HIPAA'S USE AS CODE OF SILENCE OFTEN MISINTERPRETS THE LAW

Many of us have had an experience, especially if caring for a family member or a friend, of not being able to get the most basic information when contacting a provider or a hospital on the status of a patient in our care.  Even very basic information is withheld sometimes, under the guise of "HIPAA rules won't allow us to share that". 

The New York Times published a recent article about the subject that I thought would interest you.

Here it is . . . .

I found some of the additional comments related to the article to be telling as well.  Many come from doctors and people working in the healthcare field about the reality of working with the law's requirements.

Enjoy!

A Detailed Analysis of the Republican Alternative to Obamacare

Bob Laszewski has offered a detailed look at the Republican's alternative to "Obamacare".  I agree with Bob, that it may have been easier to accept "Obamacare" as the baseline, in need of major renovations - but it seems that it won't happen.

Some of the ideas in these proposals make perfect sense, but they will have different consequences for different consumers within the market.  The other big challenge here is that these solutions proposed are also very complicated for the average person to really understand.  What do you think?

Here's Bob's article . . . .Health Care Policy and Marketplace Review - Bob Laszewski

The Next Chapter of Obamacare

As we approach this next enrollment period (11/15/2014 - 02/15/2015) for individuals and families under the Affordable Care Act there are some things to be considered.

People who are receiving subsidies today, are being told that they can "do nothing" and automatically be re-enrolled in the plan they have today.  If that plan isn't going to be available for 2015, the insurance carrier will place you in a plan that's close.

But - even if you do want to keep the plan you have, you must keep in mind that if you do nothing, the subsidy amount you are currently receiving will stay the same and your share of the premium that you'll have to pay could increase.

So, most ACA subsidy recipients, should really go to the website (Healthcare.gov) when the enrollment period begins to re-apply and do a subsidy re-determination at that time for the year 2015.  If you don't, you may be surprised when the January 2015 bill comes.

In addition, you may want to re-visit things, simply because there will be some new plan offerings and, in some cases, some new carriers available on the exchange in your area.

Some of the Pre-ACA plans will only extend through the end of 2014 for some, so even if you are not receiving any subsidy money, you'll need to go shopping for a plan to begin on January 1.  If you don't qualify for the subsidy money, you can purchase "off-exchange" plans from a variety of sources - including your local agent or broker.

If you do qualify for subsidy money, then you can get assistance from a Navigator, Agent, or broker to review the process, help you access the local exchange in your area, and assist you with selecting plans.

People who had grandfathered plans (meaning, they were effective prior to 3/23/2010) can keep them as long as they desire.  Some others have received extensions of pre-ACA style plans that are not grandfathered beyond the year 2014.  Even though people can keep these plans - they must pay attention to note any rate activity on the plans that they currently have.  That may affect a decision on what to do in the coming year.

Each of you should be receiving some type of communication from your insurance carrier regarding your personal situation.

 - For policies to be effective on January 1, 2015 (i.e., for those who will absolutely lose coverage at the end of December 2014), you'll have to shop and be enrolled no later than December 15, 2014.

 - If you enroll by 1/15/2015, you'll have an effective date of 2/1/2015.  If you enroll by 2/15/2015, then your insurance will be effective on 3/1/2015.

 - If you do nothing, your insurance will continue and any price changes will be reflected in your first billing cycle in 2015.

Bob Laszewski's latest blog post outlines many things to be considered.  Read the blogpost here . . . .

FAQ: Hospital Observation Care Can Be Costly For Medicare Patients

I have addressed this issue with many of my Medicare clients, so that they can ask the right questions regarding their status if they go to a hospital and are told to stay overnight.  A variety of difficulties can arise when your status is considered to be "outpatient". 

This becomes especially acute when someone is on a Medicare Advantage plan, as most of those plans in recent years have classified all "outpatient services" as requiring 20% coinsurance from the client.  If held in an "observation" mode in a hospital, that means the patient would be billed 20% of each charge incurred while in the hospital's care.  This can lead to thousands of dollars of coinsurance that the patient may not understand he or she owes.

Just because you're in a bed, and staying overnight in the hospital does not necessarily mean that you've been admitted.

Here's a good Frequently Asked Questions article from the Kaiser foundation that explains this phenomenon in more detail:

Medicare Observation Care FAQ

Pay Close Attention!!! You're Probably Being Overbilled For All Things Medical!!

Billing!!  Yes, billing is what's bothering me today.  I had an episode with poison ivy that landed me in the emergency room on Memorial Day.  I went in, saw a doctor for approximately 5 minutes - he looked at me, pulled out a prescription pad & wrote a scrip for prednisone.  I walked out & that was it.

When I received the hospital facility bill, the billed amount was $2,115.75!  They made a 'contractual adjustment' of $1,344.14.  The insurance company paid $498.09, and my portion was $274.52.

Then the separate bill for the physician arrived.  That bill was $440.00.  Insurance paid $352.00 and my portion is supposed to be the remaining $88.00.

When I called the hospital to ask if I could have an itemized breakdown of how 5 minutes translated into $2,115.75 I was put on hold for a long time.  I told them I had a right to understand exactly how anything could cost that much.  Was it $1000 for the doctor to stare at me?  Maybe $1100 to pull out a pad to write the prescription on?  What exactly is the breakdown?

I was then told that they probably overbilled me!  (ya think?)  Turns out that these bills are coded according to a "level" scheme that is used as a guideline from the American College of Emergency Physicians.  My hospital bill was coded as a level 4, while the doctor bill was coded as a level 3.

When I asked what a level 4 encompassed, they said they couldn't share that with me.  Why, exactly, I don't know - but apparently everything is a big secret.  We're all just supposed to pay & shut up.

I asked her what level it would be if I had presented in the emergency room with a heart attack & she said level 5.  So, I asked how poison ivy could possibly be only one level below a life threatening condition like a heart attack & she said, again - that I was probably over billed.

I looked up the levels myself (www.ACEP.org), and it turns out that my bills most likely should have been coded as a level 2, which encompasses things like "rashes, sunburn, etc.".  Also, probably for a much more reduced charge.

I then called the insurance company so that they can flag the account, since I'm now having both bills audited.  Insurance technically should have examined it & potentially denied the claim, but the answer I got from them is that since they didn't know exactly what took place in the emergency room, they often simply pay the bill. And yes, it's true - how would they know exactly what services were provided?  They have to trust the provider to some degree, since they are administering the medical care & should be allowed to proceed as needed in an emergency situation.

So, ever wonder why everything is so expensive?  The providers are robbing the insurance companies blind, and then that cost is being passed along to YOU the consumer of health care - both in the form of higher premiums and in the form of higher portions of co-insurance.  Shameful!! 

Take this as a warning - Pay very close attention to any billing you receive - you may not owe as much as you think you do.

Here's what's "got my goat" today about our Medical system . . . .

I had a Doctor's appointment scheduled for next week, and today got a call from the office today stating that when I come in I'd have to bring $100 "earnest money".  I've never been asked for this before, since I have a $40 co-pay to see a specialist.  But - since the practice was sold to the adjacent hospital, they are now saying that my doctor is an "outpatient clinic" and the co-pay no longer applies.  Therefore, I'd have to pay out of pocket until meeting my deductible.

Basically, they've redefined what an office visit is or is not - simply to suit themselves.  No one cares that I've paid for my insurance & included features like co-pays because I was willing to pay the premium for them.

With the advent of health care reform arriving on the scene, I've been seeing more consolidation - on the insurance company side of the business & now on the provider side.  As providers begin to consolidate, it seems they are re-defining what certain visits are, as well as, how certain hospital stays can be billed.

One example of what's happening with 'in-facility' stays, is the new phenomenon of keeping someone overnight (mainly after a visit to the emergency room) for "observation", and giving the impression that the patient has been admitted, when in fact, they have not.  What happens here can make a huge difference to some of my Medicare Advantage beneficiaries, since they pay a daily hospital rate if they are an inpatient that includes everything that happens while they are there (all tests, surgeries, etc).  If they are kept in an outpatient status, that same Medicare Advantage beneficiary would be subject to paying 20% of everything that happens there - so it's very much like 'a-la-carte' billing - resulting in a much higher bill.

Today, the patient has to be ever vigilant & ask very pointed questions about how they will be billed prior to having procedures done.  We're entering an age where none of this is about the patient & patient care, but is all about the money and the various corporate entities that are deciding everything about how care will be administered.

Look alert!  Make sure that if you have any type of serious illness or ongoing need for care, you involve a family member or friend to advocate on your behalf.  When you become seriously ill, you just won't have it in you to fight the good fight.

As for my situation, I told them to cancel my appointment and that I'd find another doctor who would honor my insurance with the features that I've been paying for. . . .

What will Health Insurance Cost in 2014?

This article from Bob Laszewski's Health Care Policy blog is a good synopsis of what could happen to the price of insurance under the new Affordable Care Act.  It clearly outlines items that will drive cost & how that will impact the consumer.

The Affordable Care Act: 10 Months to Launch "Obamacare" - Get Ready for Some Startling Rate Increases

The Ridiculous Cost of Health Care

This article by Brian Klepper through "Care and Cost" online, is very good summary about health care costs & potential ways to begin normalizing them.  He begins by describing his own personal experience with an outpatient procedure and how ridiculous the charges were for a diagnostic procedure. 

I have just gone through major surgery myself - the bills are beginning to roll in & even with good insurance (which I've never used, because I was always healthy), the costs and then the 'adjustments' to those costs are mind boggling.  I've only received the billing for the preliminary "outpatient" procedures that were simply to get a diagnosis and I'm sitting at about $3000 so far (that's MY expense after all insurance discounting & adjustments were made to the ridiculous, original charges).  I'm bracing myself for the in-patient hospital stay and the major surgery bill . . . .

Will the Bubble Burst?

Patients in the Dark on Medical Costs, Study Finds

Wow - do yout think???  I've always encouraged my clients to shop for things like big tests, like  MRIs and Colonoscopies.  If you can get an anwer at all, what I find is that variances between facilities can be larg e.  For MRIs, it can vary $500 -- $1200 for the one test depending on where you go. It's ludicrous that in America we got to get medical services and either never ask what things cost, or just assume we'll find a way to pay.  do we do that at restaurants? NO!   Many medical tests are unnecessary anyway & they scare people into getting them - no questions asked.  There should be uniform 'base price' lists for certain procedures & that's it - very simple.  Read about the ABC broadcast about this issue here:

Patients in the Dark on Medical Costs, Study Finds

Prudential, MetLife Sued over Death Master File

State efforts to collect on unclaimed property held by insurers has mushroomed into private action lawsuits filed in Illinois, Ohio and New York against Prudential and MetLife.
The lawsuits are coming to light against the background of a hearing Thursday on inaccuracies related to the Death Master File mainted by the Social Security Administration.


Read more here . . . .