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balancing billing of medicaid members examined

Business Week Examines Practice of Balance Billing by Medical Providers
from kaisernetwork.org: Health Policy Daily Report
Business Week on Thursday examined how “millions of confused consumers” are being asked by hospitals to pay the remaining balances of medical bills not covered by their insurers, even though the practice, called “balance billing, often is illegal.” Balance billing can occur when “medical providers participating in a managed care network believe the plan’s insurer is imposing too deep a discount on medical bills or is taking too long to pay” and demands the balance from the patient, according to Business Week.

Forty-seven states ban in-network providers from billing insured patients more than their required copayment or deductible and federal law prohibits providers from billing Medicare beneficiaries for unpaid balances. Some states also ban additional charges for insured patients who seek care from out-of-network providers and emergency departments. While national statistics on the practice are unavailable, economists and patient advocates estimate that consumers pay at least $1 billion annually for medical bills that they are not legally responsible to pay.

Some providers across the nation have faced lawsuits because of the practice but many states “have been slow to take action in billing disputes,” and many “[c]onsumers, overwhelmed by medical bills,” often “lack the resources to fight balance billing on their own,” Business Week reports


ERISA examined

MetLife V. Glenn‘: The Court Addresses a Conflict Over Conflicts in ERISA Benefit Administration,” Health Affairs: In the Web exclusive, Tim Jost of the Washington and Lee University School of Law discusses a recent U.S. Supreme Court decision that recognized the conflict of interest that often faces Employee Retirement Income Security Act plan administrators, who often both evaluate claims made by employees and pay the claims they approve. According to Jost, the Supreme Court decision made it easier for the conflict of interest to be invoked in court by employees who file lawsuits against plan administrators to reverse denied claims. Jost writes that the decision likely will lead to more approvals of employees’ health insurance claims and more litigation over denied claims

website to help consumers with RX

The AP/Boston Globe on Monday examined how the introduction of two online tools and an initiative led by FDA seek to reduce confusion caused by medications with names that appear or sound the same as the names of other treatments. According to the AP/Globe, confusion about “drug names because they look or sound alike … is among the most common types of medical mistakes, and it can be deadly.”

Last week, U.S. Pharmacopeia launched a Web site that allows patients and physicians to determine whether they have received or prescribed such medications. U.S. Pharmacopeia in a recent study found that about 1,500 medications have names that appear or sound the same as the names of other treatments. In addition, the Institute for Safe Medication Practices and iGuard this fall plans to launch a Web site that will send patients information about such medications. FDA also plans to begin a pilot program that will shift more responsibility to pharmaceutical companies for efforts to prevent confusion caused by medications with names that appear or sound the same as the names of other treatments.

Diane Cousins, a vice president at U.S. Pharmacopeia, said, “There are so many new drugs approved each year, this problem can only get worse,” adding, “We’ve had cases where a health care professional repeats what they think the patient’s on, and the patient thinks they must know what they’re talking about and agrees.”

Michael Cohen, president of the Institute for Safe Medication Practices, said that pharmacists often advise physicians to include a description of patient diagnoses with their prescriptions to help prevent medication errors. Cohen said, “What they consider most important is knowing why the medication is used,” adding, “It would go a long way to interrupt a lot of these mix-ups”

health cost on the rise

Small businesses by now are used to having their health-care costs rise much faster than large corporations. And new survey results suggest 2009 will be no different. In fact, things are so tough that an increasing number of small firms are expected to dump their health benefits altogether.

Preliminary results of the annual health-insurance survey by Mercer, a benefits consultant, show that health-insurance costs for all employers will rise about 5.7% in 2009 – the lowest annual rise in the past decade. But small employers – those with 10 to 499 employees – expect their health costs jump 10% next year.

PopoutMercer says companies, small and large, are expected to fight off the increases by continuing to pass along the costs to employees. About 19% say they will add a high-deductible health plan, such as a health savings account or a health reimbursement arrangement. Those plans often cost about 20% less than typical medical plans like HMOs or PPOs, Mercer said in a news release.

Despite the cost-savings tactics, a growing number of the smallest employers are expected to drop health-insurance coverage altogether, Mercer found. The number of small employers with 10 to 199 employees offering health insurance has fallen from 69% in 2001 to 61% in 2007.

No wonder when politicians and pundits talk about health-insurance reform these days, small businesses are center stage. The new generation of the “Harry and Louise” ad running this election season shows the married couple sitting around the breakfast table discussing how their friend who recently joined a start-up got diagnosed with cancer and doesn’t have insurance.

health insurance examined

  • Does Enrollment in a CDHP Stimulate Cost-Effective Utilization?” Medical Care Research and Review: The study — by Judith H. Hibbard, Jessica Greene and Martin Tusler of the University of Oregon — finds that people who enroll in consumer-driven health plans generally reduce their use of medical services. The authors write that CDHP members with high deductibles — who tend to have lower incomes and less education — seek care less often than members with low deductibles because of cost concerns. The study suggests providing more information to high-deductible health plan members that encourages use of necessary medical services (Hibbard et al., Medical Care Research and Review).
  • “The Distribution Of Public Spending For Health Care in The United States, 2002,” Health Affairs: According to the Web exclusive by Thomas Selden and Merrile Sing of the Agency for Healthcare Research and Quality, public health care spending is disproportionately distributed to the elderly and those in poor health, and less money goes toward low-income residents. For the study, Selden and Sing analyzed government health care outlays and tax subsidies based on age, race, income, health status and coverage status (Selden/Sing, Health Affairs).
  • Tutorial on Expanding Health Coverage to the Uninsured/Reference libraries: KaiserEDU.org: KaiserEDU.org recently posted an updated slide tutorial narrated by Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, about health coverage for uninsured U.S. residents. The tutorial examines the characteristics of the uninsured population, the effect of the lack of coverage on access to care and approaches for extending coverage to the uninsured. The Web site also updated its reference library on the uninsured with the latest data on health insurance coverage in the U.S. and various health reform proposals at the national and state levels. The reference library also includes links to analyses of issues and policies involving the uninsured. KaiserEDU.org also updated its reference library on the role of states in health policy. The updated compendium includes new resources on state-level Medicaid, SCHIP and welfare policy; efforts to expand health coverage; and the federal role in state health policy (KaiserEDU.org release)

patients decreasing doctor visit in these economic times

Twenty-two percent of respondents to a survey have reduced the number of times they visit their physician because of the current economic climate in the U.S., according to the National Association of Insurance Commissioners, the San Francisco Chronicle reports. The poll of 686 consumers, released on Tuesday and conducted in July, also found that 11% of respondents said they had reduced the amount of prescription drugs they take or the dosage of those medications to make them last longer. The survey found that 85% of respondents had not made any change to their health insurance policies, while 2% had canceled their coverage entirely.

Over the past several years, U.S. residents have been paying more of their health care costs, primarily because employers are requiring employees to contribute a greater share of health insurance premiums and copayments, or they are changing or reducing benefits, the Chronicle reports. Michael Potter, a family physician and head of the San Francisco chapter of the California Academy of Family Physicians, said, “There’s a lot of evidence that the more patients are required to pay more for their care, the more that they make economic decisions about what to get or what not,” adding, “While some of that may be perfectly reasonable and acceptable, what I worry about is people not getting care that is really essential for their health.”

Chris Ohman, CEO of the California Association of Health Plans, said, “We know from past economic downturns that employers and individuals tighten their budgets as a whole, but they certainly tighten their health budgets,” adding that although health care costs have increased at rates often double or triple the rate of inflation for years, the squeeze feels more significant as the economy worsens.

The survey did not examine details behind consumers’ decisions, and it does not track any changes in consumer behavior because NAIC has not conducted similar surveys in the past