assistance Foundation

The HealthWell Foundation similarly provides financial assistance to cover copayments, premiums, and deductibles for certain medications and therapies.

Partnership for Prescription Assistance helps qualifying patients who lack prescription-drug coverage obtain the medications they need.

Needy Meds offers information on companies assisting those who can’t afford medication.

The Patient Access Network Foundation assists patients with out-of-pocket costs associated with their treatment.

Patient Services Inc. assists with insurance premiums and copayments for people with chronic diseases.

RxHope.com helps patients obtain free or low-cost prescription medications.

The Assist Fund provides financial support to chronically ill patients with high-cost medications.

The Patient Advocate Foundation provides education, legal counseling, and referrals for people with cancer who need assistance managing insurance, financial, debt crisis, and job-discrimination issues.

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Hospital Charges Surge for Common Ailments, Data Shows

This excellent NY Times article is based on Medicare data on over 3,000 hospitals nationwide for what they charged in 2012. The data shows that the prices that hospitals charge is highly variable and has risen across the board. The article correctly points out that these increases in charges do not necessarily affect what Medicare pays because Medicare is so large that they tell hospitals what they are going to pay them independent of what they bill.

By JULIE CRESWELL, SHERI FINK and SARAH COHEN –  JUNE 2, 2014

Charges for some of the most common inpatient procedures surged at hospitals across the country in 2012 from a year earlier, some at more than four times the national rate of inflation, according to data released by Medicare officials on Monday.

While it has long been known that hospitals bill Medicare widely varying amounts — sometimes many multiples of what Medicare typically reimburses — for the same procedure, an analysis of the data by The New York Times shows how much the price of some procedures rose in just one year’s time.

Experts in the health care world differ over the meaning of hospital charges.

While hospitals say they are unimportant — Medicare beneficiaries and those covered by commercial insurance pay significantly less through negotiated payments for treatments — others say the list prices are meaningful to the uninsured, to private insurers that have to negotiate reimbursements with hospitals or to consumers with high-deductible plans.

“You’re seeing a lot more benefit packages out there with co-insurance amounts that require the holders to pay 20 percent of a lab test or 20 percent of an X-ray. Well, 20 percent of which price?” asked Glenn Melnick, a professor who holds a Blue Cross of California endowed chair at the University of Southern California. “Some hospitals will charge 20 percent of what Blue Cross Blue Shield will pay; others will play games.”
Data released by the federal government shows that hospitals across the country charge Medicare differing amounts for the same types of cases. The data includes bills submitted in 2012 by 3,300 hospitals nationwide for the 100 most commonly performed treatments and procedures like hip replacement, heart operations and gallbladder removal, among hospitals that reported at least 11 cases.

Charges for chest pain, for instance, rose 10 percent to an average of $18,505 in 2012, from $16,815 in 2011. Average hospital charges for digestive disorders climbed 8.5 percent to nearly $22,000, from $20,278 in 2011.

In 2012, hospitals charged more for every one of 98 common ailments that could be compared to the previous year. For all but seven, the increase in charges exceeded the nation’s 2 percent inflation rate for that year, according to The Times’s analysis.

Experts say the increase in the price of some of the most common procedures may be offsetting rising technology or drug costs, declines in the number of patients being admitted to hospitals and a leveling out of reimbursements from Medicare. Between 2011 and 2012, Medicare increased payment rates by only 1 percent for most inpatient stays.

The number of patients admitted for chest pain under Medicare’s fee-for-service plans plummeted more than 28,000, to 107,224 in 2012, and inpatients with digestive disorders decreased more than 29,000, to 217,514.

Over all, the number of Medicare patients discharged from hospitals for the comparable 98 most common diagnoses dropped from 7.5 million to 7.2 million. The total amount Medicare paid for their care also declined somewhat between 2011 and 2012, from $62.8 billion to $61.9 billion.
In an effort to reduce overall health care costs, hospitals have been encouraged to admit fewer patients for conditions like asthma, for example, in favor of less expensive outpatient care.

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No Easy Answers on Financing Long – Term Care

By JUDITH GRAHAM, NY Times

This article points out the difficulty in financing long term care for the elderly.  Experts believe more focus should be on finding ways to provide affordable care within the efforts to reform Medicare and Medicaid.  For now, families continue to bear the brunt of the cost associated with caring for the elderly.

The federal Long-Term Care Commission published its full report on Wednesday, but it did little to change the perception that substantial relief for caregivers will be a long time coming.

The commission had endorsed a package of 28 recommendations late last week, prior to the release of the full report. Among other measures, the recommendations call for recognizing caregivers as members of “care teams,” including information about caregivers in patient records, assessing caregivers’ need for support, and making services like respite care more widely available.

But this group of 15 experts couldn’t agree on how to pay for long-term care services needed by frail older adults or people with disabilities. The full report doesn’t change that.

Currently, only those who are impoverished and qualify for Medicaid get significant assistance from the government for long-term care. For the most part, middle-class families are left to bear the burdensome expenses: $18 an hour on average for homemaker services, $19 an hour for home healthcare aids, $3,405 a month for assisted living, $230 a day for a private nursing home room, according to the latest report from Genworth Financial.

How to ease this financial burden was the most important issue facing the commission. In the end, the report proposed two alternatives: some kind of government insurance program for long-term care, or some kind of private insurance option. Then commission members essentially threw up their hands, admitting they couldn’t agree.

When my colleague Paula Span wrote about the commission earlier this year, she asked whether its work would elicit a yawn or a cheer. For many, the answer is neither. Even some commission members feel a sharp sense of frustration and disappointment.

One is Judy Feder, a professor of public policy at Georgetown University, who voted against the commission’s final recommendations on the grounds that they didn’t fulfill Congress’s charge to come up with a comprehensive solution. I asked her about a statement from six of her fellow commissioners insisting that any new long-term care program not enlarge public budgets.

“The current system has a budgetary implication,” Dr. Feder said. “It sticks it to families.”

Another disappointed member is Judith Stein, executive director of the Center for Medicare Advocacy. “The vision in the majority report is not much more than we have now,” she said. “It is, ‘Plan, understand, think about savings and insurance, and provide for those who are impoverished.’ That kind of approach doesn’t meet our long-term care needs now, and it won’t meet them in the future.”

While several of the commission’s recommendations are welcome, they will make a difference only “around the margins,” Ms. Stein said.
Families will bear the consequences, said Ms. Stein and other experts. Elderly spouses will continue to struggle to care for each other, and adult children will strain to balance jobs and the needs of frail parents and their own children. Untold numbers of aging Americans won’t get enough care, and caregivers will suffer from stress and depression, endangering their own health.

If a public insurance program is unaffordable, as several commission members claimed, might the private market supply a solution to the aging population’s need for affordable long-term care? That seems unlikely. Premiums for private long-term care insurance have been rising dramatically, policies are becoming more restrictive, insurers have been exiting the market, and bureaucratic red tape makes it difficult for many individual and families to receive expected benefits.

Financially, the only way to make private insurance work is to spread risk over a wide base of policy holders. But the cost of long-term care coverage makes it unlikely that millions of healthy people will purchase policies. This was the economic calculus that doomed the Class Act, the voluntary long-term care insurance program that was originally part of the Affordable Care Act.

Is there a way forward? The long-term care commission recommended two options: convening a White House conference on aging to consider long-term care policies, and establishing yet another advisory committee to continue its work. But, said Dr. Joanne Lynn, a geriatrician who directs the Center for Elder Care and Advanced Illness at the Altarum Institute, “The administration has shown no interest in having that happen, and here we are on the cusp of the largest generation in history growing old.”

She believes that it’s a mistake to separate long-term care from broader reforms of Medicare and the health care delivery system. The two systems of caring for people with disabilities and older adults need to be much more tightly integrated, Dr. Lynn said. Savings from eliminating inappropriate medical care — by some estimates, as much as one-third of all care — could be used to finance the expansion of long-term care services, she suggested.

As for another commission, is there any reason to hope it will be more successful in tackling critical issues when advocates of smaller government are committed to standing against a new federal insurance program for long-term care that might rely, at least in part, on public financing?

“I think this will be a hard discussion, but it is one that we as a country will have to grapple with,” said Dr. Bruce Chernof, the commission’s chairman and president of the SCAN Foundation in California. He sees the seeds of a potential compromise embedded in the commission’s report. The two primary financing options considered by the commission share “some commonalities,” he said, including agreement on the need for strong public programs and a role for the private sector.

“If you look carefully at these two perspectives, you can begin to see a way forward.”

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10 Ways to Save on Healthcare

As health care costs continue to increase, it is extremely important for consumers to scrutinize the charges they receive.  Medical bills are difficult to understand. In fact, 77% of Americans don’t understand health insurance or medical billing. It pays to have a advocate review your bills and negotiate with medical providers on your behalf.  Their experience, available data resources and relationship with providers will save you time and money. Below are 10 ways you can save on healthcare costs.

By Margarett Burnette, Bankrate.com

As health care consumers endure higher deductibles and reduced insurance benefits, it is becoming more important to understand and even negotiate prices before receiving medical treatment.

Dr. Kathryn Stewart, medical director of care management at Mount Sinai Hospital in Chicago, believes that patients can and should be more proactive about seeking the best prices for their services.

“Hospital costs are probably 40 (percent) to 50 percent of what their (list price) charges are,” she says. But when it comes to billing, “most hospitals are happy to break even or have a little bit of profit.”

This means there is plenty of room to negotiate and reduce your out-of-pocket expenses.

Cutting costs

Shop for hospital care as you would any other consumer service, but with more effort since costs can run really high. You can save yourself a bundle using these strategies.

10 ways to reduce your medical bills
 1. Ask your doctor to be your ally
If you’re shopping around for medical services, you probably have a primary physician who directed you to seek the service in the first place. “You have to get diagnosed by somebody,” says Stewart. “So let that person be your advocate.”
She advises patients to ask their doctors where the best hospitals are for the recommended procedures, which centers will work with patients to lower out-of-pocket costs, and to even ask for help communicating with that facility’s finance department.

“If the hospital where a physician admits is approached by that physician on behalf of the patient, I think (the patient) might get somewhere with the hospital. Let’s say I have a patient in my practice who has one of these really high-deductible (insurance) plans, and they need to have a hysterectomy. (I could) approach the finance department and say ‘I’ve got this patient, but they don’t have (enough) insurance and they can’t afford to pay full price, but they can afford to pay something. Can you work with them?'”

2. Compare costs by using the CPT code
Though your doctor might be willing to initiate a conversation with the hospital finance department, you can still expect to have several conversations with them on your own. Before calling, make sure you have the “current procedural terminology,” or CPT, code for the procedure you are seeking.
“CPT is the industry term for the ‘billing code.’ It’s a five-digit number that is used to bill the procedure,” says Jane Cooper, president and CEO of Patient Care, a health advocacy company based in Milwaukee. Cooper says that your physician or physician’s office can provide you with the code, and the number is the same across hospitals. With this code, you can call multiple medical centers to compare prices for the same procedure.

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The $2.7 Trillion Medical Bill

The fragmented health care market in the United States has driven up costs, putting deep economic strains on consumers and the country. The Affordable Care Act promises to help Americans become insured and obtain access to the system. What about reducing health care cost? Reducing the cost of care has been more elusive. In the mean time consumers need to find trusted partners to reduce medical bills.

Colonoscopies Explain Why U.S. Leads the World in Health Expenditures

 By ELISABETH ROSENTHAL, NY Times

 Deirdre Yapalater’s recent colonoscopy at a surgical center near her home here on Long Island went smoothly: she was whisked from pre-op to an operating room where a gastroenterologist, assisted by an anesthesiologist and a nurse, performed the routine cancer screening procedure in less than an hour. The test, which found nothing worrisome, racked up what is likely her most expensive medical bill of the year: $6,385. That is fairly typical: in Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56. Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500. “Could that be right?” said Ms. Yapalater, stunned by charges on the statement on her dining room table. Although her insurer covered the procedure and she paid nothing, her health care costs still bite: Her premium payments jumped 10 percent last year, and rising co-payments and deductibles are straining the finances of her middle-class family, with its mission-style house in the suburbs and two S.U.V.’s parked outside. “You keep thinking it’s free,” she said. “We call it free, but of course it’s not.”

In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care. Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin.

Americans pay, on average, about four times as much for a hip replacement as patients in Switzerland or France and more than three times as much for a Caesarean section as those in New Zealand or Britain. The average price for Nasonex, a common nasal spray for allergies, is $108 in the United States compared with $21 in Spain. The costs of hospital stays here are about triple those in other developed countries, even though they last no longer, according to a recent report by the Commonwealth Fund, a foundation that studies health policy.

 While the United States medical system is famous for drugs costing hundreds of thousands of dollars and heroic care at the end of life, it turns out that a more significant factor in the nation’s $2.7 trillion annual health care bill may not be the use of extraordinary services, but the high price tag of ordinary ones. “The U.S. just pays providers of health care much more for everything,” said Tom Sackville, chief executive of the health plans federation and a former British health minister.

Colonoscopies offer a compelling case study. They are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs. Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.

 The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.

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