by US Rx Care | May 14, 2019 | Uncategorized
When your medical care provider charges more than your insurance company is willing to reimburse, you may get a bill asking you to pay the difference – a practice called “balance billing.” The Trump administration is moving to put a stop to the practice.
In a recent White House round table on limiting health care expenditures, President Trump vowed to end balance billing, citing a report from the Kaiser Family Foundation that showed that four out of 10 Americans had received a surprise medical bill in the past year.
The practice is already banned for participating Medicare and Medicaid providers, though non-participating Medicare providers who haven’t completely opted out of the program can still impose a surcharge of up to 15%.
How does balance billing happen?
Balance billing often results in a surprise medical bill, received after the services are rendered. It’s especially common when:
- A patient doesn’t ask about actual medical costs at the time of service.
- A patient accidentally receives services from an out-of-network provider.
- A patient receives a service not covered under their plan.
In theory, it should be easy to check whether your provider is in your network before seeking medical services. In practice though, things aren’t so easy. For example, even if your hospital is in-network, you can get a surprise invoice via balance billing under circumstances like these:
- They bring in an out-of-network radiologist;
- They use an out-of-network laboratory;
- They hire an out-of-network anesthesiologist; or
- They bring in an out-of-network consultant.
This is true even though someone else picked the provider, not you. You may not even have been conscious at the time.
Some states have already moved to restrict the practice – but state laws so far have generally only protected people on state-regulated plans. Those on self-insured employer plans, for example, don’t receive much protection under these state laws.
But federal officials are pushing for more transparency: The Department of Health and Human Services has already required hospitals to publicly post their list prices of all their services online, effective Jan. 1 this year.
There is also some legislation pending in Congress. Under the No More Surprise Medical Bills Act of 2018 (S. 3592) sponsored by Maggie Hassan (D-NH), providers can only charge a patient an in-network amount, unless the patient has been properly notified about the charge and has consented to it.
That bill was referred to committee last year, though its future in the new Congress is uncertain.
There’s also yet unnamed draft legislation from a bipartisan group of senators that would protect patients from out-of-network billing, set payment standards, and prevent balance billing.
The draft was written by Bill Cassidy, M.D. (R-LA), Michael Bennet (D-CO), Chuck Grassley (R-IA), Tom Carper (D-DE), Todd Young (R-IN) and Claire McCaskill (D-MO).
by US Rx Care | May 8, 2019 | Uncategorized
As more employers adopt high-deductible health plans, which leave their employees with more “skin in the game,” it’s important that you educate them on how to get the most out of the attached health savings accounts.
Unfortunately, your employees may not be using the funds in their HSAs as efficiently as they should, and they could be leaving money on the table. One of the most common ways that happens is spending those funds on inappropriate care or misdiagnosed afflictions. It’s estimated that up to $1 trillion a year is spent on this type of erroneous care.
The nice thing about HSAs is that they have a threefold tax benefit:
- Money goes into the accounts pre-tax,
- The funds in the HSA grow tax-free, and
- Funds are withdrawn tax-free if used for qualified medical expenses.
Also, funds in an HSA remain in the account. There is no use-it-or-lose-it provision and workers retain ownership of the account even if they switch employers. They also can be kept until retirement and, like an IRA, your staff can roll over or combine HSAs if they have more than one.
But it behooves your employees to learn how they may be squandering the funds they have put into their HSAs.
Examples of unnecessary care
- Duplicate tests, because doctors don’t have access to a patient’s full medical records when they go to two or more treatment centers.
- Overtreatment for common conditions such as back and joint pain, some types of cancer, and stable heart disease.
- False positives from tests, leading to follow-up tests.
- Replacement of less costly gold-standard medications and treatments with new and more expensive alternatives that may not yield better results.
- Care that was delivered on the insistence of a patient when it was not needed or medically appropriate.
Tools for corraling health spending
Fortunately, there are means available to help your employees better decide how to spend their HSA funds.
First and foremost, the majority of medical expenses, like office visits, are reimbursable and the employee should tap the HSA whenever they incur a copay, deductible or outlays for medicine.
Shopping around – If they are told they need a procedure, they can take matters into their own hands and shop around for the procedure among the available treatment facilities in the group network. Doing this can save thousands of dollars.
Second opinions – Getting a second opinion is important, particularly after:
- Receiving a diagnosis of a serious or complex health problem,
- A doctor recommends elective surgery, or
- If the diagnosis is not clear.
Fortunately, many group plans have second-opinion programs as stand-alone services or included as part of an advisory or vendor management program, and through medical centers of excellence.
Objective, evidence-based research – Supplying employees with evidence-based information on treatment options, presented in plain English, can help them understand their options, make more informed decisions, and avoid inappropriate testing and treatment.
It’s also helpful if this resource includes the option to speak with someone via phone or web chat who can answer questions about the information and suggest additional resources.
Referrals to experienced health care providers– Accurate diagnosis begins with connecting employees with the right physicians. The ability to connect workers with physicians who have proven experience and expertise in treating the condition that they’ve been diagnosed with can lower the risk of misdiagnosis and inappropriate treatment.
by US Rx Care | May 2, 2019 | Uncategorized
As promised, the Trump administration has issued proposed rules that would allow individuals to skirt Affordable Care Act regulations and buy short-term, low-coverage health plans.
Under the proposal, individuals would be able to purchase short-term plans that last up to 12 months, compared to the three-month maximum under the ACA.
The proposal would also exempt these short-term plans from ACA rules about what kind of coverage individual health plans are supposed to have, like covering 10 essential health benefits and barring insurers from rejecting individuals with pre-existing conditions.
The administration said short-term plans are meant for people who:
- Cannot afford ACA coverage purchased on exchanges,
- Are between jobs and need temporary coverage that’s cheaper than COBRA, or
- Have doctors who are not included in plans offered on public exchanges.
The Department of Health and Human Services predicted that 100,000 to 200,000 Americans would switch from individual market plans to short-term policies thanks to the new rules.
Short-term health insurance covered 148,118 people in 2015, according to the National Association of Insurance Commissioners.
Under the proposed rules, insurance companies would be required to prominently display in the contract and application materials that the policy is exempt from ACA protections.
Who would buy these plans?
Short-term health insurance is meant to provide temporary coverage for people transitioning between traditional health policies, perhaps because they are changing jobs.
Short-term plans are usually accepted at more doctors’ offices and hospitals compared with traditional insurance plans, which are often limited to narrow networks. And they are usually cheaper.
Healthier and young individuals who don’t think they need full coverage would likely choose these types of plans, which would pull them from the ACA markets. If that happened, marketplace plans could be left with an older and less healthy pool of covered individuals, which would likely force them to raise rates.
Short-term insurance plans cost an average of 25% less than bronze plans on the individual marketplace, or $65 less per month, according to data from AgileHealthInsurance.
The pricing is low because these plans don’t offer the 10 essential health benefits as normal ACA-regulated plans do (things like pregnancy care and mental health treatment) and they are not required to cover pre-existing conditions.
Currently, there are only a few players in the short-term health plan market, as the ACA allows individuals to carry short-term insurance plans for a maximum of three months. But, since the Trump administration announced in October 2017 that it would propose new regulations for short-term plans, more carriers have been exploring entering the market.
Two major industry lobby groups – America’s Health Insurance plans and the Blue Cross Blue Shield Association – have warned that the short-term plans could harm state insurance markets.
by US Rx Care | Apr 23, 2019 | Uncategorized
Do you know that Fed-OSHA has regulations on whistleblowing and employer retaliation under the Affordable Care Act?
The rules set forth procedures and time frames for reporting and processing whistleblower complaints by employees against their employers and expand the instances in which an employee can sue their employer for retaliation under the ACA.
(more…)
by US Rx Care | Apr 16, 2019 | Uncategorized
A new study has found that people enrolled in high-deductible health plans (HDHPs) actually are more likely to consider costs and quality when considering non-emergency care.
The 14th annual “Consumer Engagement in Health Care” study by the Employee Benefits Research Institute and market research firm Greenwald & Associates surveyed 2,100 adults, most of whom receive health coverage via their employers.
The survey found that people enrolled in health plans with a deductible of at least $1,350 for self only, and $2,700 for families, were more likely to take costs into account when making health care decisions.
Evidence of cost-conscious behavior:
- 55% of HDHP enrollees said they checked whether their health plan would cover their care or medication prior to purchase, compared to 41% in traditional health plans.
- 41% of HDHP enrollees said they checked the quality rating of a doctor or hospital before receiving care, compared to 33% of those in traditional plans.
- 41% of HDHP enrollees asked for a generic drug instead of a brand name drug, compared to 32% of traditional plan enrollees.
- 40% of HDHP enrollees talked to their doctor about prescription options and costs, compared to 29% of traditional plan participants.
- 25% of HDHP enrollees used online cost-tracking tools provided by their health plans to manage their health expenses, compared to 14% of people in traditional plans.
- HDHP enrollees also were more likely to take preventive measures to preserve health, including enrolling in wellness programs.
That said, the study did find some negative behavior among HDHP enrollees as well, including that 30% of HDHP enrollees said they had delayed health care in the past year because of costs, compared to 18% of traditional plan participants.
What you can do
In order to help HDHP enrollees get the most out of their plans, it’s recommended that their employers also offer health savings accounts.
This can help them pay for services that are not covered until they meet their deductible. Employers can help by matching (fully or in part) employees’ HSA contributions. This encourages them to participate.
Employers should also push preventative care. The Affordable Care Act requires all plans to cover a set of preventative care services outside of the plan deductible. Unfortunately, many people don’t know that these services must be covered by insurance with no out-of-pocket expenses for the enrollees.
Some employee benefits experts are recommending that employers tie the amount of premiums employees are required to contribute to how well they comply with preventative guidelines.
Non-enrollment in HSAs
These are the reasons employees cite for not enrolling in their company’s HSA:
- Do not see any advantages: 57%
- Do not have enough money to contribute to the account: 24%
- Their employer doesn’t contribute to the account: 10%
- Did not take the time to enroll: 8%
- Do not understand what the HSA is for: 6%
The key to getting your staff to take advantage of the tax-savings feature of HSAs is education. You should make sure all of your eligible staff understand how they work.
And if you are not currently contributing some funds to their HSAs, now might be the time to consider doing that.
by US Rx Care | Apr 9, 2019 | Uncategorized
It’s no secret that the cost of pharmaceuticals is going through the roof. You’ve heard the stories of price-gouging by some companies that have jacked up prices thousands of percent.
Drug costs are starting to weigh heavily on the cost of care, in turn driving up health insurance premiums, which individuals, employees and employers are all feeling. The cost of some medications is so extreme that a single dose may far surpass the total premium paid for coverage.
Also, most people never really know the true price of a drug unless they are 100% on the hook for medications under their health plan. Often, you may have a copay that may differ depending on the type of drug, so people usually only see what they pay. However, every year more people are on the hook for the price of their drug due to high-deductible insurance plans and formulary changes.
The website Goodrx.com, a service for comparing and locating the best prescription prices, publishes a list every year of the most expensive drugs in the country.
While few individuals will pay these full amounts, some do because of their poor choice of health plans (like ones that saddle them with 100% of drug costs) or because they have been placed in a high-deductible health plan. The following is the top 10 list, in reverse order, of monthly prices that are set by the drug companies and known as the wholesale acquisition cost:
- Cuprimine – $31,426
Cuprimine removes copper build-up caused by Wilson’s disease. Patients take one capsule of Cuprimine after every meal. The list price is $261.89 per pill.
- Harvoni – $31,500
Harvoni is the first, once-daily combination drug used to treat Hepatitis C. Patients usually take it for 12 weeks. The cost per tablet: $1,125.
- Firazyr – $32,468.40
Firazyr is an injectable medicine used after an attack of hereditary angioedema. The typical patient suffers two to four attacks per month. A pack of three syringes costs $32,468.
- Juxtapid – $36,992
Juxtapid is used to treat people with homozygous familial hypercholesterolemia, a gene mutation that leads to cardiovascular disease. The dosage is about one day. The cost per capsule: $1,321.
- H.P. Acthar – $38,892
Also referred to as Acthar, this medicine is used to treat multiple conditions, including lupus, rheumatoid arthritis, multiple sclerosis, infantile spasms, ophthalmic conditions, and psoriatic arthritis. The dosage is one vial a month, which costs $38,892 (for perspective, a vial cost $40.17 in 2001 and the price shot up after a new manufacturer took over).
- Myalept – $42,137
Myalept is used to treat leptin deficiency in patients with generalized lipodystrophy. Myalept is self-administered once a day in measured doses from vials, each one of which lasts about three days. The cost per vial: $4,213.
- Chenodal – $42,570
Chenodal is used to dissolve gallstones. Dosing varies and pills are manufactured at different strengths. Sadly, while this medicine is off-patent, which means that other manufacturers could legally produce generics, Chenodal is protected under what is referred to as a “closed distribution system.” That prevents generic drug-makers from purchasing a brand name drug. The list price for a month’s supply of Chenodal is $42,570.
- Cinryze – $44,140
Cinryze is used to treat hereditary angioedema, a rare life-threatening genetic condition that causes swelling in various parts of the body, including hands, face and throat. A one month’s supply runs to 16 vials, and the cost per vial is $2,758.
- Daraprim – $45,000
Daraprim is commonly given to AIDS and transplant patients to prevent infection, and is used to treat toxoplasmosis in otherwise healthy people. This is the medicine that got Martin Shkreli in hot water after the company at which he was CEO in 2015 raised the price per pill from $13.50 a pop to $750 almost overnight. While Daraprim can now often be obtained for $473 a tablet, the list price remains at around $45,000 for a month’s supply of 60 pills.
- Actimmune – $52,321
This is used to treat osteopetrosis and chronic granulomatous disease, which causes the immune system to malfunction. Patients use about 12 single-use vials a month, and each vial costs $4,360.
