Friday, September 13, 2019

Breaking (Good) News: Dorian SEP

Just now in email from CMS:

"SEP Available for Victims of 2019 Hurricane Dorian"

This addresses concerns that folks who had become eligible for an SEP but unable to finalize a new plan because of storm-related issues will get another bite at the apple:

"Consumers who qualified for an enrollment period, such as an SEP, but were unable to complete a Marketplace application, plan selection, or enrollment process due to Hurricane Dorian, may have access to an Exceptional Circumstances SEP."

They get an extra 2 months (well, 60 days) to log in and enroll, and "request a retroactive start date based on when he or she would have picked a plan if not for Hurricane Dorian."


[Additional info is available here or by calling 1-800-318-2596]

Heads' up Dayton (OH) folks

As part of our Strides Against Breast Cancer fundraising, we're helping out with Brunch & Beer at the 5th Street Brewpub in the St Anne's District:

“Love, Hope & Faith” team for the Making Strides Against Breast Cancer Walk will be hosting a Fundraising Event at the Fifth Street Brewpub on Sunday, September 15th from 10 AM to 2 PM.
Come and join us for Sunday Brunch.
The team will be “Guest Bartenders” during the event and will be raising money for the fight against Breast Cancer. The walk is on October 19th at Fifth Third Field in Downtown Dayton.

Thursday, September 12, 2019

Lowe's blows

Back on August 31, we purchased a new oven from our local Lowe's store (wanted to support the local folks instead of ordering online). That proved to be a mistake.

We were promised delivery by today (September 12), and that was the last we heard from them.

No follow-up, no notification, nothing.

So I called the store this morning, and was informed that the delivery had been pushed out to the 22nd.

Again, no one bothered to communicate this to me. I only learned of it because I initiated the call. I told the manager that this was not acceptable, and that I expected delivery today. He insisted several times that he couldn't promise that. No effort was made to accommodate or offer alternatives.

So I called corporate, and was informed that the oven had been delivered to the local store, but because Lowe's store managers are incompetent, I had to learn from the nice lady on the phone that their rule is that they can't send items out for delivery on the same day, and that tomorrow's deliveries are already booked.

To her credit, she reached out to the "delivery coordinator" and promised me that she'd have him contact me directly to make arrangements. I eventually heard back from the coordinator, who was able to move the delivery up to this coming Sunday (Yay!).

So, all's well that ends well?

Not hardly: I should not have had to call them to find out what was happening, and the fact that each person I spoke with had a different story, is unacceptably poor customer "service."

 We have had been long-time, loyal customers, but no longer.

It's worth noting that  other stores, like Home Depot and Best Buy, will generally match Lowe's prices.

Nataline Redux

In which I play the bad guy:

Regular readers may recall the sad case of  Nataline Sarkisyan, "a 17-year-old girl who died hours after her health insurer reversed its previous decision and said it would pay for a liver transplant planned."

There was a lot of finger-pointing, and plenty of blame to go around, but there were also some key issues that prompted much circumspection:

The insurance carrier (Cigna) had initially refused a liver transplant, the fact that experimental treatments are (at best) problematic, and whether PR should override best practices.

Regardless, Ms Sarkisyan ultimately passed from her condition.

Now, fast forward almost a dozen years, and we learn of a young mother who, having undergone "major surgery to remove thyroid cancer ... has never truly recovered." She was fortunate to find a "world-renowned expert in dysautonomia and autonomic neuropathies," and began treatment.

Unfortunately, these appear to have been largely ineffectual, and she's now at a very dark place indeed:

"The only treatment that is anticipated to help her is expensive, costing $6000-7,000 per infusion, and the doctor has prescribed 6 infusions to enable her body to reconstitute itself and get her on the road to recovery."

To that end, her family has set up a GoFundMe campaign [full disclosure: I have donated to it] hoping to raise enough money to cover most (if not all) of the expected costs.

Okay, a worthy cause, but why isn't her insurance company covering it (or at least most) of it)?

Well, that's because the carrier, Aetna, "has refused to pay for the treatments, calling the drug "experimental" and providing no recourse for her worsening condition."

Seems familiar, no?

[ed: for the purposes of this post, we'll table discussion of an insurer's putative responsibility to offer alternative treatment suggestions]

As noted in the GFM, there have been appeals and advocates, apparently to no avail.

As a parent and husband myself, I can certainly sympathize with the family's plight, but I have some questions.

So I've reached out to both Sarah's family and her insurance company, and would like to share what I've learned:

Her father, who was very nice and forthcoming, had no direct knowledge of the plan's details. He in turn put me in touch with his son-in-law (whose employer's coverage is the insurance at issue). Unfortunately, he has yet to respond (I'll update the post if/when he does).

In the meantime, I also reached out to Aetna:

"Good morning!

We're working on a post about [the GoFundMe], and would like to have Aetna's side, as well. We understand that you can't comment about this case specifically, but would be interested in speaking/emailing with a claims person who can address the dynamic between experimental vs medically necessary treatments.

Looking forward to hearing from you

About which co-blogger Bob gently prodded me:

"Still tilting at windmills?

Carriers RARELY set their own standards for medical necessity, experimental, provisional. Much easier to follow CMS guidelines as in  "it's not my fault, this is how Medicare handles it."

Doubt you will get very far with this, even without factoring PHI complexitie

I knew that he was right, but "in for a penny...."

In the event, I did, in fact, hear back from them:

"Hi Henry:

My name is Ethan Slavin and I work in the Communications department at Aetna. While we can’t comment on this specific situation (as you noted), we can provide you with our general overview on how we make coverage decisions.

You are welcome to use information from this page for your post, as you see fit.

Please let me know if you have any questions

Which was not unexpected, and actually helpful.

I would still like to know whether or not the plan in question is self-funded (because that could make a difference), but the reality is that Bob's correct, and while sad, this is pretty standard, and not subject to online petitions and the like.

Again, I'd ask why the venom is being directed at Aetna and not the folks with the high-priced meds, or the providers who would administer them.

But that's just me.

Wednesday, September 11, 2019

Offered with no comment

Okay, one comment: Heh.

[Hat Tip: The Gormogons]

Medicare MSAs

[Full disclosure: I am not active in the Medicare Supplement/Advantage market]

Recently received this in email:

"New for 2020: Lasso Medicare Savings Account Plan"

Medicare MSA's appear to be the post-65 version of what we typically see as Health Savings Accounts (HSAs) in the pre-65 market, with some interesting twists:
• $0 Premium
• MSAs are one type of Medicare Advantage (MA) plan that the Centers for Medicare and Medicaid Services (CMS) partners with private insurance companies to offer. MSAs combine a high deductible health plan covering Medicare A/B expenses with an IRS-approved trust/ custodial savings account.
• No admin/monthly fees for MSA account while beneficiary is on plan
• See any provider or hospital that excepts [sic] Medicare!
• Individual must enroll in a stand-alone [Part D Rx Plan].
• HSA account funds can transferred into new MSA accounts. 
• Plans are available in every county in the states where they are available [ed: go figure].

I checked with co-blogger Bob V (who's very active in the Medicare market) and he confirmed that the idea is legit.

This particular iteration is intriguing, since the vendor, not the insured, is making the actual deposit. Once that's made into the insured's account, it's immediately vested, and can be used for medical-related items (like doctors' visits and rx co-pays). Since it's 100% the insured's money, there's definitely some 'skin in the game,' and we can see that in action:

"[A]s of September 1, 2019, 81% of all Lasso Healthcare MSA plan members had spent less than $1,000 in their current benefit period!"


[ed: I reached out to see if the insured/beneficiary could also contribute to the account, and will update this post if/when they reply]

Currently, the Lasso plan is available in over 25 states (almost half of them!).

Cool idea.

[Hat Tip: TLC Recruiting]

Tuesday, September 10, 2019

Contra Conventional Wisdom

Our friend Holly R sent this along:

"The share of Americans with health insurance fell last year, despite a strong economy that lifted families out of poverty." [emphasis added]


More likely: because (better wages = lower/no subsidy)

It's just common sense.

That sinking feeling

You've likely read about the tragic story of the diving boat incident that claimed almost 3 dozen lives last week. One of the unexpected things that happened pretty quickly was a lawsuit ...

Wait a minute, Henry: why would that be a surprise? Of course the families of those killed would seek some kind of compensation.

Well, that's true, of course, but this lawsuit was actually filed by the boat's owner against those families.


Well, it seems that there's a longstanding maritime law that enables a boat's owners to limit (or even prohibit) monetary damages as a result of this kind of tragedy:

"The owners of the diving vessel that caught fire in California and killed 34 people last week filed a pre-emptive lawsuit last week, seeking to limit payouts to the families of victims. The lawsuit was filed three days after the boat caught fire, while families were still grieving, and bodies of the victims were still being removed from the water."

Wow, talk about heartless.

But maybe not:

"The owners ... have blamed their insurers for a lawsuit that they  filed to limit their payouts to victims' families, calling it an "unfortunate side of these tragedies."

Oh sure, blame the insurer.

On the other hand, it's the insurer's duty to its policyholders and owners (stockholders) to limit those damages, and that's why they keep lawyers on hand for just this kind of situation. It does seem rather crass, but the insurer is also bound to do all it can to mitigate the damages. And the timing, while unfortunate, may have little to do with lack of compassion, and much to do with timely filing.

Our hearts, of course, go out to those families, but this seems to be strictly business.

Monday, September 09, 2019

Making Strides Against Breast Cancer: v2019

Once again, I'm raising money with my team: Love, Hope and Faith. Our walk is Saturday, October 19th.

Will you please help out by making a donation - Any amount helps.

Thank You!!

Problem solved? Sorta, maybe.

Just about two years ago, we reported on a potential problem still lurking under the radar:

"For decades, life insurance carriers ... sold permanent universal life insurance policies, marketed as "insurance for life," utilizing outdated mortality tables that did not take into account the fact that Americans were, and are, increasingly living to and past the age of 100."

To be sure, there are still quite a few other permanent-type plans out there with the same issue.

And what issue is that, Henry?

Well, when these plans "mature" while the insured is still alive, that person is likely to be hit with a pretty hefty tax bill; that is, the policy is paid out as a lump sum to the insured, and any excess over the total premiums paid are taxable. That could be a sizeable sum indeed, and is a double whammy (since that policy is now canceled).

Until now, there really wasn't much one could do about in-force plans (hence the clarion call for a class action lawsuit).

But in a Long Term Care insurance (LTCi) product training session last week, I learned about another product that might be a solution to the tax issue:

OneAmerica Life offers an annuity product that's available to folks up to 99 years old, and doesn't require forced annuitization (or Required Minimum Distributions). While marketed as a potential LTCi alternative, it struck me as solving at least part of that "maturation" problem, since there's no immediate funds to pay out and thus be taxed. Called "Legacy Care®,"  it lets one roll-over the cash value of an existing life insurance policy and continue to defer taking the tax "hit" (although it's going to fall to one's heirs eventually).

Not perfect, of course, but at least a little light at the end of the tunnel.

[Hat Tip: FoIB Randy G]

Friday, September 06, 2019


So a while back, we blogged on the potential issues one might face as a trans/other-American in the market for life insurance. It's now back in the news (sorta) due to this rather silly Tweet:

It's silly because (for starters) trans/other Americans comprise barely a rounding error of the general population. Actuaries, by definition, work with very large groups, not infinitesimally-small ones, which would yield an essentially meaningless sample.

But wait, it gets "better:"

Actuaries estimate "probability of risk," that is, the likely number of expected deaths from a (again, large) population; it's merely a pricing tool.

The only opinion that matters here is the underwriter's, because his job is assessing the specific risk, and then deciding whether or not it's acceptable, and at what premium (rating factor).

In the event, neither of these folks would ever even see such an application in the first place, for a very simple reason: all life applications require one to provide name, social security number, date of birth, and sex (among other things). Applications missing this information will be returned to the agent for completion.

There's also the small problem of the "misstatement of age or sex" clause, which would come into play at claim time.

But even more important, from that underwriter's point-of-view, is this:

"As I discussed with a life field rep friend a while back, the life company is likely to decline the case altogether because of the increased suicide risk."

By the way, these issues would also come into play with auto, disability income, long term care and other types of insurance, as well. Which means a lot of wasted time for a trifle.

Talk about much ado ....

Thursday, September 05, 2019

Up next from MoO

Mutual of Omaha, that is:

"We hope the first video interview we did with Demerri Bond was helpful and insightful. Now, we're excited to bring you the next in the series, an interview with underwriter Carol Carville."

MoO is currently our primary LTCi carrier (due to great value and strong financials), but the points Carol makes apply to pretty much all carriers.

Wednesday, September 04, 2019

That Word Doesn’t Mean What You Think It Means

What do you think of when you hear the word emergency?

According to Webster’s Dictionary an Emergency is “an unforeseen combination of circumstances or the resulting state that calls for immediate action.”

However, insurers in Minnesota think it means something different.

Minnesota lawmakers are seeking more transparency from air ambulance companies about the prices of their rides, according to the Post Bulletin.”

Why would lawmakers be interested in making these prices transparent, since the only time you would use an Air Ambulance is in an Emergency?

Because customers have received “surprise air ambulance bills …from insurers that have denied claims for emergency transport, saying the rides weren't preauthorized or weren't necessary.”

I have seen my share of unwarranted denials, but this takes the cake. In an emergency there is no time to get a Preauthorization. A Preauthorization is usually required for any type of surgery, lab, test, or medication that will require a significant reimbursement by an insurer. Preauthorization’s can take anywhere from 48 hours to weeks to obtain. Obviously if you are bleeding on the side of the road and will die without immediate medical coverage you cannot wait for a Preauthorization.

As to the necessity, once again, it is self-evident.

It is this idiocracy of thinking by insurance companies that hinder medical decision making. While this is an extreme of insurance meddling in medical decision making, this interference occurs hundreds of times a day in every medical facility across the nation.

Tuesday, September 03, 2019

Privacy issues, anyone?


[Hat Tip: FoIB Holly R]

Insulin: A Dilemma

As with "surprise billing," coverage for insulin is currently a major shanda in the news:

"Diabetic, 27, dies after taking cheaper insulin as he lost private health insurance."

Josh Wilkerson had recently come off of his stepfather's health insurance (he had reached that magical age of 26) and had elected not to buy his own. As usual, the reporter doesn't bother to ask why Mr Wilkerson chose to "go bare;" at his age a catastrophic ACA plan would have cost about $300 a month (assuming he didn't use tobacco). At least one plan appears to cover insulin.

Be that as it may, the high cost of "regular" versions of the med have become quite expensive, which is a problem for any number of reasons, not the least of which is this:

"Remember those guys who actually discovered insulin back in 1921? Dr. Frederick Banting and Charles Best were the main two, along with Dr. James Collip -- all three had their names attached to the patent awarded in January 1923 to their method of making insulin.Well, did you know that their original intellectual property rights were sold for just $3 in Canadian money?"

(It's more now)

How we got here is outside the scope of this post, but there appears to be more than enough blame to spread around.

So what is the point of this post, you ask?

Well, it's actually quite simple (for certain values of "simple"):

Regardless of how we got here, it's a big problem, so how do we fix it?

Of course, many folks would have the government wave its magic wand and legislate that it be covered at little or no expense (for those who are insured) or provided at little or no cost (to those who are not).

Which seems reasonable on its face, until one considers this:

It would also likely have a chilling effect in development of other vital medications: how does the manufacturer know that his expensive, hard-won work won't be confiscated by the government?

One possible ray of sunshine is the possibility of importing less expensive versions from Canada, but then, that also creats (unintended?) side-effects.

As I said, there don't seem to be any easy answers.

[Hat Tip: FoIB Sam B]

Friday, August 30, 2019

The MVNHS©, Explained


[click to embiggen]

Long live the Much Vaunted National Health Service©.


Hurricane Dorian Heads' Up [Updated]

From our friends at Lexis-Nexis:

"Homeowners insurance: 7 things to know about what hurricane-related damage is covered"

These include special deductibles (typically found in policies issued in hurricane-prone locales) and exclusions like water damage (which is where flood insurance can come in handy)

Don't assume, and if you have any questions make sure to call your agent. We're here to help.


(No nukes, either)

Thursday, August 29, 2019

1,000 Words on LTCi

From Bill Comfort, CLTC:

[click to embiggen]

Says it all, really. Have a plan.

STC Redux

As in Short Term Care insurance.

Recently saw this:

To which I replied "And I'm sure it will be every bit the value that AARP's affiliate MedSupp plans are.

And BTW: This is hardly "new "


In fact, we blogged on them here over 7 years ago:

Hence the "Short" Term label.

La plus ca change....

Tuesday, August 27, 2019

Who'da thunk it?

From our favorite actuary:

Or more succinctly:


Monday, August 26, 2019

Bending that cost curve down: MVNHS©-style

Hard to beat this:


Friday, August 23, 2019

Rock and Hard Place: Grandpa edition

Well, technically "Grandfathered:" the plan in question dates from 2010, when we wrote it for a younger couple and their 3 (now 4) children. This was one of my favorite plan designs: Anthem's Lumenos HSA product, a legit cat (catastrophic) plan with a $10,000 family deductible, then 100% after. Fit their needs well, and was a great value.

Fast forward 9 years, and (sadly) they're divorcing. Which wouldn't be the end of the world insurance-wise but for a couple complications:

First, now ex-hubby has opted for a Sharing Ministry for himself and the kids, and has failed to pay the August premium. Oh, did I mention that I just learned about all this yesterday?


Anyway, Jane reached out to me to fill me in and to ask about her options, . since she would prefer an actual insurance plan. It doesn't look like she'd be eligible for a Special Open Enrollment opportunity (since her plan isn't ACA-compliant), but perhaps she could keep the Lumenos/Anthem plan?

So I reached out to Anthem and learned that she could, in fact, keep the plan (there are some hoops through which she'll need to jump, including getting ex-hubby's signature on the change request).

So what's the dilemma, Henry?

Well, since the August premium is apparently unpaid, the plan is in the 30 day grace period, and that clock is ticking. Once that's over, so's the plan, and the opportunity to keep it. In the meantime, she's waiting to learn whether or not she's been approved for the new job for which she's applied, but won't know that until the 30th.

Which is also the deadline for the change request.


I've suggested that she submit the request anyway, since it doesn't involve sending in any actual money, and she can always change her mind if/when she gets that new gig.

Meantime, it's wait and see.

The Infallibility of Doctors' “Mindset”

The ongoing saga of Mount Carmel Health System in my home state of Ohio should be a wakeup call for all Medical Organizations. Specifically, that Doctors are fallible.

But to the root of the problem, how did this happen. It happened because Medical Organizations are created by Doctors who have a "negativity bias."

How does the negativity bias affect patient care? Catherine Hambley, PhD discusses this in an article, “What you can do about the negativity bias in Medicine.

The negativity bias is alive and well in medicine. It starts in medical school where students are frequently exposed to teaching methods that create feelings of shame, ineptitude and incompetency. Early on in their careers, physicians learn both the importance of preventing and avoiding errors as well as the need for perfection.”

This trait is then carried over into their working lives and into the Medical Practices and Organizations in which they create and work. Staff is expected to maintain this super human level of perfection, which causes tremendous stress and burn out. As Dr. Hambley states:

“…we know that mistakes are inevitable. We also know that if we talk about them, we are more likely to prevent their recurrence. The problem is that healthcare workers often avoid acknowledging that an error has occurred. This is typically due to a culture where mistakes are accompanied by some form of punishment, and people often feel humiliated and blamed. Hospital settings can also perpetuate a culture where the negativity bias is enhanced with physician peer review committees and incident reporting systems.”

I have seen this negativity time and again in the Medical Profession. Staff are intimidated not to complain about the “Bad Doctor” because they have seen their peers who do complain punished. In job interviews I am always asked about dealing with the “Bad Doctor”. I always know when that question is coming because the interviewer becomes quiet, usually sighs or breaths in audibly, and then tentatively begins the question. The question is asked because there is a “Bad Doctor” in the organization that has been ignored, supported, and accommodated when in reality he/she should have been acknowledged, discouraged, and censored.

What happens instead is that good, ethical employees become jaundiced to management, which effects their job performance and ultimately leads to less than adequate care. The case of Mount Carmel is the extreme, but it will happen again as long as the Infallibility Mindset is a part of Medical Management.

Thursday, August 22, 2019

Telemedicine in the News

We last blogged on telemedicine last Fall:

"[U]nlimited same-day/next-day doctor appointments for acute issues at $10 a visit and around-the-clock telemedicine for no out-of-pocket cost."

It was in that post that we first learned the newest buzz-phrase "Virtual Primary Care."

Anyway, fast forward a bit, and now the feature will be a required benefit in health insurance plans marketed here in The Buckeye State:

"Private insurance companies in Ohio are now required to cover doctor visits over the phone or on the computer."

The new reg is touted as a benefit to both consumers (for convenience) and providers (who will now be assured of reimbursement):

"Doctors have been anxious to include telemedicine in their practice but until law guaranteed insurance payments, some were reluctant to purchase equipment and learn how to do it."

Quite so.

Of course, no one's addressing the actual elephant in the room: who pays for this?

If you guessed "I, the policyholder, will be paying for it with increased premiums," please collect your winnings at the ticket window to your left.

[Hat Tp: FoIB Bill M]

Terrible Carrier Tricks: Policy Holder Service edition

One of my life insurance clients called the other day to see if I could help her with her sons' policies. Seems she had bought each of them a Universal Life policy some years ago (before we'd met) and she wanted to professional advice. I was of course happy to oblige, and asked her a few questions:

The plans were about 20 or so years old, and written by her Auto Owners Insurance agent. He has since retired, and the agency to which the plans were re-assigned hasn't been particularly helpful. She did have the annual statements handy, and we were able to determine that the plans were doing well so far (a welcome relief: they often get "upside down" this far in). But it seemed to me that it wouldn't hurt to increase the premium a bit as a hedge against future slumps. To that end, I suggested that she contact AO directly to see about obtaining in-force illustrations (aka "what-ifs") for each plan.

Here's why: due to various tax laws over the years, there is a cap on how much one can put into a given UL each year (yeah. I think that's dumb, too, but there you go). So we needed to determine if we could bump the premiums, and if so, to what effect. Quite routine, really.

What happened next is decidedly not routine: when she called the Home Office, she was told that only her agent could order these illustrations. Putting aside the obvious question of what if she had no agent, why is it the carrier's business if she wanted them? As the owner of the policies, she has every right to this information (as well as changing beneficiaries, premiums, etc).

And even if she wasn't the owner, she should have been told that her sons would need to make the request themselves (not her on their behalf). There's just no excuse for how poorly this was handled. One wonders how she would have been treated if it was a claim.

Shame on Auto Owners Insurance.

[ed: we generally like to give carriers a heads' up on, and opportunity to correct, these types of issues, but AO doesn't seem to have a media relations contact email available]

Wednesday, August 21, 2019

(Very) Mixed Feelings

Don't know how I missed this [ed: yes I do, it flew completely under the radar] but:

"Simple Health claimed to offer comprehensive health insurance or PPOs that would cover many medical needs, but instead sold only medical discount memberships, limited benefit plans, and other products that provide a small reimbursement or discount for a few services."

And then folks started to complain.

A lot.

I've used the marketing company, Health Insurance Innovations, for various short term medical plans, but thankfully never used their Simple Health "plan."

Anyway, the cacophony has apparently reached a crescendo, and the Rocket Surgeons in DC
© have opened up a Special Open Enrollment Period (SEP) for folks who've been bamboozled:

"The SEP will run from July 1, 2019 until September 4, 2019.  Eligible consumers should have received a notice ... advising them of the availability of this SEP. CMS will evaluate an individual’s eligibility for the SEP using Simple Health Plan enrollment information."

Oh goody.

Here's why I'm ambivalent about this:

There were plenty of folks who played by the rules of the game and bought legit policies who were then left high and dry. Why are the SHP folks given preferential treatment? Perhaps it's because the FTC is suing the carrier, but what does that have to do with CMS?

"They bought their tickets..."

Tuesday, August 20, 2019

UHC Jumps in the Pol

The MEWA pool that is:

"Previously only available to larger employers, the Ohio Chamber Health Benefit Program now provides small businesses access to features from UnitedHealthcare Primary Advantage® plans."

Like its competitors from Anthem and Medical Mutual of Ohio, this plan (which is yet to be released in the wild) will require membership in a local Chamber of Commerce, and will likely offer the potential of better rates than off-the-shelf ObamaGroup plans.

How's that, you ask?

Well, unlike ACA plans, these are medically underwritten, so healthier groups benefit from actual risk assessment (instead of one-size-fits-all Community Rating).

So far, though, it's vaporware.

Will be interesting to see how it stacks up with already established plans.

Monday, August 19, 2019

Top o'the week Spindle Clearing

While we continue the rush to implement #Medicaid4All here in the States, it's instructive to see how that's working out for our Neighbors to the North©:

"[M]ore than 63,000 Canadians left their country to have surgery in 2016."

As Americans contemplate overturning our health system in favor of one similar to Canada’s, we must ask why so many leave.


"After being advised that they need a procedure done, only about 35% of Canadians had their surgery within a month."

Why do Bernie, Elizabeth and the rest of the field hate Canucks?

This isn't really "news" to those of us who've been paying attention, but:

"End of ‘individual mandate’ hasn’t killed Obamacare"

It's always been about the Benjamins (both premiums and cost-sharing).

The Much Vaunted National Health Service© continues to cover itself with glory:

"GP surgeries in England ordered to stop half-day closing  Practices will have to seek permission to close during working hours, or risk losing funding worth more than £40,000."


The backstory here is that it turns out that [WARNING: Spoiler Alert ahead] nationalized health "care" schemes aren't very good at actually providing medical care.


Bonus Item: Meanwhile, back here in flyover country, insurers and hospitals are beginning to meaningfully address "shock claims" to employers with group plans:

"St. Elizabeth Healthcare is the first hospital system in Greater Cincinnati to partner with Anthem Blue Cross and Blue Shield to help patients and their employers limit so-called shock claims, which can cost $1 million or more to treat a catastrophic illness such as cancer."

As regular readers know, in recent years the "number of million-dollar medical claims has nearly doubled, with cancer care remaining the most costly health condition."

So this new collaboration is welcome news, if only for folks covered under certain group plans.

[Hat Tip: FoIB Holly R]

Important ACA insight

Thanks to co-blogger Patrick P: He says to pay particular attention to the 2nd sentence:

The more you know...

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.