Friday, August 16, 2019

A Billing “Never Event”

In medical terms, a “Never Event” is an event that should never happen, like a wrong site surgery or killing a patient. An article in today’s medical reading clearly demonstrates a real time Billing Never Event, that unfortunately occurs much too often in medical clinics.

According to WCPO in Cincinnati (OH), a mom had to be pay a bill before her daughter would be seen at a walk in clinic.

The story begins: 

Jessica Vance wanted to avoid a $1,000-plus emergency room bill, when her 8-year old daughter recently developed a cough and fever. 

So she took her to a walk-in clinic inside a local grocery store.”

Problem number one: Why doesn’t this family have a Family Practice Doctor? One of the cited reasons for America’s high health costs is the use of Emergency Rooms for non-emergent conditions, such as this case. If mom had established herself with a Family Practice Doctor, she would have either been seen that day, or at the very least prescribed a medication with a follow up visit, for the cost of a co-payment.

But I digress, let’s continue the saga:

“But when Vance spoke to the woman at the desk, she received some stunning news. The employee said Vance had a $690 unpaid balance, from an insurance payment that had not yet processed.
So the employee said Vance's daughter could not see the nurse, and suggested they go to an emergency room if they needed immediate help.

"I said 'what do you meant you won't see her?' Vance said. "They told me I have a balance due. I asked them 'can't you call insurance?' They said no, they could not."

So she reluctantly she put the past due amount on her credit card, rather than drive across town to an emergency room, and a much larger bill.

"I ended up having to pay $690 that day for her to be seen," Vance said.”

This is where the clinic made its mistake, and it is a huge mistake. Yes, clinics, doctors, etc. can refuse care for non-emergent cases when the patient has a balance due. However, in this case there was not a balance due. Let’s look at the sentence again:

“Vance had a $690 unpaid balance, from an insurance payment that had not yet processed

If the claim had not yet been processed by the insurance company, there is no balance for the patient to pay. When a medical entity agrees to be an in-network provider, which means that the entity agrees in a contract to submit claims to an insurance company for payment and not collect from the patient at time of service, then the patient cannot be billed for any monies owed until that claim is processed. The clinic violated the contract with the Insurance Company and as such the Insurance Company has grounds to nullify that contract, resulting in the clinic becoming a non-participating provider.

Now to make matters worse, the article reports that the Insurance Company paid the balance due in full but mom has not yet been reimbursed the funds. This is the ultimate insult.

While a clinic has a right to deny treatment based on an unpaid balance, the patient would have to be notified in writing that this was the policy and the patient would have to sign a document acknowledging that policy. (When I manage an office, my Policy and Procedure Contract with Patients is about 11 pages long.) Without that signed documentation, the clinic cannot deny treatment based on monies due, as this is outside the contract that the Patient and the Insurance Company have with the provider.

Thursday, August 15, 2019

More face-palming?

Oh yeah:

So what does this mean, exactly?


ACA-compliant plans have certain features and rules, one of which is that chronic care can't be considered a first-dollar expense. That is, unlike, say, a routine physical, chronic expenses must first be applied to one's deductible and co-insurance (if any). Turns out that a lot of folks who actually suffer from these issues would like relief from this requirement.

This becomes a problem for HSA policy holders, because doing that would render their plans non-compliant (and result in all kinds of nasty consequences). And so, the generous folks at the IRS have issued a ruling that reverses (or negates) that, and specifically allows such plans to cover some chronic expenses "first dollar."

Which is nice, but just as insurancecare, coverage ≠  "free."


Well, according to the folks at Snell & Wilmer, this notice now provides "free preventive care for certain chronic conditions."


And how do the physicians who actually provide it feel about working gratis?

And then this little gem:

"Employers that want to take advantage of these new rules may need to adopt plan amendments and prepare employee communications explaining the new rules."

Oh, because compliance is already such a bargain; I'm sure they're just chompin' at the bit.

Wednesday, August 14, 2019

Free Health "Care"

Courtesy of our Neighbors to the North©:

But hey: Free!

It's that time of year again...

When Summer starts to fade, and we cast our eyes on Fall and the annual Breast Cancer Awareness Walk.

Our friends (and teammates) at InsuranceWorks are kicking off their efforts early:

"Insurance Works for You! Is giving you an opportunity to DONATE to Making Strides against Cancer Walk without asking you for money.

If you call or e-mail between September 1st and September 30th and request an insurance quote for Life, Home or Auto Coverage. we will donate $ 1.00 for each quote completed.

Call at 937-424-5633 or email and mention the American Cancer Society

Gun Insurance: Oy

The stupid, it burns:

"[T]he mayor of San Jose, Calif., on Monday proposed what is being called a first-in-the-nation move to require all gun owners to carry liability insurance for their weapons."


And how would that work?


"[T]he insurance would cover any accidental discharge of a firearm and any intentional acts carried out by a person who has stolen or borrowed the gun. It would not cover the policyholder for any intentional discharge that he or she carries out."

So let me get this right: I would be forced to buy an insurance policy (that does not, in fact, actually exist) to cover the illegal actions of a person who steals my firearm? Do I have that correct? How many pills did you actually take?

We've written about the concept of CCW insurance and the like for quite a while. Here for instance:

"The United States Concealed Carry Association (USCCA) provides a policy for its members designed to provide immediate assistance after an incident."

The "catch," of course, is that it protects only the licensed CCW holder, and even then only for his or her intentional act of self defense.

In other words, Hizzoner wants to require legal gun owners to buy a product that if it actually existed would be of zero benefit to themselves.

And how does he justify this?

Pure rocket surgery:

"Liccardo said that his plan is based on similar laws in California that make it illegal to drive a vehicle without insurance."

No, it does not. Like every other state, it requires one to have insurance if, and only if, one intends to drive on public thoroughfares. I would also love for him to identify which Constitutional penumbra relates to driving a car.

I'll wait.

Tuesday, August 13, 2019

Another Nail

Good news from an Insurer in today’s readings:

Health insurer Anthem plans to launch a new mobile app that will enable its 40 million members to get quicker access to personalized health information and treatment options.
Through the app, members also will be able to text with a doctor at a lower cost than visiting a physician's office.”

Well good news for the patient, but it is another nail in the coffin for the Primary Care Physician.

Anthem is using an app, called CareSpree, which will allow patients the ability to put in their symptoms and through AI receive possible diagnosis. Anthem incorporated technology from a digital health company, K Health, to create an artificial intelligence that will offer potential diagnosis based on historic data from medical records. It will take into account the users’ medical history, age, and gender.

The app will enable Anthem members to see how doctors have diagnosed and treated other patients experiencing similar symptoms. The health information is provided at no cost. Patients can then connect with a doctor via text for follow-up advice for less than the cost of a copay, according to the companies.”

As a Manager in Medical Offices, a major complaint from patients was the cost of their appointment for a simple diagnosis. I explained that the cost for the appointment is based on many factors, one of which was the physician’s time and expertise in diagnosing their problem. In terms of coding, this is called “medical decision making”. In essence, you are paying for the knowledge of a physician that he/she is utilizing in your medical care.

Anthem has removed that cost by creating an AI that has all the knowledge of your doctor and hundreds of others.

Allon Bloch, CEO and co-founder of K Health, summed it up best:

We developed a platform that allows us to use real data from the real world to offer potential diagnosis and treatment options and that costs less than a primary care visit today”.

Now a patient can, in real time, utilize the app to diagnose their symptoms, text with a doctor about treatments and receive a prescription if needed, schedule a follow up appointment with a specialist and even schedule labs and testing if the situation warrants it.

If this works as promised, it will be a game changer for the Private Practice Primary Care Physician. Urgent Cares, Walk-In Clinics, and the utilization of Mid-Level Providers (i.e. Nurse Practitioners) have already taken a toll on their patient base and finances. As another nail is pounded in, the next faster, cheaper, mode of delivering medical care is waiting around the corner, with another nail.

States vs Ministries

Health Care Sharing Ministries, to be precise.

We've long been proponents of the concept, perhaps not so much the execution. Be that as it may, HCSMs have proven to be a viable model, with at least a million souls enrolled. And we also know that, like Direct Primary Care, these non-insurance plans are ObamaCare-compliant; that is, they satisfy the (Evil) Mandate.

Our concern has always been that folks are prone to conflate such alternatives as "the real McCoy." and this can lead to problems. The question arises, then, as to whether there's a role for The State to play, given that the plans are themselves unregulated and unsupervised (which are not necessarily "bad" things).

And it looks like we have a contender:

As I mentioned in response, Mr Kreidler (the Evergreen State's insurance commissioner ) isn't wrong:

"member contribution payments ≠ premiums"

That is, these plans have contributions, not actuarially determined premiums, and that's an important distinction. And at least one of these ministries touts options that mimic ACA metal tiers (eg Bronze, Silver, etc). This can be terribly confusing to the uneducated consumer, and lead folks to incorrectly assume that the plans adhere to ACA regulations (which they are not required to do, and in fact do not).

I then took it a bit further:

"I have the opportunity to sell these, and have always taken a hard pass.


Well, see here."

In that post, I explained that my reluctance has nothing to do with my faith, but my profession:

"Well, what happens when my client has a claim that the Medishare folks decline? He's going to come back to me and ask why I sold him an insurance plan that wasn't insurance. And how do you think the court's going to decide?"

And that's why I think that maybe Mr K has a point, and perhaps a solid case.

Time will tell, of course.

Monday, August 12, 2019

A (Double) Tragedy, and a Question

This sad story out of The Evergreen State raises a few questions:

"A Washington state man allegedly killed himself after killing his wife, and left a note for authorities saying that he was driven to do so because they could not afford to pay for medical care for her serious health conditions."

Apparently both he and his 76 year oild wife had been dealing a with some severe and expensive, health issues, and as a result facing an uncertain financial future.

But: they were both in their 70's, which seems to me to mean that they were on Medicare. Most folks on Medicare have either a supplement or a Medicare Advantage plan, both of which are supposed to mitigate the likelihood of just this result.

So I reached out to both co-blogger Bob V and FoIB Scott M, both of whom are active in the over-65 market, for their thoughts.

Bob offered this take:

"Hard to say

Original Medicare + supplement = minimal OOP except Rx. No cap on Rx.

Advantage = a lot of OOP . . . usually capped at $6700 for in network health care. No cap on Rx.

Darryl Dragon was supposedly bankrupt or near that when he died.

Tennille filed for divorce in 2014. At the time, her filing referenced health insurance coverage and previously, in 2010, she’d written that Dragon was living with a Parkinsonian neurological condition that caused harsh tremors.

That article made casual reference to health insurance but I recall seeing something a few years ago about health related money issues

Scott added that:

"Unless they had expensive medications, it’s hard to fathom not being able to afford their care.  Granted, with a Medicare Advantage plan they could have had max out of pocket limits as high as $6,700 each.  But still."

He also noted:

"I found this line to be quite disturbing:

Jones allegedly shot his wife once, and himself three times

How does one shot themselves 3 times?

Indeed, but that's another post.

I did reach out to the Fox News reporter on whose article this post is based, seeing if she could shed any light n the matter. She responded that she did not, in fact, have that information, but did suggest that we reach out to family members once things have settled down.

That's a good suggestion, and may be worth following up. Regardless, we appreciate her prompt reply.

Meantime, may the couple's memory be for a blessing.

1,000 Words on 2019 Health "Care"

[Hat Tip: FoIB Beverly G]

Friday, August 09, 2019

Where there's a will...

There's generally a lot less confusion and ill feelings. Case in point: the Queen of Soul, Aretha Franklin, who passed away last year after a losing fight with pancreatic cancer.

So why is this an issue for InsureBlog?

Well, because life insurance, wills and trusts are all part of a complete estate plan, and can help stave off intra-family squabbles and even IRS issues. In this case, however, it seems that there may have been too many wills:

"...a 2014 document shows her son Kecalf Franklin was also named a representative. In a 2010 document, the names of White and Owens were crossed out, but they appear again in the handwritten will."

By the way, leaving conflicting (or, often no) instructions on how one would like one's affairs settled post-death, is surprisingly common among celebrities who, one would presume, have access to top-flight legal and tax counsel. For example, Honest Abe, himself a lawyer and MLK Jr, Jimi Hendrix and even Prince all neglected to have one drawn up.

For most folks, it's a pretty simple and inexpensive process.


Thursday, August 08, 2019

Sighted: Flying Pigs

Here's something you don't see every day:

"Blue Cross wants to lower rates for Obamacare policies"

The Tar Heel State's largest health insurer claims to have "figured out how to make money after six years of selling subsidized policies under the Affordable Care Act," and want to pass along some of those savings to its insureds.

Now how did they accomplish this feat?

Well, by switching from an 'ala carte' claims model to a bundled one, where instead of multiple claims from various providers (hospitals, radiologists, surgeons, etc) they pay one "global" claim.


Oh, the kicker?

They have to petition the bureauweenies in Raleigh for permission to lower those rates.


[Hat Tip: FoIB Jeff M]