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Is anybody surprised that enforcement of the "Red Flag Rule" (requiring "Creditors" to have a plan to prevent identity theft) has been postponed once again?  Link to one of many previous posts.  This time, the Federal Trade Commission postponed at the request of Congress. 

Here is the link: Friday's FTC Announcement

What charges are you supposed to pay if you have a PPO, POS. or an HMO type of insurance plan? Deductibles and copays, right? If you receive a bill from a non participating provider, you may be asked to pay more than your fair share of the bill. In some situations you may not even know you were receiving services from a non participating provider, or even had a chance to choose a provider, which is often the case when the doctor or hospital you did choose, uses the services of providers who do not participate in your plan, or any other plans.

For instance, you my need surgery and not have a choice of anesthestists, or you may need a lab test which is rendered in your doctor's office or a hospital. The provider may choose the pathologist that meets their needs, whom they have relationships with, without regard to your health plan or whether they are using a participating provider for such services.

Insurers then, in turn, deny charges that they deem excessive and the provider bills you for those denied amounts, in addition to any deductible and coinsurancem, even though you did not choose that provider. Insurers base their denied payments on arbitrary information.

This practice is referred to as Balance Billing. Most states prohibit balance billing. Be sure to find an experienced consumer advocate who can help you get these charges removed from your bill.

As a patient, if this occurs to you, you might consider the following pre-emptive strike. Forewarned is forearmed and it is far better to play offense, than defense, with aggressive providers.

* Read and understand your managed care plan contract. Know your duties and responsibilities. Follow the rules.

* Privately inform your medial provider that you are aware of the “contract-medicine” concept.

* Confidently tell the provider to put the BB invoice in writing, under his personal signature.

* Whisper to him/her you will fax it to your employer, third-party payer, attorney, IRS, OIG, DOJ and/or insurance commissioner for a collegial second-opinion check of the amount billed.

Finally, once the problem has been resolved, politely inform the provider that true BB is illegal; and suggest that if your health plan’s compensation is too low, he/she should enlist in the plan.

Contact TeamGail for help with balance due medical bills

For more on this issue: Balance-Billing Conundrum

If nonprofit hospitals spend far less money on providing charity care for the poor and uninsured than the value of their federal, state and local tax exemptions, do they deserve those exemptions? What about if they turn away indigent patients or hound them with aggressive collection practices?

More on this...

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Doctors and the fee-for-service system are at the center of the health care debate. This article defines how insurance was created in 1929. A very simple concept that has been controversial since inception. Well worth reading this from the NY Times.

www.nytimes.com

Once again, Wendell raises some really strong points that America needs to listen to. His words speak volumes. Having been an insurance insider myself for many years, sitting on many boards, and WAY too many Kool-Aid meetings, I echo his sentiments. Seems at the moment that the public option has strong support, but the fear tactics raised by the opposition are casting a large and ever growing shadow upon it.

We can not afford to kill reform like we did in the 90's. The entire economy is at stake.  The public option is the ONLY thing that has made any sense since in decades.  For goodness sake America - it's time to end the BUCA cartel!!!

"nonprofit co-operatives don?t stand a snowball?s chance of competing with those big companies and making a whit of a difference in the lives of the 75 million Americans who either have no insurance or have such marginal insurance they might as well have no insurance."  

"Almost all metropolitan areas in the country?and states that are more rural than urban? are now dominated by just two or three insurers. It is impossible for even one of the other large insurers to break into a market dominated by its competitors."

"If CIGNA can?t overcome the huge barriers to entering that market, a nonprofit co-op wouldn?t have a chance."

"To be sure, health insurers take every opportunity to badmouth co-ops, saying they are a backdoor to socialized medicine. Their criticism is disingenuous. Secretly, they would love to have a bill that creates co-ops that won?t work instead of a single-payer or public option that has proven successful in other western countries."

Co-Op Kool Aid

In reflection of just how delicate this debate has become, the 250,000 member physician group AMA has largely backtracked from its opposition of a public plan.

"Make no mistake: health reform that covers the uninsured is AMA'stop priority this year," a clarifying statement from the group read. "Every American deserves affordable, high-quality health care coverage.

"Today's New York Times story creates a false impression about the AMA's position on a public plan option in health care reform legislation. The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of the public plan that are currently under discussion in Congress. This includes a federally chartered co-op health plan or a level playing field option for all plans. The AMA is working to achieve meaningful health reform this year and is ready to stand behind legislation that includes coverage options that work for patients and physicians."

For more on this article see

Huffington Post

If you don/t follow Maggie Mahar - I suggest you do. Here is one of her posts:

The American Medical Association has announced its opposition to a public-sector health plan that would compete with private insurers. Why? Because the AMA fears that Medicare E (for everyone) might not pay some specialists as handsomely as private insurers do now.  Why do private insurers pay more? Because they can pass the cost along to you and I in the form of higher premiums.  Medicare E has no one to pass costs on to except taxpayers. And taxpayers will already be helping to subsidize those who cannot afford insurance.

Everyone agrees that primary care physicians are underpaid. Democrats in both the House and the Senate propose raising their fees, as does the Medicare Payment AdvisoryCommission (MedPac)---the group that might take over setting fees for Medicare. Moreover, the House, the Senate,President Obama and MedPac have made it clear that they do not favor theacross-the-board-cuts called for under the sustainable growth rate (SGR)formula. Congress has consistently refused to make those cuts and PresidentObama did not include them in the 2010 budget that he originally sent to Congress.  On that score, the AMA has nothing to worry about. 

Read More >>>

Maggie Mahar

Tax-exempt hospitals do not have to pay federal income taxes. The Congressional Joint Committee on Taxation estimates the value of these tax breaks at more than $6 billion a year.

Before 1969, the Internal Revenue Service required hospitalsto provide charity care to qualify for tax-exempt status. Since then,the agency has not specifically required charity care, but communitiesmust benefit in other ways.

Consumer groups and Patient Advocates can’t describe the benefits provided to their communities in consideration of the nonprofit tax exempt status because they are not visible. What is more visible, is that nonprofit hospitals have denied care to some uninsured patients and used aggressive tactics to collect bills owed by low-income people, they say.

The SenateFinance Committee is considering a bipartisan proposal that would require hospitals to provide a minimum annual level of charitable careas a condition forgetting or keeping the tax-exempt status available to charitable organizations.

Under the Amendment # 295, to to HR1, Senator Grassley proposes that hospitals could not refuse service because of a patient’s inability to pay, and they would have to follow certain procedures before taking collection actions against patients.If a hospital violated these standards, the government could revoke its tax-exempt status or impose excise taxes as a penalty.

Charles E. Grassley of Iowa proposed this amendment because he feels that many hospitals got a tremendous advantage from their tax-exempt status,but did not provide enough charity care to justify it.

Hospitals plan to begin a lobbying campaign this week to prevent Congress from including charity care requirements in legislation to overhaul the health care system.In a bulletin on Thursday, the American Hospital Association urged hospital leaders around the country to contact Congress to oppose this amendment.

PUT YOUR CAR KEYS BESIDE YOUR BED AT NIGHT

Put your car keys beside your bed at night. If you hear a noise outside your home or someone trying to get in your house, just press the panic button for your car. The alarm will be set off, and the horn will continue to sound until either you turn it off or the car battery dies.

If your car alarm goes off when someone is trying to break into your house, odds are the intruder won't stick around... After a few seconds all the neighbors will be looking out their windows to see who is out there and sure enough the criminal won't want that.

As if access to healthcare wasn't already overwhelming and increasingly limited, new tactics will be utilized by hospitals beforeyou even walk through the door. Why bother obtaining and paying for a high deductible policy which you can't afford, only to discover that healthcare is still out of your reach?

Access to healthcare will be left to those who are still employed and who also work for large companies, or the wealthy. For the middle class and low income individuals, or those who don't work for a large company, or who have become unemployed, or who may have health issues, healthcare is not an option!!

Why are hospitals who are guilty of these practices still allowed to operate as non profits?!

Hospital Tactics

Recently the AMA filed class action lawsuits against Aetna, Cigna and Welpoint for underpaying out of network claims. The AMA was also recently awarded $350m against United Healthcare for the same allegations.

In recent years some of these same industry giants lost litigation related to denying claims for medical necessity. In those class-action lawsuits, physicians alleged that many of the nation's largest insurance companies delayed or denied reimbursements for health services and illegally rejected claims for necessary medical treatments as part of a racketeering conspiracy. Doctors claimed that their medical services were "downcoded" by insurance companies so that reimbursements would be smaller.

In 2005 Wellpoint became the fifth company to settle claims brought by more than 700,000 physicians against major U.S. health insurers. Aetna settled in May 2003, followed later that year by Cigna. Health Net and Prudential Insurance, which sold its health insurance business to Aetna, also settled in 2005.

Including the WellPoint settlement, the insurers' settlements up to 2005, totaled $590 million in cash.This consisted of $367 million for physicians, $40 million for a not-for-profit health care foundation and $183 million in attorneys' fees.

Industry analysts at the time and still today predict that WellPoint and the other insurance giants will likely increase premiums to cover the lawsuit's cost -- which includes lawyers fees, payments to doctors and implementation of new billing systems - WHO PAYS FOR THIS?! SALLY & JOE, me and you - that's who!

In May of 2007, 23 Blue Cross and Blue Shield Association plans settled a class action lawsuit filed by 900,000 physicians. Under the settlement, the BCBS plans will contribute $128 million to a fund to which physicians can submit previously disputed claims and pay as much as $49 million in legal fees. In addition, BCBS plans agreed to establish new external review boards to address disputed claims, make their fee schedules and reimbursement explanations more transparent, standardize definitions and review procedures used to determine whether services are medically necessary.

In an article written July 13, 2005, Medical News Today quoted WellPoint CEO Larry Glasscock in a statement that said, "We see this agreement as a very important step in further collaborating with physicians" (Miami Herald, 7/12/05). Sam Nussbaum, WellPoint's executive vice president and chief medical officer, said, "This agreement ... will also help to support more efficient and high quality health care that will enable physicians to spend more time with patients and that ultimately benefits everyone, including our members" (AP/Hartford Courant, 7/12/05).

This article also quoted Michael Sexton, president of the California Medical Association, who said WellPoint "will no longer be in the exam room with the physician and patient," adding, "The patient will get the appropriate care they need when they need it" (Washington Post, 7/12/05).

Yeah...right.

HAS ANY OF THIS RESULTED IN SAVINGS TO CONSUMERS?!

Lower medical bills?

Reduced premiums?

Less red tape?

More time with your doctor?

Less denied care?

IS THERE ANY LESS ADMINISTRATIVE EXPENSE FOR PROVIDERS?

REDUCED ADMINISTRATIVE EXPENSE FOR INSURANCE COMPANIES?

I welcome replies from just ONE consumer who can say he has saved time or money from any of this litigation, or who thinks he is protected from balance billing, and not caught between his provider and his insurance company, save for a few isolated HMO participants.

The American Medical Association is among several medical societies that have filed a class action lawsuit against WellPoint, Inc., the largest health insurer in the United States.  The lawsuit, filed earlier this week in Los Angeles federal court, alleges that WellPoint colluded with others to underpay physicians for out-of-network medical services, resulting in patients paying an excessive portion of the medical bill. 

The AMA filed similar class action lawsuits last month against Aetna Health, Inc. and the CIGNA Corporation. United Healthcare owns the database (Ingenix) that is used by these payers. In January, the AMA was awarded $350 million in a lawsuit against UnitedHealthcare and Ingenix. 

These lawsuits will take years to be settled and will set historic precedents. In the interim, premiums will rocket to cover the costs of defense for these payers and to cover the eventual settlements.

Payers have been underpaying claims on the basis of unreasonable charges (a plan exclusion commonly referred to as UCR) for decades.  It is used to control costs when a provider is not under a cost control contract with a payer.

When a plan participant utilizes a non participating provider, either by choice or enforced due to lack of options, there are no means to control the costs so long is it is medically necessary, which is another subject in its entirety.

The Ingenix database replaced a predecessor database that was in existence before the early 1970's! There are no other databases that exist today, or beforehand, that accumulate billed charges nationally. Prior to Ingenix's purchase by United Healthcare, it was independently owned which in itself aided to the defense of the data used by payers. The data now used under the ownership of UHC can be seen as self serving. 

There are many flaws to the Ingenix system, most of which will not be detailed in this blog. However, a little history and the writer's opinion on arbitrary reductions is appropriate.

In my professional experience as an ex insurance company executive, I can report that Ingenix accumulates billed charges that are submitted by various insurance companies, mainly the same payers involved in the litigation. The Ingenix predecessor was owned and named HIAA - the Health Insurance Association of America. HIAA has since been replaced by AHIP - Americas Health Insurance Plans. AHIP or HIAA sold the database to Ingenix and Ingenix was then acquired by United Healthcare. The rest is history.

By definition, unreasonable charges are most commonly defined by the amount billed (regardless of payment), by the majority of providers in the same area. Payers have tightened their plan language over the years to decrease appeals and strengthen their denials but the concept has remained the same. 

The database is scored by percentile based by procedure codes. For example, a payer might choose to pay the 80th percentile (very common) and would pay what 80% of all providers BILLED within the same three or five digit zip code. OR they can choose the 50th percentile. The percentile choice is solely at the discretion of the payer. No industry standards exist.

Regardless of the percentile chosen, another flaw with the database is that if there is only one provider then that provider's charge is the sole determining factor and becomes all the percentiles! There can be no comparison of charges for the same procedure in the same area when there is only one or no providers who have billed for that procedure in its zip code.

UCR reductions by their very nature are arbitrary and often a matter of judgement rather than based upon facts. The judgement call could be a simple as an IT analyst determining which database it can program into its system to be compatible with electronic claims processing and the volume of claims. Or it could be as simple as a claims examiner deciding what to base a payment on if the system flags a claim for review. If the examiner's payment authorization is exceeded by the amount of the claim it may get a supervisors review, again an arbitrary decision will be made and the results will stand pending an appeal which would then be subject to state and federal regulations.

States and the federal government have established appeals procedures but they are always modified and hard to weed through without an attorney.The appeals process is time intensive and requires significant expertise and resources which smaller providers and consumers just don't have.Hence the current class action lawsuits.

It's hard enough to get a preauthorization before a service is rendered and all that means is that the procedure has been determined to be necessary for a patient. It has no bearing upon the eligibility of a claim, or the payment that will be made. Imagine the energy drain from obtaining preauthorizations and then fighting a denial of underpayment on the same claim!

Recently states have enacted balance billing problems that are intended to take consumers out of the middle of payment disputes when a provider simply gives up and bills that patient for the amounts that an insurance company has denied. However, the regulations only apply to HMO claims, not ERISA claims, indemnity, commercial, self funded health or PPO plans.

Providers are seeking justice for short pays and time and energy spent on appeals for underpaid claims.

In the defense of insurance companies however, if there is no limit on the amount an insurance company pays for claims the cost of healthcare would be even more prohibitive that it is today.

Providers often subsidize managed care payments by not participating in smaller health plans. The smaller the health plan the less negotiation strength of the plan and the more it will pay, subsidizing the BUCA giant (Blue Cross, United, Cigna, Aetna).

The crisis is decades old and has been perpetuated by managed care. Medical inflation was a lot less significant before managed care.

These are class action lawsuits and the class will take forever to be determined and the winners will be the attorneys. If the insurance companies settle or lose, premiums will become unfathomable. The arbitrary nature of underpayments based upon this criteria and the implied allegations of manipulation will cause insurance companies to settle this and just raise premiums to cover the settlement.

It needs to be settled or ended by the federal government before its too late. There is no way this is going to reduce the cost of healthcare in the future. All it will accomplish is PERHAPS repair some damage done at the cost of future premium increase.

Of course this is just my opinion and simply based upon my professional experience.

Pleae contact TeamGail if you need help with a denied claim. We are experts in this field and can help with underpaid or denied claims. We are patient advocates and have significant resources and staff to assist.

Excellent free tools for creating business plans, cash flow projections and more!              

Business plans & more

What treatment does my doctor recommend, and do I understand it?
What are my other treatment options?
How do I choose the right care for my needs and pocketbook?
How to do I locate doctors, facilities and pharmacies?

Help is here!

The law is on your side!!  Prohibitions on balance billing that have been enacted in 

many states are very supportive of consumers and will stop medical debt 

collectors. 

TeamGail can help you!!! 

Health Claim - Balance Billing Prohibited: 

A contracted or non-contracted Florida licensed medical provider or facility

can not bill a subscriber if the HMO fails to pay a claim for a covered service.  

Florida Law prohibits providers from billing members

for covered services except for applicable co-payments, co-insurance or 

deductibles.  The medical provider or facility may bill the subscriber for 

services received that are not covered by the HMO contract. 

HMO (Individual and Group):  Statute 641.3154
Standard & Basic (HMO & Insurance): Statute 641.3154

Florida Statues: Balance Billing

The Fed is making a list and checking it twice. But, financial institutions must comply with that list well before Christmas. On Jan. 1, new regulations from the Federal Reserve Board went into effect requiring all banks and financial institutions to improve efforts to combat identity theft.

These RED FLAG RULES say that all financial institutions, including banks, credit unions, mortgage lenders, and more, that store consumer accounts to develop and implement identity theft prevention programs that will help combat ID theft in connection with new and existing accounts.

Financial institutions must create reasonable policies and procedures for preventing ID theft, identify red flag signals of possible identity theft, and notify victims. With the compliance deadline Nov. 1, 2009, financial institutions have a mere 50 business days to fulfill seven requirements.

Contact TeamGail for help understanding COBRA - we are experts!

http/www.teamgail.com/contact.htm

As health-care costs continue to soar, millions of confused consumers are paying medical bills they don't actually owe. Typically this occurs when an insurance plan covers less than what a doctor, hospital, or lab service wants to be paid. The health-care provider demands the balance from the patient. Uncertain and fearing the calls of a debt collector, the patient pays up.

Most consumers don't realize it, but this common practice, known as balance billing, often is illegal. When doctors or hospitals think an insurer has reimbursed too little, state and federal laws generally bar the medical providers from pressuring patients to pay the difference. Instead, doctors and hospitals should be wrangling directly with insurers. Economists and patient advocates estimate that consumers pay $1 billion or more a year for which they're not responsible.

Balance billing most frequently occurs when medical providers participating in a managed-care network believe the plan's insurer is imposing too deep a discount on medical bills or is taking too long to pay. California, New Jersey, and 45 other states ban in-network providers from billing insured patients beyond co-payments or co-insurance required by the plan. Similarly, federal law prohibits providers from billing Medicare patients for unpaid balances.

These laws require medical providers to seek payment only from the insurer for services covered by the plan. Many states also shield insured patients from balance billing by out-of-network hospitals and doctors in emergencies, since patients usually don't control who treats them in those situations. (Bans on balance billing generally don't apply when a patient gets an elective procedure, such as cosmetic surgery, or seeks out-of-network, non-emergency service without a referral.)

Hospital comparisons - this is a great site to compare hospitals within any radius. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national, standardized survey of hospital patients. HCAHPS (pronounced "H-caps") was created to publicly report the patient's perspective of hospital care. The survey asks a random sample of recently discharged patients about important aspects of their hospital experience.The HCAHPS results allow consumers to make fair and objective comparisons between hospitals, and of individual hospitals to state and national benchmarks, on ten important measures of patients' perspectives of care. 

www.abouthealthsatisfaction.org