Friday
May052017

Different Approaches in Tackling the Surprise Medical Bill Problem

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By Clive Riddle, May 5, 2017

 

Surprise medical bills – from out of network physicians affiliated with network hospitals, and other similar situations – have been a long standing problem vexing consumers, providers, plans, employers and regulators. This simmering issue began boiling over the past few years as growth in narrow networks and ever increasing retail charges exacerbated the problem.

 

Arizona last week had Senate Bill 1441 signed into law: “The legislation, which takes effect in 2019, will allow a consumer with an out-of-network bill exceeding $1,000 to contact the Arizona Department of Insurance to request the appointment of an arbitrator. The insurer and health-care provider must try to settle the dispute through an informal telephone conference within 30 days of the consumer's arbitration request. The case advances to arbitration if the two sides cannot agree to an amount, with the insurer and health-care provider splitting the cost. Either party would have the right to appeal an arbitrator's decision to the county Superior Court.”

 

Oregon, Texas and Nevada, to name some states, currently have legislative activity of different kinds on this front.

 

Gastroenterology & Endoscopy News ran a nice April 20th 2017 article, Out-of-Network Billing: ‘Surprise Billing’ or ‘Surprise Gaps In Insurance Coverage’? that included a great summary of state level initiatives addressing these surprises.  Included in this discussion was:

·         A number of states are linking reimbursement to rates determined by the independent third-party database.

·         In New York  “Hospitals must disclose which health plans they accept and list standard charges for services. Perhaps most important, they must alert patients that physicians working at an in-network facility may not actually participate in the insurance network and can therefore bill patients directly.”

·         “California recently passed a law that settles out-of-network billing disputes by using one of two benchmarks. Providers will be reimbursed the greater of either 125% of Medicare rates or the insurer’s average contracted rate for the same or similar services in the same geographic region.”…but “not surprisingly, the California law is already being challenged in court.”

·         “Florida’s new law sets reimbursement for out-of-network claims at the lesser of: the provider’s charges; the UCR provider charges for similar services in the community where the services were provided; or the charge mutually agreed to by the insurer and the provider within 60 days of the submittal of the claim. The key in Florida moving forward will be how UCR is defined.”

 

The American Journal of Managed Care  has just issued a release discussing an article in their current issue: Battling the Chargemaster: A Simple Remedy to Balance Billing for Unavoidable Out-of-Network Care, in which “two doctors and two lawyers say they have a solution that doesn’t require legislation: better use of contract law…..Authors Barak D. Richman, JD, PhD; Nick Kitzman, JD; Arnold Milstein, MD, MPH; and Kevin A. Schulman, MD, say the problem starts with the ‘chargemaster,’ a hospital’s master list of prices for billable services. The authors say the defining feature of the chargemaster is that it is ‘devoid of any calculation related to cost,’ and has no relation to local market conditions.”

 

They release continues that “acontract law solution empowers the very parties who currently are being exploited by out-of-network charges,” they write. An emerging consensus, supported by a key court ruling, finds that providers are not entitled to ‘chargemaster’ rates, because neither the patient nor the payer agreed to them. Instead, the authors write, the law “entitles providers to collect no more than the prevailing negotiated market prices” for out-of-network care. In other words, rates already negotiated by hospitals, doctors, and area payers are the norm, not those artificially inflated on the ‘chargemaster.’ This leads to a stark conclusion, the authors find. ‘Providers have no legal authority to collect chargemaster charges that exceed market prices for out-of-network services, nor are payers under any obligation to pay such chargemaster prices.’ The authors make their case in a legal analysis available online.”

 

So while “the authors praise state legislators for trying to end surprise medical bills, they say the courtroom is the proper place for these disputes. Other remedies, like bans on out-of-network bills, don’t encourage cost-saving steps or competition.”

 
Friday
May052017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

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Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

Winners And Losers Under The House GOP Health Bill

House Republicans have passed a bill to replace the Affordable Care Act. If it is signed into law, the American Health Care Act will affect access to health care for millions of people in the U.S. NPR. May 4, 2017

 

GOP Senators to Draft Their Own Obamacare Replacement Bill

A top Senate Republican said Thursday that even though the House spent months on a health care bill that would repeal and replace the Affordable Care Act, the Senate will use that legislation as a starting point to draft a separate measure. Morning Consult. May 4, 2017.

 

What’s in the AHCA: The Major Provisions of the Republican Health Bill

The House health care bill up for a vote on Thursday would roll back the Affordable Care Act’s expansion of Medicaid, eliminate tax penalties for people who do not have health insurance and end taxes on certain high-income people, insurers, drug companies and manufacturers of medical devices to finance the current health law. NYTimes. May 4, 2017

 

Blue Shield CEO Says GOP’s ‘Flawed’ Health Bill Would Harm Sicker Consumers

The chief executive of Blue Shield of California, the largest insurer on the state’s insurance marketplace, issued a blunt critique of the Republican health care bill, saying it would once more lock Americans with preexisting conditions out of affordable coverage.

Kaiser Health News. May 3, 2017

 

NIH to get a $2 billion funding boost as Congress rebuffs Trump’s call for cuts

The National Institutes of Health will get a $2 billion funding boost over the next five months, under a bipartisan spending deal reached late Sunday night in Congress. The agreement marks a sharp rejection of President Trump’s proposal to cut $1.2 billion from the medical research agency in the current fiscal year. Stat News May 1, 2017

 

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

 
Friday
Apr282017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

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Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

U.S. appeals court blocks Anthem bid to merge with rival Cigna

A U.S. appeals court blocked health insurer Anthem Inc's (ANTM.N) bid to merge with Cigna (CI.N) on Friday, upholding a lower court's decision that the $54 billion deal should not be allowed because it would lead to higher prices for healthcare. Reuters April 28, 2017

 

4 key questions surrounding Obamacare repeal

House Republicans are mounting yet another effort to tear down Obamacare and remake the health care system — but the path to delivering on one of the GOP's longest-standing priorities remains complicated and fraught with uncertainty. Politico April 27, 2017

 

Amid budget talks, White House says it will continue ACA subsidies

The White House on Wednesday pledged to continue payments critical to the success of Affordable Care Act exchanges, Politico reports. The pledge will come as a relief to insurers and providers after the administration’s earlier indication that it might withhold payments as a bargaining chip in this week’s budget negotiations.

Stat News April 26, 2017

 

PBM Express Scripts loses biggest client Anthem

Express Scripts said Monday that its biggest client, Anthem, will not renew its contract with the pharmacy benefit manager after the current agreement expires at the end of 2019.

Modern Healthcare April 24, 2017

 

Health Care In America: An Employment Bonanza And A Runaway-Cost Crisis

In many ways, the health care industry has been a great friend to the U.S. economy. Its plentiful jobs helped lift the country out of the Great Recession and, partly due to the Affordable Care Act, it now employs 1 in 9 Americans — up from 1 in 12 in 2000.

Kaiser Health News April 24, 2017

 

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

 
Thursday
Apr272017

What Goes into Combating Healthcare Fraud

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By Claire Thayer, April 27, 2017

According to the National Health Care Anti-Fraud Association, most health care fraud is committed by organized crime groups and a very small minority of dishonest health care provider. The NHCAA tells us that the most common types of fraud include:

·         Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.

·         Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).

·         Performing medically unnecessary services solely for the purpose of generating insurance payments.

·         Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.

·         Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.

·         Unbundling - billing each step of a procedure as if it were a separate procedure.

·         Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

·         Accepting kickbacks for patient referrals.

·         Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship").

While the U.S. Department of Justice, FBI, CMS and other government entities are busy identifying and tracking down fraud schemes, Deloitte research points out that an emerging area of interest in health care fraud and abuse enforcement is that of relationship scrutiny.

This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, highlights some of the costs associated with fighting healthcare fraud:

(Click to View Full Size Image)

What goes into combating healthcare fraud?

(Click to View Full Size Image)


MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more
here.

 
Thursday
Apr272017

Clicks-and-Mortar: Health Care's Future

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By Kim Bellard, April 27, 2017

 

The woes of the retail industry are well known, and are usually blamed on the impact of the Internet.  Credit Suisse projects that 8,600 brick-and-mortar stores will close in 2017, which would beat the record set in 2008, at the height of the last recession.   And then there's health care, where the retail business is booming.

 

In a recent Wall Street Journal article, Christopher Mims set forth Three Hard Lessons the Internet is Teaching Traditional Stores.  The lessons are:

1.             Data is King

2.             Personalization + Automation = Profits

3.             Legacy Tech Won't Cut It

 

It's easy to see how all those also apply to health care.

 

But health care is different, right?  Patients want to see their physician.  That physical touch, that personal interaction, is a key part of the process.  It's not something that can be replicated over a computer screen.  

 

Yeah, well, the retail industry has been through all that.  Retail once primarily meant local mom-and-pop stores.  They knew their customers and made choices on their behalf.  But it was all very personal.

 

Still, though, when Amazon came along, booksellers were adamant: no one wants to buy books sight unseen!  When that truism was proven false, other sectors of retail had their turn in the Internet spotlight, and the last twenty years of results haven't been pretty for them.  

 

It turns out that the personal touch isn't quite as important as retailers liked to think.

 

So why hasn't health care been more disrupted by the Internet?  Well, for one thing, when you buy a book online, your state doesn't require that you buy it from a bookstore that is licensed by its not-so-friendly licensing board, as is true with seeing doctors over the internet.  

Strike one for disruption.

For another thing, we (usually) trust our doctors.  Then again, we used to trust recommendations from bookstore staff too.  That is, when they had time for us, if they seemed knowledgeable, and if they were making recommendations that fit us rather than just their own preferences.

Think the same thing won't happen when AI 
gets better at diagnoses? 


Let's go back to Mr. Mims three lessons and see how they apply to health care:

·         Data is King: Health care collects a lot of data, and will get even more with all the new sensors.  The big tech companies know their customers very well and tailor interactions accordingly; health care must as well.

·         Personalization + Automation = Profits:, We're stuck in waiting rooms, filling out forms we've already filled out elsewhere. That is not a personal experience that can survive in the 21st century.  It has to be smoother, faster, and friction-less.  

·         Legacy Tech Won't Cut It: EHRs that no one likes.  Claims systems that take weeks to process a claim.  Billing processes that produce bills no one can understand.   The list could go on almost indefinitely.  All too often, health care's tech is not ready for prime time.  

 

The question is, are health care's leaders learning these lessons?

 

The future of retail appears to be in "clicks-and-mortar" (or "bricks-and-clicks").  

 

Health care can act like B Dalton or Borders, assuming until it is too late that their consumers will visit them in person, because they always had.  Or it can act now to jump to the data-driven "clicks-and-mortar" approach that other retail businesses are moving to.  

 

Health care organizations which get that right will be the one to survive.  


This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

 
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