Halloween: P&C Claims Style

[Hat Tip: FoIB Amanda A]

SHOP - Not as "Easy as Buying a Plane Ticket"

Ohio is one of five states with early access to the Small Business Health Options Program (SHOP). The SHOP is the only place where an employer can receive a small business tax credit and offer multiple insurance companies and plans. With early access we have the green light to quote plans and rates for 2015 right now. Yesterday was my first "experience" in the system.

One of my clients believes they will receive a substantial tax credit for health insurance. Their accountant told them it would be advantageous to take it - if they qualify. Last year they dropped employer sponsored insurance but are looking to go back because they are having difficulty retaining employees and are worried about the individual plan rate increases.

Here is how the process went.

First, you create an account using the same platform as an individual does. This is where we encountered our first issue. The CEO had created an individual account with his email address and even though we were in the SHOP it wouldn't allow him to create another account with the same email.

After creating another email we finally established the account. Then we had to verify that the CEO was the CEO. The same personal questions from the individual market were asked of my client. Before committing to answer he asked a very good question that I'm sure nobody has an answer to yet:  "What if I leave the company? Is there a transfer of this account to the new person in charge?" We couldn't get an answer from the call center.

He reluctantly completed the verification and we hit enter. Then this occurred...

Back at it again this morning we were finally able to verify and began (again!) entering all of the employer information. While redundant, it seemed like we were going in the right direction. Success is achieved. Next step.

It asked us to begin entering information for each employee. We could either do that or download an excel document and populate it into the system. We elected to view the excel document and see what all is needed to complete the process.

Oh boy, this isn't going to be fun. The spreadsheet has 20 columns to complete for each employee. Each dependent has an additional 8 columns to complete. You must provide date of birth, social security number, date of hire, address, employee code, and a preferred method of contact for each employee and their dependents.

We are stopped once again. The employer needs to have someone complete the spreadsheet with the proper format. Cut and paste are great tools and hopefully will make transposing easier. But the company still has to get dates of birth and social security numbers of spouses and dependents.

At this point the employer is stopping the process. Without knowing the rates and benefits it doesn't make sense to waste productivity gathering all of the data. Instead we will wait until the insurance companies are allowed to quote the plans directly. When will that be? I'm not sure but I'll bet it won't be until after next Tuesday.

From Bad to Worse...

The 2015 Open Enrollment begins in a couple of weeks, and carriers, agents, HHS and all the rest are busy gearing up for it.

That's the good news.

Sort of.

Here's the reality: if you're thinking about buying on the ObamaTax Exchange, be sure your LifeLock plan is paid up:

"IRS Warned about Protecting Taxpayer Information on Health Exchanges ... The IRS must do more to ensure that federal tax information submitted to the ACA exchanges is protected and prevent its unauthorized disclosure"

Or else ... what? It's not like the current administration has a track record of going after its own (cf: Secret Service, Benghazi). And it's also not like there's an alternative: if you qualify for - and wish to use - a subsidy, you're going through the Exchange. For better or worse.

But mostly worse.

On the other hand, once you have that brand new subsidized health insurance plan, you'll have plenty of opportunity to use it.

Or maybe not. As FoIB Jeff M tips us:

"Over 214,000 doctors won't participate in the new plans under the [ObamaTax] ... Reimbursements under Obamacare are at bottom-dollar - they are even lower than Medicare reimbursements"

As we've noted, doc's can't afford to keep eating their losses, and there's no Doc Fix for the ACA. It's possible, bordering on likely, that more providers will opt out than actually participate.

Welcome to the future of American "healthcare."

Cavalcade of Risk #220: Tricks and Treats edition

Louise Norris has a real bag of goodies for us this week, with risky posts from drones to (metaphorical) tsunamis. And not a marshmallow peanut in sight.

A Holly Jolly LinkFest

Our good friend Holly R sends us some interesting links:

■ We've written before about how carriers have gotten, erm, imaginative in their efforts to rein in costs under the ObamaTax regime. In addition to rx limitations, another neat "trick" is to unbundle the cost of care:

"The therapist worked out of a local hospital ... he was surprised when the bill for each visit contained two charges: the approximately $100 he expected to see for the therapist — and a similar fee for the room, which was not covered."

Making it that much more challenging to predict the actual cost of care, and increasing that cost. Nice job, O'Care!

■ One way to cut costs, of course, is to encourage consumers to pick and choose their care with an eye toward efficiency and price. That's the premise behind Health Savings Accounts, and it's also the foundation of a new startup called Vitrals, which offers "a direct cash incentive to have your procedure at the health facility preferred by your employer and plan."

Thereby putting its money where your mouth (or other body part) is.

Very cool.

■ As we head into the midterms next week, the ObamaTax is sure to be on voters' minds:

"Americans who hold private health insurance spent more on medical services in 2013 even though they used fewer of them."

So much for the promise to lower both premiums and the actual cost of care.

L'Chaim - To Life!

Ebola. ISIS. Enterovirus. Scary stuff, and sure to get one considering one's own mortality. Not to mention the state of one's life insurance. Life Happens, "a nonprofit organization dedicated to helping Americans take personal financial responsibility through the ownership of life insurance and related products," has a new video out covering the basics.

If you already own this invaluable coverage, perhaps it's time to review it: is it enough? Are my premiums and beneficiaries up to date?

If you don't own a policy, have you considered whether you need one? What do your loved ones think about that?

Food for thought.

[Hat Tip: Bill Coffin]

Cavalcade of Risk #220: Call for submissions

Louise Norris hosts next week's edition. Entries are due by Monday (the 27th).

To submit your risk-related post, just click here to email it.

You'll need to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post

PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like). And please only submit if you are willing to link back to the carnival if your submission is accepted.

Apples To Oranges? Try Rotten Bananas

Fourth quarter GRANDMOTHERED small employer health insurance renewals have been rolling out. Many of them here in Ohio are in the 7%-15% range with few exceptions. These aren't easy for employers to swallow. Until I show them the ACA compliant alternatives.

Benefits are Apples to Oranges

Strict actuarial value guidelines are causing plans to be canceled. The plans replacing them must have a more cookie cutter benefit structure. There is little to no room for creativity or innovation from the insurance companies as they are bound by these new rules. The new benefits have different copays, deductibles, maximum out-of-pocket limits (MOOP), prescription drug coverage, and provider networks.

For most ESI plans the benefits are a reduction from what they were. Supporters won't tell us this. Instead they point to the fact that plans must now cover a few "new" benefits that impact a small portion of our population.

Rates, well...they are Rotten Bananas

Whoever believes that "rate shock" isn't going to occur hasn't spent a day in the trenches of health insurance. This is because ACA compliant plans must follow community rating guidelines. Regardless of health status everyone's rates must be the same (exceptions: age, tobacco use, location). If you have a vibrant healthy workforce congratulations. You are now subsidizing the unhealthy workforce.

Kudos to the companies who found savings through community rating. These folks all made the transition last year when they had an advantage. Note that we didn't hear very much cheerleading from this group because it was extremely small. How many small businesses do you know who went to ACA compliant plans and said "This is GREAT!!!"?

Fortunately here in Ohio the Legislature, Department of Insurance, and insurance companies took advantage of our weak-kneed President's "If you like your current plan" transitional relief gesture. For the short term my clients and other small businesses have the ability to renew their old plans for a couple more years. This is comparable to putting a Band-Aid on a jugular wound.

When the ACA option is looking at lesser benefits and a 50% or more increase it doesn't matter if my client likes their current plan or not, they are definitely keeping it.

Saving the MVNHS©

On Facebook, Doc Emer asks "What's wrong with the NHS?" and links to a story about the service's "own answer to whether it can survive as a unique system of healthcare."

I suggested that the more important question is whether (and why) the MVNHS© should be saved.

After almost 10 years of blogging on the Much Vaunted National Health Service©, it seems to me that the problems are endemic, and systemic. One of the biggest challenges is that, contra its supporters, the folks who run it have had no more success in reining in health care costs than any other system, the Liverpool Pathway notwithstanding.

The linked story begins propitiously enough: titled "How to save the NHS in just 50 pages," it sets forth a kind of Five Year Plan [ed: how ironic] the purpose of which is to "make the case for some of the changes we’re going to need.” And what are these changes?

That's a good question.

Unfortunately, the answer's a bit vague: "It’s not a one-size-fits-all blueprint for every part of the country, let alone a detailed plan for everything that needs to happen."

So, a typical government white paper, long on rhetoric and short on substance. No real surprise there. What I do find startling, though, is that the article explicitly sets forth the real problems facing the service:

"And as no political party wants the NHS to visibly decline on its watch, this is a not-so-subtle public warning that without extra billions, bad headlines and public discontent will follow."

Short version: "It sucks, we can't justify its continued existence,but I can't be the one to pull the trigger."

Which is pretty much where we'll be with a few more years of the ObamaTax under our belt.

Health Wonk Review: All the leaves are brown edition

Louise Norris hosts an outstanding edition of the Health Wonk Review. What's so outstanding about it, you ask? To begin with, it's a diverse group of posts, covering the ObamaTax to Ebola, virtual wards to healing prayer.

Kudos, Louise!

Can I Charge Interest?

One of my clients dropped their employer sponsored insurance plan effective May 1, 2014. This forced 21 of their employees (including the owners) to find individual coverage. We met and worked with all of them to secure coverage either off the exchange or through goodluck.gov.

In another month we will perform this exercise in patience once again. To really do a good job for our clients this process is frustrating, complex, and time consuming.

It's even more frustrating for me though when one of the insurance companies still hasn't paid my commissions yet.

For the last six months we have continued to help with service questions for the employees I enrolled with this particular insurer and have spend an inordinate amount of time trying to get paid. We knew there would be problems with this whole process and I understand that the initial issues could be a result of mistakes from all parties. However, those items were fixed a couple of months ago.

When will I get paid? Who knows. Its too bad I can't charge them interest though.

VaderCare? "Pray I don't alter it any further"

As the Halbig saga slogs on, the industry itself is moving forward:

"[I]nsurance companies offering plans on HealthCare.gov this year had a new clause inserted into their contracts ... that allows them to cancel plans if federal premium subsidies are eliminated."

Hunh.

Now why do you suppose that Ms Burntwell and her minions might agree to that?

It isn't very difficult to connect the dots.

Another Ebola Insurance update

Well, the more the merrier! This latest comes to us via email from Medical Mutual of Ohio:

"All fully insured and self-funded health plans administered by Medical Mutual Mutual and Mutual Health Services will cover treatment for Ebola as if it were any other illness, subject to terms and conditions of the member’s plan."

This is crucial language: it means that items like isolation and special travel arrangements are likely covered. On the other hand:

"[W]e do not have specific information about treatments considered “unproven,” experimental or investigational, such as plasma transfusions from recovered patients or the medication Zmapp."

They do go on to note, though, that they would "likely" be covered. I understand this: no one really knows what we're getting into here. And if this does in fact become pandemic, well, all bets are off.

Blue Cross Wrist Slap

Received this via email:

"The ruling confirms last year's judgment by a federal court in Detroit, which found that BCBSM collected millions of dollars in hidden fees over a nearly 20-year period from the  employee health plan for Hi-Lex Controls, Inc. and Hi-Lex America, Inc."

Over the years, we've blogged on the Blues' various legal travails more than once (most recently here). It's nice to see one that's actually "gone the distance," though.

The case at hand actually took 3 years to wend its way to SCOTUS, but it's apparently not the last:

"The Hi-Lex matter is the first of nearly fifty cases filed by Varnum [law firm] over the fraudulent fees."

It seems that BX was acting as the claims payor for self-insured plans, and reporting different amounts than were actually being charged. Even more egregiously, managers apparently knew of the practice, but discouraged employees from mentioning it, making them unwitting accomplices.

It appears that BX has since discontinued this practice, perhaps as a result of the litigation.

[Hat Tip: Tyler Lecceadone]

Have Faith (and Insurance)!

For the past 14 or so years, I've participated in a healing prayer group with some friends. We meet weekly and pray for the health of folks running the gamut from broken limbs to terminal illnesses. The one hard-and-fast rule we have is that the person for whom we're praying must know that we are praying for him (or her) and must have given us explicit permission to do so (there are exceptions, of course: someone in a coma is unlikely to meet those criteria for a while).

That rule is because we believe that the key to our efforts is that we are connected to and with the folks on the list. To that end, we also endeavor to get regular, timely updates from them on their progress (If any). We acknowledge that we don't know - can never "know" - whether or not our efforts have been successful, but we continue to meet week in and week out because we believe that we are making a difference in these people's lives.

Which may explain why my interest was immediately piqued by this item:

"I was parked in front of a patient’s home before my visit, running through my checklist. Patient’s diagnosis and prognosis. Any known family members or friends supporting the patient. Religious affiliation, if any. Patient’s name – you should always recheck the patient’s name. It’s good to know little about a patient’s medical concerns, but as chaplain, my concern is not what the patient’s illness is, but who the patient is. I want to address their spiritual needs and see how their spiritual health affects their overall health."

Turns out, the (anonymous) author works for an ACO (Accountable Care Organization - healthcare companies that are paid as a percentage of the money saved through their care management) called MissionPoint Health Partners. The folks in my healing prayer group were also intrigued,and urged me to connect with the firm to find out more.

So I reached out via their site's contact form, and even sent a LinkedIn invite to whom it appears is their media outreach person.

Days later: /crickets.

That's a shame, too, since this concept shows real promise, and there are some key questions that we'd like to see addressed.

For assistance: how do they deal with atheists who express an interest in this service?

And what metric do they employ to measure "success?" That is, they claim that this service reduces expenses, but how do they know this?

Oh, well, they missed an opportunity.

Double Whammy, ObamaTax-style

First the bad news:

"ObamaCare shoppers in search of the lowest-cost plan may come down with a mild case of rate shock when 2015 exchange enrollment begins next month ... the cost of the cheapest bronze plan will jump an average of 13.9%"

Remember when we were promised that we'd have 3000% rates decreases?

Good times, good times.

But wait, it gets better worse:

Turns out, the folks who actually buy these plans can't afford to use them:

"[E]ven among those who receive enough subsidy money from the rest of us to offset the high premiums, killer deductibles make their coverage much more expensive in practice, to the point of rendering them virtually useless."

It's simple mathematics, after all: thousands (perhaps tens of thousands) of dollars in premium plus thousands ((perhaps tens of thousands) in out-of-pocket costs means that a lot of folks now can't afford to use the insurance they scrimped and saved to buy.

But hey: so much better than the old system, no?

Cancer Walk Thank You [Updated!]

So, the Making Strides Against Cancer walk took place this morning, and I'm happy to report that we all made it through the grueling 3.1 mile course. Thankfully, the rain held off until we'd finished (Yay!); some 10,000 people took part in ours.

Our team finished a very respectable 21st out of 539 (top 4% - WooHoo!), and my terrific contributors donated $800 as of this morning. But don't feel left out: you can still donate here.

Thank You!

I'll post our team picture shortly.

ICYMI: We already *had* an Ebola Czar

Prior to appointing political hack well-regarded activist Ron Klain to the position, actual Dr Nicole Lurie was the official frontman .. er, woman for this important post.

What, you didn't know that?

Don't blame yourself:

"Nicole Lurie, M.D., M.S.P.H., has been completely M.I.A. ... She's the Assistant Secretary for Preparedness and Response"

What, now she's in isolation? Hunh.

Econ vs Engineering: A Case Study

Uber-wonk John Goodman has an outstanding piece at Forbes contrasting the perspectives of various players in the health care arena, focusing specifically on the (mis-)handling of the Ebola crisis at the hands of the CDC.

Basically, he argues (persuasively) that engineering-oriented folks focus primarily on planning as a function of organization, and that self-interest is largely unimportant. They believe, he argues, that "incentives don’t matter [very much]."

Economics-oriented individuals, on the other hand, believe that incentives matter a great deal; that "people find that when they pursue their own interests, they are also meeting the needs of others."

You can see the problem.

His thesis is fairly simple, and therein lies its elegance:

"[M]ost people in health policy take the engineering approach. That is why there have been so many mistakes and so many failures of policy – ranging from Obamacare to Ebola control."

Read the whole thing for his explication of this unfortunate truth. You'll be glad you did.

Friday LinkFest

■ The Bay State's Medicaid explosion, er, expansion looks to be growing at a much faster clip than originally anticipated. Wonder why?

Wonder no longer:

"[A]nalysis of financial filings indicates that the subsidized Medicaid program known as MassHealth has for the past four years incurred $500 million in deficits that have been hidden by a quirk in the state’s budget process."

Ooops. And this has been going on for quite a while, racking up "billions in cash shortfalls."

■ While we've been focusing on the financial implications of The ObamaTax, the impact on the delivery of health care is equally critical. And equally in shambles:

"Doctors are ramping up our protests against the government's expanding role into health care ... We are instead protesting silently through our practice decisions."

And the "practice decision" being made by an increasing number of doc's is: we're outta here.

■ We've posted before on the fact that the Exchanges are quick to take folks cash, not so quick to pay out commissions to those who actually helped people navigate (heh) the onerous 404Care site. That may be changing:

"The long-awaited fix to the National Producer Number (NPN) is expected to be in place by Nov. 15 and will allow brokers to enter their identifiable information and receive commissions"

What's stupid is that we've been using the NPN numbers for a long time now - in fact, it's the only acceptable form of identification for many states' Continuing Education requirements. Why am I not surprised that the Feds are so far behind on this simple piece of infrastructure?