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US Healthcare: an oxymoron

October 19, 2012 in Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt

It was very exciting to read about Amanda’s grass roots Twitter research.  Amanda, you have started an activist conversation that we, the people, need to have.  Comments from so many people on what Amanda started touched on a deep and growing moral and economic issue for which we must demand answers: loss of a job means loss of insurance, medical debt, loss of shelter and bankruptcy is not a rarity, unaffordable insurance premiums as the norm for the middle class, poor medical care for the disenfranchised, etc.  I will add another observation.  Do you know that if you have a very serious mental illness, have MassHealth, and need to be in hospital, you may wait 2-3 days in an ER for a bed?  Or, if you have poor insurance, be treated in the ER, and when you are medicated and are saner, sent home? There also were a couple of comments from folks who wanted to know why the US did not have systems of care like The UK and Canada.  People want to move to Vermont where there is a progressive move toward single payer healthcare for everybody.  There IS an organization in the US committed to healthcare for all. PNHP was started by public health physicians in 1985!

Does anyone wonder why there is no political will in the US? PNHP started in 1985 with the inception of “managed care”, also viewed by many of us as for-profit healthcare. In this case “healthcare” is an oxymoron, isn’t it? Read the rest of this entry →

How to Protect Yourself from Higher Than Expected Medical Bills

September 28, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care

If you are insured and visit your local emergency room at a hospital network in your area of residence, you expect to pay the stated co-pay that shows on your insurance card, right? This is, in some senses, a reasonable expectation, but it’s not always what happens. News media outlets around the country have aggressively broadcast many cases where huge out-of-network charges for secondary providers have led to excessive medical billing amounts for patients who simply visited the wrong hospital at the wrong time.

The Problem: Hospital Network Staff Outsourcing

This major problem, that results in more out of pocket dollars than expected, really has to do with how hospitals staff. Hospitals may simply bring in outside doctors, nurses, technicians and other staff who aren’t effectively on staff at that facility, in order to help fully staff an emergency room or other hospital department. This is a convenient fix for hospitals, but what’s enraging is the idea that hospital administrators don’t think about the dramatic impact that out-of-network charges can have on patients.

What happens with out-of-network charges is that when outside physicians or other staffers happen to provide care to a particular patient, that patient is simply billed for the balance of that care because of an automatic insurer denial. Insurance companies won’t usually pay for the work of out-of-network professionals, but hospitals hire them anyway. Read the rest of this entry →

Will Medicare Changes Result in Better Quality?

September 3, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt, Medicare

As the price of health care in America keeps rising, you may be among those that are frustrated by the kind of generic approach taken by  health insurance companies and government entitlement programs. The traditional fee-for-service format of health care reimbursement means that the best hospitals and doctor’s offices don’t get rewarded and the lower performing offices don’t have consequences. But, this is all likely to change with new Medicare rules that are slated to pursue more of a ‘meritocracy’ in the way that health care dollars get paid out.

New Medicare Rules

Reports from the Centers for Medicare and Medicaid Services show that Medicare is going to begin making some changes in the way that it reimburses health care providers starting late this year. In what Medicare officials call a ‘value-based purchasing’ program, Medicare will consider various aspects of a provider’s operations in setting the reimbursement rates for that particular office. Key factors will include observation of outcomes, or in other words, whether the procedures and services performed at an office actually help patients to recover from illnesses and improve quality of life.

Responses to the Changes

For you, this represents a major change and a big potential edge in making sure you get what you deserve for the money, especially when you have out of pocket expenses. On the downside, though, some providers are arguing that hospitals and offices in rural areas, or those with other significant disadvantages, may be punished unfairly. Read the rest of this entry →

How Much is Health Insurance Coverage Really Costing You?

August 30, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Care, Medical Debt, Medicare

Just when you think you have the health care business figured out, new reports come out showing even more dark details about how American patients are simply charged massive amounts of money for health care services on a pretty arbitrary basis.

The newest wrinkle in this story actually turns the conventional wisdom about payment for health care on its ear: where many assume that most uninsured patients get the highest bills, new reports are showing that, in many cases, the “cash-up-front” deals given to cash-paying patients may be as little as less than half of a contractually agreed price that the hospital would bill the insurance company. Why is this a problem? Because it means that many of those who pay high deductibles, premiums and coinsurance on a health plan may still be paying more for each service, visit or procedure than someone who doesn’t have any insurance at all. It also injects a huge monkey wrench into the now established idea that everyone needs health insurance to make health care affordable. On the flip side, if you have a high deductible but choose to self-pay a medical bill, how will you ever meet your deductible? This is particularly troublesome should you have a catastrophic event. Read the rest of this entry →

Practice is Proactive in Patient Relationships

August 25, 2012 in health care costs, Health Insurance, Medical Care

The Commonwealth Fund’s 2010 study found that almost 50% of US adults were either underinsured or uninsured.  This is a 7% increase from 2007 for the underinsured population. It used to be that having coverage was simply enough. Today, however, having the right type of coverage and amount are key factors in choosing a plan. What happens when you don’t have coverage for a specific procedure? One forward thinking practice in the Chicagoland area takes the time to explain your options and provides the cash discount rate – up front. Before you even ask. That’s mightily refreshing given the lack of communication in many healthcare organizations. And, it’s a win win for both parties. The practice receives a bill paid in full without expending additional dollars in the collections process and the patient is educated a little bit more on how the billing and insurance process works. Let’s hope that more practices implement this customer service level in the near future.

Challenging Rejected Health Insurance Claims

August 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt

According to the AHA (American Hospital Association), 87% of hospitals expect bad medical debt to continue to grow.  And it’s no wonder with situations like a very common one experienced by patients across the nation. You are seen by your healthcare provider for a service or procedure that should be covered under your insurance plan per plan benefits. However, when the Explanation of Benefits is received from the insurance carrier, charges have been denied for coverage. What happened?

Reimbursement is based on a few key areas including plan benefits and coverage period, medical necessity, correct patient information, diagnosis code, and procedure/service code (CPT), etc. An incorrect key stroke can cause your claim to be rejected. Or, an erroneous code can result in zero dollars paid. What can you do?

Begin by appealing the rejection to your doctor and the insurance company. As described above, it may have been a simple clerical error that caused charges to be dismissed. In other situations, you want to confirm that the CPT and diagnosis codes are cross referenced. What may have happened is that the CPT code did not support the diagnosis or the reverse. Codes are chosen based on the physician’s notes, documentation, and national coding guidelines. Sometimes, the CPT code may not be specific enough or it may have incorrectly described the level of care. Most insurance companies have their own unique process and timeline for appeal submissions.

If you’ve exhausted your appeal efforts and your claim remains unpaid, you may want to file a complaint with your state’s health insurance commissioner and or enlist a medical bill advocate to navigate the process for you. Whichever route you choose, be persistent, professional, and follow through.

Medical Claim Error Rates Decline According to Latest Report Card

June 24, 2012 in health care costs, Health Insurance, News

News from the medical industry shows that the American Medical Association or AMA is working with private health insurers to lower the rates of medical billing errors within the American healthcare system. For a while now, the AMA has been talking about a collaborative effort to make medical billing more efficient, and it seems that this initiative is starting to pay off, according to this year’s National Health Insurers Report Card, an annual report released by the AMA to document national trends.

Overall Error Rates for Medical Claims

The new report shows inaccuracies for private health insurer payments dropping from nearly 20% in 2011 to just under 10% in 2012. The AMA claims that this 50% reduction has saved the industry over $8 billion, and that there’s a lot more potential for improvement. In a press release this month, AMA Board Chairman Robert M. Wah is quoted as saying that first-time accuracy in medical claim payments “saves precious healthcare dollars and frees physicians from needless administrative tasks” – that’s the idea behind these sorts of efforts to increase accuracy. These improvements help physician offices manage revenue cycles, while they also help you to understand your financial responsibility and contribute to greater transparency in the healthcare market.

Other Numbers

The National Health Insurer Report Card also provide some other assessments of this year’s trends within the medical industry. While the report shows improved response times for medical claim payments, and indicates greater transparency by health insurance companies, it also shows that medical claim denials are now on the rise. The AMA sites a prior decline between 2008 and 2011 that was reversed this year with an increase of nearly 70%. This increase, according to the AMA report, was across the board, as all major insurers declined many more claims than they had the previous year. Denials will be an issue that third party medical advocates and others will continue to evaluate in order to make sure that you are getting a fair shake when it comes to your healthcare costs.

We face a lot of challenges in identifying and controlling our health care costs. Keep informed on what’s happening in the health care industry as it affects you.

Beware of Balance Billing in Hospital Bills

May 12, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

Balance billing occurs when a healthcare provider bills a patient for some or the entire amount that should have been declared an insurance discount (contractual allowance). The fact that Prime Healthcare Services in California recently settled a suit for $1.2 million and discontinued the practice suggests that this is a problem. In fact, several states have statutes that prohibit balance billing.

How do you tell if you’ve been balanced billed? First, you have to determine if your treatment was performed by an in or out-of-network healthcare professional. Then, you have to check your EOB (Explanation of Benefits).

In- Network

Check an erroneous charge simply by seeing if the bill for the service exceeds the amount on the EOB. If it does, let your insurance company know and let them handle it.

Out-of-Network (OON)

There are two scenarios:

  • If you have an OON benefit, the OON deductible and co-insurance will apply first. The insurance company pays the balance above that like always. However, if the provider billed you for more than the deductible and co-insurance you may be the victim of a scam. Check the EOB. Did insurance pay the provider? If so, report it. It’s a scam and it is wrong.
  • If you do not have an OON benefit and accidentally got treated by the provider, tell them you want to be treated like an uninsured patient. A standard discount will be applied.

When in doubt, check with a medical bill advocate.

Understanding your premium increase- an almost impossible task

October 3, 2011 in Member Stories

I attempted to find out why my health care premium, purchased through Connector Commonwealth Choice, increased by 30+ percent after one year.

I learned:

  • There is no simple way to get the answer. Customer service employees at Blue Cross Blue Shield of MA (my carrier), The Connector and the Department of Insurance are not trained to answer specific customer questions about rate increases. I believe that is intentional. It leaves all three organizations unaccountable for what is a very complicated, inconsistent and sometimes difficult to defend set of calculations. Ask two senior staff members at BCBS the same question about your premium and you will get two different answers.
  • There is no transparency in the system. The rating factors that carriers use to determine an individual’s premium (and subsequent increases) is not public information, not what the factors are (for example age, where you live, plan usage) or how much a person’s premium can be increased because of any given factor. According to the manager of member services at BCBS, the DOI approves both the rating factors and the percentage “range” a carrier can increase a premium due to any given rating factor. (The DOI disputes this, maintaining that maximum range increases are limited by the law, not set by the DOI.) The single biggest rating factor seems to be age. The DOI (if you go with BCBS’s version of events) gave BCBS of MA approval to increase an individual’s premium up to 15 percent in a given year for age. I received the full 15 percent increase.
  • Base rate increases, a phrase commonly written about in the media, talked about by politicians and referred to by carriers, are misleading indicators of how much health insurance costs are really going up (or being “contained”, as they like to say). Read the rest of this entry →

Staggering Oral Surgery

September 30, 2011 in Member Stories

While I was in college my dentist told me that as long as I was still on my parent’s health plan, I should get my wisdom teeth taken out. They hadn’t yet become a problem and I put it off for another seven years. Had I known then what I know now, I could have saved myself a lot of discomfort, time, and money.

After getting a steady job with benefits I used my company’s dental plan to see the dentist for the first time in years. My wisdom teeth had become impacted and they were developing cavities.

I did some research and found out that my insurance plan entailed:

$50 annual deductible

20% co-pay of a $200 extraction

50% co-pay of a $500 partial-bony removal

50% co-pay of a $800 bony removal

$1500 maximum paid by insurance annually

So when I visited the oral surgeon I tried to get them to figure out which of my teeth would be considered bony and which would be considered extractions. Read the rest of this entry →