“The Dallas team forced the dismissal by aggressively pursuing discovery deep into the recesses of the Plaintiffs’ billing practices. In the end, the Plaintiffs decided they preferred to dismiss the case rather than testify about the inner workings and methodology of their billing system and practices.”
Archive for November, 2012
The National Alliance for Insurance Education & Research has released the first edition of “Risk Manager Profile: Knowledge and Responsibilities for a Growing Profession,” a study offering a look into the career paths and responsibilities of working risk managers.The study draws from a survey of nearly 500 risk managers as well as 10 in-depth interviews, the organization said Wednesday in a statement.The research is intended to help professionals compare their responsibilities and compensation with those of others with similar experience and education; longer interviews offer a look at how others began and made their way through the industry, the group said in the statement. The survey showed a wide variety of experiences, but Jim Cuprisin, research director for the National Alliance Research Academy, noted a few key findings: About 37% of risk managers have an advanced degree, which is above the norm, and about 88% of those surveyed were over 40 years old. “It takes awhile for people to move into the risk management field,” said Mr. Cuprisin, adding that many cross over from the insurance, financial and other industries.The study is available at www.TheNationalAlliance.com. The digital edition costs $45, and the print edition costs $55 plus shipping.
Mercer L.L.C. said it is launching a new health insurance exchange in which retired employees eligible for Medicare can choose from an array of different health care plans.While the prevalence of employers offering coverage to Medicare-eligible retirees continues to decline, about one-third still do, according to Mercer.Through an exchange, employers no longer directly offer coverage, relieving them of a significant administrative burden while giving retirees more benefit choices, Mercer notes. In addition, the exchange, which Mercer is offering along with Connextions, Inc., a technology solutions company, will provide assistance to retirees during enrollment periods and throughout the year.
Statistics show that about 80% of Americans believe in heaven. A clear majority, to be certain, but reason enough to provide a benefit allowing employees to connect to the afterlife?
One man is hoping it is. Robert Fahey, PhD., a self-proclaimed psychic spirit medium and clairvoyant, has been carving out a business niche for himself by working with employers to help workers reach out to deceased loved ones.
Not sure what you’d call this: Ancillary afterlife? Heaven benefits?
Whatever term you prefer, Fahey is building a decent client roster for himself, saying that intuitive knowing for workers about their future life translates into higher profits.
“Once a worker experiences the paranormal prescription of a spiritual message from the beyond or by way of an afterlife encounter, it delivers a boost in job competency skills, work interest, motivation, and kindness for the making of better communications and relationships,” Fahey says.
All things employers are after — particularly in today’s low engagement environment.
However, Fahey’s results don’t come cheap: According to his website, a one-time event costs $1,250 for a group of 2-10 participants, with an additional $125 per person charge for groups of 11 or more.
On November 20, 2012, the DOL, HHS and Treasury (Departments) jointly issued proposed regulations on wellness programs (2012 Proposed Regulations) reflecting changes made under health care reform that would:
- Increase the maximum allowed reward for standards-based wellness programs offered in connection with a group health plan from 20% to 30% of the cost of coverage.
- Further increase the maximum allowed reward for wellness programs designed to prevent or reduce tobacco use to 50%.
By Rob Lamberts, MD
“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees.
Section 1813(b) of the Act prescribes the method for computing the amount of the inpatient hospital deductible. The inpatient hospital deductible is an amount equal to the inpatient hospital deductible for the preceding CY, adjusted by our best estimate of the payment-weighted average of the applicable percentage increases (as defined in section 1886(b)(3)(B) of the Act) used for updating the payment rates to hospitals for discharges in the fiscal year (FY) that begins on October 1 of the same preceding CY, and adjusted to reflect changes in real case-mix. The adjustment to reflect real case-mix is determined on the basis of the most recent case-mix data available. The amount determined under this formula is rounded to the nearest multiple of $4 (or, if midway between two multiples of $4, to the next higher multiple of $4).
I don’t know about you, but this sounds to me like one of those problems where you are trying to figure out the time the westbound train leaving Philadelphia at 55 miles per hour will intersect with the eastbound train that leaves Poughkeepsie going 62 miles an hour. I am not sure which part of the public can understand this verbiage enough to comment, but I don’t want to have to sit next to them at a cocktail party. Just think what Rap Genius could do for these people! The inpatient hospital deductible would make sense and hundreds of confused phone calls could be avoided.
Lisa Suennen – The Health Care Blog.
States have until December 12 of this year to decide if they will set up the insurance exchanges mandated by the Obamacare Law. These exchanges will be the marketplace where health insurance is to be sold under the so-called Affordable Care Act.
The government’s short, concise, Readers Digest Condensed Version of PPACA can be found at www.healthcare.gov, a government sponsored website devoted to ObamaCare.
The latest summary of ObamaCare is found here: http://housedocs.house.gov/energycommerce/ppacacon.pdf
Editor’s Note: This summary is over two years old but still on the government’s website. We are looking forward to publication of the Summary of the Summary. In the meantime, check this out – http://www.ofr.gov/(X(1)S(3eazrwqxitchboyccjmcpaoe))/inspection.aspx?AspxAutoDetectCookieSupport=1
Editor’s Note: Will ObamaCare require only one prescription per catagory to be covered at a minimum? Sounds reasonable to us. Need an antibiotic, ObamaCare will only cover xyz drug, otherwise you pay for it. And what about an employer who offers the minimum actuarial valued plan? How about paying 60% of Medicaid? Sounds go to us too. Narrow provider network? Hey, thay works for us! Need a colonoscopy, we will only pay if you go to Dr. Botchitup. Employers who want to keep their group medical costs as low as possible will need to explore these limits.
…..”employer-sponsored plans with nonstandard features would be able to generate an initial value using a calculator and then engage a certified actuary to make appropriate adjustments that take into consideration the nonstandard features.”
Editor’s Note: A self-funded employer who seeks to provide the minimum actuarial value of their health plan under ObamaCare will need to obtain an actuarial certification.
Hi Bill & Jeanne, First of all, Happy Thanksgiving. I hope your holiday week is relaxing and meaningful.
Since you are my two colleagues/foot soldiers fighting for simplicity and truth in health care, I thought I would share the following. Attached, you will see a bill for MRI services. (MRI bill2) A student of mine gave me this bill for me to be a patient advocate and do some due diligence. Unfortunately for him, he is going to have to pay the $1234.38 that is due. This is because he has not met his deductible and Anthem responded back to the imaging center demanding that he pay that amount. The problem is this:
The billed charges are arbitrary and obscene. Similar to Bill’s fight with the “discounted PPO rates,” the $4367.47 that was billed is similar to the sticker price on the Toyota Camry sitting on the car lot. Thankfully, this patient’s deductible was not higher, otherwise he would have been stuck paying much more.
This is an example of why patient’s need to be better consumers. RPN charges $339.00 for CPT 70553. Mink Radiology charged $3814.00. That is a difference of $3475.00! Or in other sobering terms, RPN’s discount is 91% when compared to Mink Radiology.
This patient also had another procedure done, CPT 70544 and was billed $1740.00. RPN’s price is $249.00 resulting in a difference of $1491.00.
Now these “retail” prices that radiology companies use are artificial numbers because the insurance carriers negotiate much lower reimbursements. For instance, for the two charges above, Anthem probably has negotiated a reimbursement of $500.00 for CPT 70553 and $400.00 for CPT 70544 and the radiology firms are happy to receive that. However, if these radiology providers can inflate these charges, it impacts the patient’s wallet much greater via meeting their deductibles. The entire process is rigged and patients need to wake up.
I admire the two of you for what you are doing and quite frankly, it makes me feel less alone in this fight. For that, I am extremely thankful to have you both in my life.
Feel free to use this story, document as I blocked out the PHI.
Editor’s Note: Jeanne’s website is http://clearhealthcosts.com/
“Early last year, I directed the Secretary of Health, Education, and Welfare to prepare a new and improved plan for comprehensive health insurance. That plan, as I indicated in my State of the Union message, has been developed and I am presenting it to the Congress today. I urge its enactment as soon as possible. ”
The elections are over and regardless of who you voted for, the fact remains that PPACA is here to stay. While many of you have been utilizing our firm to assist in your compliance needs, we have never publicly announced that our team of experts can assist your organization with Regulatory Compliance issues until now.
Our experts navigate the complexities of regulatory law as they relate to the health care industry. So, regardless of whether your inquiry relates to State or Federal regulation; issues involving State Insurance Departments, the NAIC, HHS, CMS, and DOL, our complance team can handle it.
Happy Thanksgiving everyone and make sure you work off those extra pounds in some way!
Adam V. Russo, Esq.
“Turns out,” Galvin said, “the government wrote a pretty smart bill,” because “the government doesn’t want employer-sponsored insurance to go away … Someone’s got to pay for this.”………He added that even for employers who are tempted to pay per-employee penalties rather than provide health insurance, “the math really doesn’t work out.
Source: 1200 News Radio WOAI
by: Jim Forsyth
The Texas MedClinic chain of neighborhood emergency clinics today dropped Blue Cross Blue Shield of Texas from its list of accepted health insurance plans, effective later this month, in a glimpse of what the next major health care fight is likely to be, 1200 WOAI news reports.
“We were confronted with Blue Cross not increasing our fees significantly over the last five years,” Dr. Bernard Swift, the CEO of Texas MedClinic told 1200 WOAI news. “You can’t run a business when your costs increase, and your revenue doesn’t increase as well.”
Texas MedClinic has 14 locations in San Antonio, New Braunfels, and Austin, which treat minor emergencies and urgent medical illnesses. The company points out that it is a ‘quality and significant cost saving alternative’ to expensive hospital emergency rooms.
But Dr. Swift says insurance companies are trying to cut health care costs by cutting reimbursements to physicians. He says doctors offices are small businesses, with fixed costs for overhead, utilities, and staff, and he says the company simply can’t keep doing business with an insurance company which doesn’t properly reimburse physicians.
“Access to care is going to become a problem as more and more physicians reject what not only the federal government, but what private insurers, Blue Cross in particular, are attempting to do to physicians today,” he said.
Swift pointed out that Medicare and Medicaid are also cutting reimbursements to doctors, and much of Obamacare is predicated on reducing physician reimbursements.
He says all the insurance in the world isn’t much good if you can’t find a doctor who will accept it.
Visit http://www.texasmedclinic.com/main/bcbs.php for more information.
With a few clicks you can create medical fee schedules without government downloads or complicated formulas. Most users have mastered our software in 5 minutes!
Our customers include: physicians and other providers, office managers, insurance companies and other providers (HMO, PPO, TPA, PHO, IPA), CFOs, CEOs, CPAs, consultants, state and federal agencies, medical societies, associations, payers, billing services, accountants, actuaries, lawyers, life care planners and other healthcare professionals.
“Let’s face it…” The Phia Group’s CEO Adam V. Russo, Esq. stated, “The Patient Protection and Affordable Care Act is here to stay. The only question we need to ask is whether we will rise to the challenge, or collapse under the regulatory burden.”
Plan pays 125% of Medicare. Plan participants can log in on their smart phone while at the providers office and key in the procedure code. “Excuse me nurse, what is the procedure code for that lab test you want me to take? Oh, $500 you say? Well, my plan will pay $200 for that test, will you accept that as payment in full?
That will be almost like in the old days, around 1966 when I twisted my leg while in pole vaulting practice. My mother took me to the doctor and before any treatment was tendered, my mother asked “What will this cost?” A simple, direct question. “It will be $15.” Ok, I can afford that, will you take a check?”
Do you have a session concept you feel would add value to the 26th Annual Benefits Forum & Expo program? We are accepting speaker and session proposals for this program until December 13, 2012.
Instead of relying on work-based insurance to pay for doctor’s appointments and hospital visits, Californians leaned heavily on government programs for low-income families.
(Bloomberg) — HCA Holdings Inc. and other hospitals will get more paying customers while insurers like UnitedHealth Group Inc. will see profits squeezed as President Barack Obama moves to preserve the health care overhaul he championed.
“This is here to stay,” said J.D. Piro, a senior vice president at Aon Hewitt who leads the company’s health law consulting group. “I’ve been saying for a couple of years this is by and large an entitlement program, and entitlement programs are very rarely repealed. They can be amended or changed around the edges. But it hasn’t been overturned in court or at the ballot box.”
If the election had turned out differently, it would have been easier to repeal Obamacare. But that does not mean that Obamacare is here to stay. The only difference is that dismantling it will now be a more protracted and messy process.
Under ObamaCare, the year 2014 will be pivitol. All citizens (except a select few) will be required to purchase health insurance or face punishment. However, like mandatory auto insurance in Texas, many will just ignore the law and spend their money on more useful things. After all, the IRS cannot enforce the individual tax under PPACA.
Employers with 50 or more employees though, cannot ignore or dodge ObamaCare. They are going to pay for something, either in benefits or in punishment taxes, or a combination of both. IRS enforcement will be stringent and aggressive.
So where is the relief for employers with 50 or more employees who will be facing stiff increases in health care costs? What can an employer do to minimize costs and stay off the radar screen from federal enforcers?
There are several strategies to be employed. (1). Directed health care – employer steerage of medical care through carefully selected and directly contracted providers (2). Charge employees the maximum 9.5% of gross income as allowed by PPACA towards the cost of group health insurance (3). build a benefit plan that provides the minumum 60% actuarial benefit value (4). pay hospitals and other health care facilities their cost as reported to CMS plus a margin (profit) or Medicare rates, whichever is greater.
The unintended diamond in PPACA is that ObamaCare does not dictate that all providers must be covered nor does ObamaCare dictate how much a provider must be paid. To pay a hospital 100% of Medicare, for example, is less than paying typical managed care rates. Hospital executives are sucking eggs these days.
It is our opinion that implementing these four strategies will reduce an employers health care costs by as much as 60%.
Cost Plus Health Insurance will gain rapid market acceptance in the next 18 months. We expect to see hybrids tied to high deductible plans and cash savings accounts. Those with the foresight to recognize and seize opportunities in this cottage industry will join the ranks of a new class of rich people, much to the pleasure of Democrats seeking additional revenue sources.
Interesting stuff Bill! The law of unintended consequences. But what about us individual policy holders? Any opportunities there?
Clarence Brown is a United HealthCare representative from the Austin, Texas area. We like his message of fiscal responsibility and wish him success tomorrow.
We hope Scott Brown of Mass. does well too.
While all eyes focused on the presidential race, the ultimate fate of the Affordable Care Act (ACA) could depend on the Senate contests in the states.
If an insurance company had influence over the information technology architecture used to run the exchange, it could interpret federal standards in a way to exclude competitors or make it more difficult for them to win approval, say some insurance experts. Or it could have an inside track on knowing how to design plans that meet the standards.
The once-steady stream of regulations and rules from the Obama administration — instructions for insurance companies, hospitals and states on how to put the law in place — has slowed to a trickle in recent months in an attempt to avoid controversies before the election. Get ready for post election flood of rules and regulations……………)
Molly Mulebriar, ace forensic investigator and former Rhodes Scholar reports that Flash Gordon is back! Working incognito, disguised as an insurance consultant, Gordon scored big in bringing a Texas county’s self-funded medical plan back on course. (See – http://blog.riskmanagers.us/?p=9313)
Seeking to stem a $1.2 million annual hemmorage without reducing or eliminating benefits, Flash Gordon did the impossible………through innovative strategies and high testosterone levels shared jointly with Commissioners Court, Flash improved benefits, kept funding static (we assume) while projecting a savings to the county in the coming plan year.
The local newspaper reported:
“The (county) judge was very, very clear… He would like not to cut benefits; he would like that the hospitals, the doctors, and county commissioners get along,” Gordon told the court regarding this year’s quest to find the best proposals. Gordon said although a lofty goal, he is pleased to announce that they were able to accomplish that.
Mulebriar writes: “As a head fake, Gordon added completly useless aggregate insurance coverage as well as a fully-insured, potentially commissionable transplant policy. Dr. No, local naysayer, applauds this diversionary tactic.”
According to Mulebriar, moving away from managed care contracts was Gordon’s only sensible strategy (other than recommending the county terminate their group medical plan). “Direct contracting with the local hospital was brilliant” Mulebriar panted in excitement as she filed her report. “In addition, paying other facilities on a cost plus basis (see www.costplusinsurance.com ) will certainly lower the county’s cost” she explained to our incredulous staff during Friday afternoon’s Martini Brunch. “Just look at what the Corpus Christi Independent School District was projected to save had they done the same thing! Lack of testosterone killed that deal it seems.”
Embarking on our third round of martinis, and on a roll, Mulebriar offered “One would hope, we suppose, that plan participants will seek care at the cost-plus hospitals instead of the locally contracted hospital to keep the county’s cost as low as possible for the coming year.”
Editor’s Note: Molly Mulebriar is currently investigating a recent public bid for group medical insurance that may expose bid law violations and tortous interference, slander, boycott and unfair trade practices. www.mollymulebriar.org
The health care delivery system continues to evolve and adapt, despite (or because of) an ever changing political climate.
In our opinion ObamaCare is the best thing that has happened to our health care delivery system and is as dynamic to the market as was the ship owners in London who established Lloyds several hundred years ago – it has “upset the apple cart”, fundamentally releasing a dormant, energizing drive among the private sector to provide competitive solutions based on the principle that a good product fullfills needs common to most at a reasonable profit supported by consumers who perceive value.
Surgery Center Network seeks to provide competitive and transparent pricing – http://www.surgerycenternetwork.com/
So far, 10 organizations—including the Colorado Business Group on Health, the Leapfrog Group, the National Business Coalition on Health, the National Partnership for Women & Families and the Corporate Health Care Coalition—have endorsed CPR’s statement, which lays out two expectations: first, that by January 2014, providers will not restrict health plans from making price and quality information available for use in transparency tools (MANAGED CARE CONTRACTS PROHIBIT PRICING DISCLOSURE – WILL THAT NECESSARILY CHANGE?) , and second, that by the same time, health plans will give self-insured customers full use of their own claims data (TEXAS HOUSE BILL 2015 ON STEROIDS!)