Archive for December, 2012
“….the IRS is putting a great deal of thought into identifying and blocking stratagems that employers may use to try to evade the requirements of the mandate. ”
A series of hard-hitting government adverts featuring people smoking cigarettes with a tumour growing from the end is being launched in England.
The ads will tell smokers that just 15 cigarettes can cause a mutation that leads to cancerous tumours in what marks a return to shock campaigning
“Federal law prohibits this practice for Medicare patients and the Supreme Court ruled that balance billing for out of network emergency care is prohibited. The AMA however is lobbying fervently so that there is no ban on balance billing and instead suggests the Healthcare Balance Billing Disclosure Model Act, which promotes transparency of out-of-network heath care costs.”
Hobby Lobby refuses to comply with ObamaCare? What if every employer joined in a civil disobedience revolution?
Cuba is moving towards a private economic system, Russia is no longer a communist state, China has adopted capitalism in business, and now England is beginning to look to the private sector to solve health care costs in that country.
The United States is moving the opposite direction, racing towards government interference in market activities including government takeover of 17% of our economy (healthcare). The lessons of history have been ignored.
Richard Branson – “There is no point getting into business unless you do it out of frustration”
Germany accused of ‘deporting’ its elderly: Rising numbers moved to Asia and Eastern Europe because of sky-high care costs
The thrust of the lawsuit revolves around certain undisclosed fees associated with pharmacy benefits. Transparency in health care financing can be elusive at times.
“It is doctors who seem to be the primary obstacle. Doctors are paid for seeing patients, not for sorting through more than 14,000 diagnostic codes and 4,500 procedure codes while a patient sits on the exam table.”
This capability allows a provider to bill for services at the “point of service.” A fully adjudicated response is returned from Humana, detailing the total charge submitted and allowable charges, as well as the patient’s responsibility.
“The patient is not the consumer unless the patient is writing the check. Until then the patient is the cash cow, there to be milked.”
Homer T. Farnsworth, M.D.
Doctors are most likely to reject Medicaid patients more than any health care consumer, a new survey published in Health Affairs finds.
More than three in 10 doctors—31 percent—say they wouldn’t accept new Medicaid patients.
It could spell trouble for the Patient Protection and Affordable Care Act, which aims to expand Medicaid. The number of those patients could increase by as much as 16 million due to health reform.
Less than 70 percent of doctors said they were accepting new Medicaid patients, much lower than those accepting privately insured patients (81 percent) or Medicare patients (83 patients). The reason for this is fairly obvious: Doctors get less money for treating Medicaid patients.
Sandra Decker, an economist with the Center for Disease Controls, used a survey of 4,326 office-based physicians from across the country.
The numbers did vary significantly by state. In Wyoming, for example, 99 percent of doctors were willing to accept new Medicaid patients. But only 40 percent of New Jersey doctors said they would do the same, according to the study.
October 1, 2012 • Reprints
A new, nationwide survey of U.S. physicians shows that 34 percent say they will quit practicing medicine in the next decade, blaming health care reform and economic woes.
Their reasons for ditching medicine were split; 56 percent cited economic factors—medical malpractice and overhead costs—for retiring or leaving medicine in 2012, while 51 percent cited health reform as their reason for leaving.
This year alone, 16 percent of physicians are going part-time, retiring or leaving medicine—or at least considering it, according to the survey conducted by Jackson Healthcare, one of the nation’s largest health care staffing companies.
“Physicians are retiring in large numbers just as baby boomers are starting to turn 65,” says Richard Jackson, chairman and CEO of Jackson Healthcare. “That creates a real health care access problem. Many are demoralized and weighing their options.”
Doctor associations have been quick to voice their opposition to health reform. For the most part, doctors say the PPACA will have little impact on patients’ access to medical care and only create bureaucratic hoops.
According to the Jackson Healthcare survey, specialists showing the greatest inclination to leave the profession in the next decade are: oncologists and hematologists (57 percent); ear/nose/throat specialist (49 percent); general surgeons (49 percent); cardiologists (45 percent); and urologists (42 percent).
“For doctors, there is little reward in this era of high costs, high regulation,” Jackson says. “The future of medicine is not what it used to be.”
The survey of 2,218 doctors was conducted in April, prior to the U.S. Supreme Court ruling upholding much of the Affordable Care Act.
WASHINGTON (AP) — New taxes are coming Jan. 1 to help finance President Barack Obama’s health care overhaul. Most people may not notice. But they will pay attention if Congress decides to start taxing employer-sponsored health insurance, one option in play if lawmakers can ever agree on a budget deal to reduce federal deficits.
The last thing we want to do is discourage businesses from hiring full-time workers, expanding their businesses, or undertaking complicated maneuvers to avoid fines. But as things stand, it’s looking more and more likely that the health care law would do just that.
It is surprising that most employers pride themselves on shrewd vendor negotiations but when it comes to negotiating their health discounts they fail miserably. A percent discount off an incredibly inflated and constantly increasing price is not sensible
It’s time to shed the high cost of collections and “middleman” services that no longer add any value to the Patient, Provider and Employer. It’s time for self funded employers to move to a Point of Service payment system that eliminates enormous unnecessary cost and uses technology to instantly negotiate a fair price then deliver the payment in a timely manner.
“Beginning in the year 2014, American hospitals will forever lose grossly profitable private payer levels of reimbursement and will necessarily need to base future budgets on Medicare and Medicaid reimbursement levels earned from both government plans and what few private sector plans remain. PPO networks will become a footnote in history.”
“Since hospitals don’t balance bill governmental payers, any attempts to balance bill the few remaining private payers who pay the same level of reimbursement as governmental plans, will be met with strong regulatory dictats influenced by seething public outrage.”
“Hospital financing will undergo a fundamental change. Cost Plus medical plans will become common.” (www.costplusinsurance.com )
“What is good for the goose is good for the gander”
In a previous post we wrote about two of the BUCA’s and their out-of-network reimbursement fees that are tied to a percentage of Medicare – http://blog.riskmanagers.us/?p=9455
We have now confirmed a third BUCA’s out-of-network reimbursment schedule is 110% of Medicare.
All we need to determine now is the out-of-network reimbursement model of the fourth and final BUCA.
How do the BUCA’s protect their members from out-of-network balance billing issues? They probably don’t. If that is the case, then why should employers who sponsor Medicare Plus or Cost Plus plans do any different?
Effective in just 12 months and 12 days from now, an employer with 50 full-time employees who does not offer an approved group health plan for their employees will be punished by the federal government if just one of their employees receives a federal subsidy to buy coverage through an exchange.
In the case of paying a penalty, the good news is the first 30 employees don’t count, they are “free” of any penalty. We have no idea why.
Here is an example: ABC Fence Company has 200 employees and decides not to offer an ObamaCare approved health plan. Smith, the janitor working the night shift who is eligible for a government subsidy,finds his wife is pregnant, so he runs down to the insurance exchange to get pre-existing condition coverage.
Bingo, ABC Fence Company is now subject to a punishment fine.
Here is how the fine is calculated: 200 employees – 30 “freebies” = 170 full time employees X $2000 punishment tax = $ $340,000.
ABC Fence Company has 12 months and 12 days from now to make a decision: Do they provide an approved ObamaCare group health plan or pay the equivalent of $141.66 per employee per month in punishment taxes?
Editor’s Note: Does anyone reading this blog know where ABC Fence Company can get a group ObamaCare approved health plan for an employee monthly cost of $141.66 or less? Despite much of what you read these days, many employers will simply take the least expensive route. Is it time to say goodbye employer sponsored health insurance?
From a TPA:
Yes, from what we have read so far a policy that reimburses at Medicaid rates can comply and meet that target. (http://blog.riskmanagers.us/?p=9769). Invloves some cherry picking and we need to see how the Rx requirement plays out but on paper we think it will pencil out. Working with some reinsurers now to sell it on a self funded basis.
A lot of low margin high maintenance business. I rather sell very little of it but employers appreciate the solution and give us their normal slightly less low margin administration.
We expect that actual enrollment would be low but by offering the plan the employer avoids the penalty. We think many of these non tax payors will continue to waive and not pay the penalty when they don’t pay federal taxes now.
Javier Vazquez, executive director of the Cameron Willacy County Medical Society, said it’s not unusual for dual-eligible patients to comprise 80 to 90 percent of a Valley physician’s patient load.
House Speaker Nancy Pelosi was widely mocked when she said of Obamacare, “We have to pass the bill so that you can find out what is in it.” At the time, March 2010, Pelosi’s words accurately described the Democrats’ just-get-it-done approach to passing a national health care bill. But now it turns out Pelosi was wrong. In fact, we have to implement Obamacare so that you can find out what is in it.
An uptick in PPACA enforcement appears to be underway, and many plan sponsors have received EBSA audit notices. See actual audit letter – DOL Audit Letter
Editor’s Note: Are you prepared for a DOL audit? We recommend that you make sure your plan is in compliance, with documents at the ready for a potential audit.
There is significant interest in Medicare Plus repricing. Though this idea has been floating around the market for some time, it only now appears to be gaining more mainstream attention.
If a lab test shows high cholesterol, Folch is quick to call or email. No patient can leave the office without scheduling an annual eye exam, a key preventive test. A missed exam or an appointment leads to another call. “We are a real pain in their necks,” joked Folch, a primary care physician in suburban Boston. “We track them down.”
That kind of attention has always been good medicine. For Folch, 59, it’s now good business.
Moving away from managed care contracts can be fraught with nightmares of ruined credit. No one wants to be classifed as a deadbeat and go to court. What say you, Bill OReilly?
Moving away from managed care contracts is becoming a major trend of late. We are seeing more third party administrators entering into cost plus reimbursment strategies in an effort to reign in ever increasing health care costs for their clients. We have identified at least eight (8) TPA’s who are active in Cost Plus Insurance.
Now we find one more TPA active in the Cost Plus Insurance market – Payer Fusion:
“Our unique approach to claims reimbursement creates significant savings for our client partners while allowing providers a fair reimbursement based on the actual costs of service. Our unique Cost-Plus Pricing Methodology assesses each claim compared to national data reported by federal agencies. Utilizing this data we are able to determine the actual cost of service, needs of the provider to offset losses from Medicare patients and the fair retail cost of the service provided.”
Editor’s Note: As was the case with the $3 hand calculator retailing for $100 in 1972, so goes the cost of administrating health care plans using cost plus strategies. Competition is a good thing.
Self-insured group health plans and insured large group health plans are not required to cover so-called essential health benefits – but they are prohibited from imposing annual or lifetime dollar limits on any essential health benefits that are covered.
The regulatory agencies (the IRS, DOL, and HHS) have started to fill in some (but by no means all) of the gaps in the Affordable Care Act guidance needed to implement the transformation of health coverage that is supposed to happen in 2014. Here is a rundown of new guidance relevant to employers that sponsor group health plans for their employees.
“The contract between Aetna and Weslaco Independent School District provided that Aetna would be compensated by a Value Based Fee System (schedule) wherein Aetna would retain 9.7% of the difference between the billed charges and negotiated (PPO)rate.”
Editor’s Note: This is further evidence that not all PPO “discounts” are passed on to the consumer. Revenue sharing with providers can be lucrative. If billed charges for Weslaco ISD for the year were $17,000,000, and “negotiated” rates brought that down to $9,000,000, Aetna’s fees in this fabricated example would have been $776,000.
“In place of consumers ruling their healthcare in the US, well-positioned, giant stakeholders have persuaded lawmakers to offer physicians bonus money (that will later be taken away), not for curing patients, but for using digital records “in a meaningful manner.” It’s called Clicking for Cash.”
“….While it’s impossible to know precisely why doctors and hospitals moved to better-paying codes in recent years, it’s likely that the trend in part reflects ‘upcoding,’ — the practice of charging for more extensive and costly services than delivered…”
The government backtracked from an initial proposal made in December that would have let health plans cover as few as one drug per class of medicine, a move opposed by drugmakers and patient-advocacy groups that argued it would limit choices.
The federal government instead proposed that insurers can cover the same number of drugs per class as state benchmark plans, which are typically greater than the single-drug option the Obama administration had considered. The change is a win for pharmaceutical companies, which had lobbied for coverage of more medicines, said Dan Mendelson, chief executive officer of Avalere Health LLC, a Washington-based consulting company.
“Cost Plus is a Real Plus – The industry at large is now contemplating new pricing methodologies, whereby the benefit plan identifies a fixed rate upon which it bases what it deems to be a fair market value. The benchmark can be based upon some percentage of Medicare, or any other number of parameters. ”
….”Many Plan Sponsors view the lack of transparency within PPO contract(s) as a hindrance to Plan management.” …….”Respectfully, I would suggest that Mr. Page’s Memo is a step backward and an attempt to preserve a delivery model that was not effective in the past and won’t be in the future. ” – Steve Kelly
|CT and CTA with Contrast Composite||Average Charge||Average Cost||Average Medicare|
|Mercy – Anderson Hospital Cincinnati, OH||$1,680.00||$167.00||$598.00|
|TriHealth – Good Samaritan Hospital Cincinnati, OH||$1,283.00||$205.00||$595.00|
|St. Elizabeth Health Center – Youngstown, OH||$1,753.00||$179.00||$571.00|
|Source: American Hospital Directory|
By Nicole Fallon
The Patient Protection and Affordable Care Act (commonly referred to as the health reform act) contains many changes to how we access, deliver, and pay for health care in this country. At its core is the requirement that every U.S. citizen have affordable Affordable: Coverage where the employee contribution is less than 9.5 percent of household income. health care coverage beginning in 2014. This impacts all of us, as individuals and employers, and it is generating a multitude of questions. While rules and regulations will be issued in the coming months explaining specifically how these provisions will be implemented, here are some of the basic requirements.
Slack was an innovative, out-of-the-box sort of guy who seized opportunties while his competitors sat back and scratched their balls.
“Providers want to be paid as soon as possible. It takes approximately 30 seconds to submit a claim and be paid.” www.simplicityhealthplans.com
An MBGH survey further found that employers of all sizes plan to offer consumer-directed health plans, such as an HSA/HRA option. Of those surveyed, among small group employers – 200 or fewer employees – 50% plan to offer a form of CDHP, for large groups – more than 5,000 — that increases to 100%.
“Acknowledging some ambiguity in the ACA statute, the proposed rule clarifies that these cost-sharing limitations (such as maximum deductibles and out-of-pocket amounts) apply only in the small group market. They do not apply to self-insured plans, nor to health insurance issuers offering coverage in the large group market.”
If the Administration wants to make good on President Obama’s election night promise to work across the aisle to solve the nation’s problems, a good place to start would be how it implements a key provision of Obamacare – namely, the Republican idea buried in Section 1334.
“………policies aimed at individuals and Medicaid beneficiaries will look a bit different than those commonly sold to employer groups. They will feature smaller networks of doctors and hospitals……”,
The percentage of companies that self-insure has grown steadily since 2006, according to a new report from the Employee Benefit Research Institute. In 2011, about 60 percent of American workers were covered by their employers’ self-insured plans, which reduce companies’ administration, exempt them from state-mandated coverage and allow them to offer standard coverage across states, The Hill’s Healthwatch reported.
However, small businesses with fewer than 50 employees aren’t following the self-insurance trend. Only 10 percent of employees working for small employers were self-insured in 2011, reported BenefitsPro.
The report did find that self-insured rates differ throughout the country. Hawaii had one of the lowest self-insured rates, with just 30 percent of its workers enrolled in such a plan. Indiana and Minnesota fell on the other side of the spectrum, with more than 70 percent of employees enrolled in a self-insured plan, reported Kaiser Health News.
Amid a flurry of merger activity in the health insurance industry, a new report says 70 percent of the commercial insurance markets are “highly concentrated,” threatening consumer choice of doctors and contributing to higher health care costs.
Residents of states that refuse to set up health insurance exchanges under Obamacare are set to be hit with higher premiums under new rules announced by the Health and Human Services Department.
Email sent by Dr. Pruitt to his contacts in the dental profession this morning:
Doc, have your fees been reduced by a “Most Favored Nation” clause in your PPO contract, even though you are not a nation?
If you are one of many dentists who have discovered that dental PPOs limit your allowable fees to the lowest bidders in dentistry, you just might be angry enough to want to do something about it. Am I right?
A friend of mine is investigating the legality of the clause and needs more information about the process to determine if he can be of assistance to our profession. If you are interested in sharing what you know, and a chance to possibly put an end to the MFN clause for dentists, please email your contact information to me at firstname.lastname@example.org and I will forward it to my friend, who will contact you.
Editor’s Note: Dr. Pruitt is a practicing dentist in Ft. Worth, Texas
Editor’s Note: Cost Plus Insurance (www.costplusinsurance.com) is gaining market acceptance by plan sponsors desparate to reign in ever increasing health care costs. Providers are guaranteed a profit margin in excess of their cost-to-charge ratios as reported to CMS. Employing a magic wand, balance billing issues are “poofed away”, and plan sponsors are legally immune.
PPO’s and their provider partners should take note that critical thinking is the capacity of a person to distinguish claims (I have great discounts!) from evidence (our costs keep going up year after year). Managed Care Under Siege
Cost Plus Insurance – “Don’t bother doing something unless your radically different from the competition” – Richard Branson