The Word For Today Is SURPRISE

Surprise, Americans really do care about health care.  Surprise, repealing the Patient Protection and Affordable Care Act (Obamacare) is no longer good enough, especially when you don’t have a replacement plan.  And Surprise, there are a whole lot of Republican Senators (22) up for reelection in 2020.  There is a way, a bipartisan way, to address all of these issues.  Today we are going to discuss Surprise Billings.


According to the Kaiser Family Foundation:

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers. Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network.  These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others.  In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network.¹    In these non-emergency situations, too, the in-network provider or facility generally arranges for the other treating providers, not the patient.

This is actually a real issue.  Back in 2016, before my little health adventure, I spent several hours trying to verify that every doctor I was about to encounter was in my health insurance network.  I couldn’t do it.  I called both the insurer (Anthem) and the hospital (University Hospital).  I was completely at their mercy.  Luckily, everyone involved was in network.


Emergency care is even more of a crap shoot.  The patient normally has no choice where care is provided nor which doctors are seen.  20% of hospital admissions in 2014 that originated in the emergency room resulted in surprise billings. (Source – Health Affairs).  You may have the ambulance take you to a hospital in your network only to learn, after the fact, that the Emergency Room physician isn’t in your or any network.


There are several bills under consideration in Congress.  Most are bipartisan.  The Trump administration has been supportive.  With this opening, the stakeholders are starting to get more vocal and present possible solutions.   One coalition includes the National Association of Health Underwriters, the National Retail Federation, American’s Physician Groups, America’s Health Insurance Plans, American Benefits Council, Blue Cross Blue Shield Association, ERISA Industry Committee, and the HR Policy Association.  This group understands the nuts and bolts of medical billing and how Surprise Billing directly impacts clients, employees, and average Americans.  It is reasonable to expect that more consumer, business, and labor groups will sign on as action becomes more likely.


The group is organizing around the following principals:

• Banning balance billing in situations where patients are involuntarily treated by an out-of-network provider. This includes: (a) emergency health care services provided at any hospital; (b) ambulatory transportation to any health care facility in an emergency; and (c) any health care services or treatment performed at an in-network facility by an out-of-network provider not selected by the patient.
• Requiring health insurance providers to reimburse non-participating doctors or clinicians based on a federal standard in the above scenarios. All health plans should be required to reimburse a non-contracted hospital or health care provider in the above scenarios an amount equal to the negotiated rate for the same service under the patient’s health plan contract. If no such rate is ascertainable, then the plan should be obligated to pay the amount required for Medicare Parts A or B or a median contracted rate. These requirements should be applied to all ERISA self-funded health plans, and non-ERISA and insured plans, with the option for states to establish similar standards, so long as the state methodology would not increase patient cost-sharing or premiums.
• Mandating hospitals and providers disclose the network status for attending physicians and clinicians prior to patients receiving care. For non-emergency situations, hospitals should be required to notify patients at their first point of contact, including by a provider on a patient’s behalf (e.g., scheduling surgeon), that some providers assigned to them may be out-of-network and inform them of their right to select in-network providers or decline care. This notice should be for informational purposes only and not constitute a waiver of patient rights, nor should it act as a statement of consent by the patient to pay for services provided.

This is a great first step.  There is a real possibility that Congress will pass legislation this term and that the president will sign it.  Good news out of Washington – Surprise.


DAVE


www.cunixinsurance.com


Picture – Dr Thunder Monk Courtesy of Joan Naro – David L Cunix

Practicing What I Preach

It was a Monday morning, a few weeks ago, and I was interviewing a new oncologist.  Yes, interviewing because he was applying for a job, a really important job.  My clients have heard me say this before.  You are in charge of your health care.  It is up to you to assemble a team of professionals and experts.  They work for YOU.  Do these doctors answer all of your questions?  Do they answer the questions you don’t know enough to ask?  Do you have confidence in them?  If not, find another.  It is only at this initial meeting that you are truly in control, because when you really need them, when you really need to rely on their expertise, you better be sure that you are prepared to cede to them an awful lot of control.  I had an excellent meeting with the doctor and he has been welcomed to my team. 


It has now been three years since my little health adventure and August will mark the three year anniversary of the end of my radiation therapy.  Though I am not taking any medication or treatment I still incur tens of thousands of dollars of testing every year.  Blood tests.  CT Scans.  Doctors’ visits.  It costs a lot of money to prove I’m still here.  My new oncologist had the pleasure of reviewing my latest semi-annual CT Scan.  Each of these costs me $3,000.  If I need this, I need it.  My question was whether I still did.  The answer, maybe not.  We discussed this and decided that my next CT Scan could wait till May 2020, three months after I go onto Medicare.  It doesn’t hurt to ask.


It was a few days later and it was time for my annual eye exam.  The doctor saw something that got his attention.  He called it a macular abnormality.  He didn’t think that it was the beginnings of macular degeneration, but he wasn’t positive.  He wanted me to see a specialist.  So I asked, “Is this something that we’re going to monitor and I should check-in with a specialist after Medicare kicks in next February or should I stop at their offices on my way home?”  The doctor said that it wasn’t an emergency but that it shouldn’t be put off till next year.  Again, no unnecessary tests or procedures, but we don’t skip that what needs to be done.  I contacted an ophthalmologist friend and was in his office the next Monday.  The results – no problem.  The first doctor did not overreact.  He was right to express concern.  The specialist, armed with the most up-to-date technology, was able to offer a more comprehensive diagnosis.


We talk about this often. Is every blood test necessary?  Can the results be shared with everyone on the team?  It is up to us to take charge.

                          *                      *                        *                      

There is an advantage to being billed for your insurance, for knowing that your policy has been paid.  Most health policies don’t charge extra for paper bills.  I believe in online banking.  I authorize my bank to pay my policy, usually the first week of the month for the payment due on the first of the next month.  The payment comes out of my account around the 28^th and I know that I am safe.  I try to get all of my clients to do this.  Sadly, not everyone listens.  Two of my Medicare clients lost their Part D (Rx) policies because their auto-drafts failed.  This happens.  They will not be able to purchase prescription coverage again till this year’s Open Enrollment in October.

Even worse are the people who insist on having their Medicare Advantage premiums or their Medicare Part D (Rx) premiums come directly from their Social Security checks.  Think about this.  You are asking the government to write a check to the insurance company for an amount that changes every year.  What could go wrong?  Lots!  According to Kaiser Health News, Social Security screwed up the coverage of over 250,000 people.  It wasn’t until a few weeks ago that it was discovered that these people hadn’t paid any premiums this year.  Over 43,000 Aetna clients were affected.  Humana, over 33,000.  Some of these people were cancelled and will hopefully be reinstated.  All of them owe back premiums that will have to be repaid.  This is a preventable problem.  All it takes is a bill in the mail.

You are in charge of your health care.  Whether we are talking about assembling your health care team, making sure that you only get the tests that you need, or just verifying that your monthly premium is paid, it is your responsibility to take care of you.  What could be more important?

DAVE

www.cunixinsurance.com

Picture – LOW CARB Cherry Pie – David L Cunix