• Welcome to OGBoards 10.0, keep in mind that we will be making LOTS of changes to smooth out the experience here and make it as close as possible functionally to the old software, but feel free to drop suggestions or requests in the Tech Support subforum!

ACA Running Thread

Congress passed two interesting ACA changes today, eliminating the Cadillac Tax and ending the infamous health insurance tax/fee that insurers pay.

In my opinion, the Cadillac tax was a good concept that was turned into a bad law. It was severely flawed and eventually every group would end up paying it, which wasn't the intent. Its good that its been eliminated but again, I always found the premise to be solid (high cost plans drive medical trend).

The HIT is a whole different story. Its a tax that insurers pay and pass along to groups, consumers. etc based on their market share. I always thought it was ironic that there was a tax that increased premiums by 2.5% that the feds would then partially cover through subsidies. Its been temporarily suspended 2 times and looks like the repeal in 2021 is permanent. It was a big source of revenue to cover the ACA costs so eliminating it requires the ACA to be funded through some other cut/tax/etc.

These changes shed light on how large entitlement programs are funded / not funded.
 
CHDeac said:
Congress passed two interesting ACA changes today, eliminating the Cadillac Tax and ending the infamous health insurance tax/fee that insurers pay.

In my opinion, the Cadillac tax was a good concept that was turned into a bad law. It was severely flawed and eventually every group would end up paying it, which wasn't the intent. Its good that its been eliminated but again, I always found the premise to be solid (high cost plans drive medical trend).

The HIT is a whole different story. Its a tax that insurers pay and pass along to groups, consumers. etc based on their market share. I always thought it was ironic that there was a tax that increased premiums by 2.5% that the feds would then partially cover through subsidies. Its been temporarily suspended 2 times and looks like the repeal in 2021 is permanent. It was a big source of revenue to cover the ACA costs so eliminating it requires the ACA to be funded through some other cut/tax/etc.

These changes shed light on how large entitlement programs are funded / not funded.
Click to expand...

I believe the latter was a reason all of our small business premiums went up this year?
 
https://www.npr.org/sections/health...9/for-her-head-cold-insurer-coughed-up-25-865

For Her Head Cold, Insurer Coughed Up $25,865

Alexa Kasdan had a cold and a sore throat.

The 40-year-old public policy consultant from Brooklyn, N.Y., didn't want her upcoming vacation trip ruined by strep throat. So after it had lingered for more than a week, she decided to get it checked out.

Kasdan visited her primary care physician, Roya Fathollahi, at Manhattan Specialty Care just off Park Avenue South and not far from tony Gramercy Park.

Do you have a medical bill you'd like us to investigate? You can tell us about it and submit it here.

The visit was quick. Kasdan got her throat swabbed, gave a tube of blood and was sent out the door with a prescription for antibiotics.

She soon felt better, and the trip went off without a hitch.

Then the bill came.

Patient: Alexa Kasdan, 40, a public policy consultant in New York City, insured by Blue Cross and Blue Shield of Minnesota through her partner's employer.

Total bill: $28,395.50 for an out-of-network throat swab. Her insurer cut a check for $25,865.24.

Service provider: Dr. Roya Fathollahi, Manhattan Specialty Care.

Medical service: lab tests to look at potential bacteria and viruses that could be related to Kasdan's cough and sore throat.

What gives: When Kasdan got back from the overseas trip, she says there were "several messages on my phone, and I have an email from the billing department at Dr. Fathollahi's office."

The news was that her insurance company was mailing her family a check — for more than $25,000 — to cover some out-of-network lab tests. The actual bill was $28,395.50, but the doctor's office said it would waive her portion of the bill: $2,530.26.

"I thought it was a mistake," she says. "I thought maybe they meant $250. I couldn't fathom in what universe I would go to a doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill."

The doctor's office kept assuring Kasdan by phone and by email that the tests and charges were perfectly normal. The office sent a courier to her house to pick up the check.

How could a throat swab possibly cost that much? Let us count three reasons.

First, the doctor sent Kasdan's throat swab for a sophisticated smorgasbord of DNA tests looking for viruses and bacteria that might explain Kasdan's cold symptoms.

Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine, says such scrutiny was unnecessary.

"In my 20 years of being a doctor, I've never ordered any of these tests, let alone seen any of my colleagues, students and other physicians order anything like that in the outpatient setting," she says. "I have no idea why they were ordered."

The tests might conceivably make sense for a patient in the intensive care unit or with a difficult case of pneumonia, Mishori says. The ones for influenza are potentially useful, since there are medicines that can help, but there's a cheap rapid test that could have been used instead.

"There are about 250 viruses that cause the symptoms for the common cold, and even if you did know that there was virus A versus virus B, it would make no difference because there's no treatment anyway," she says.

(Kasdan's lab results didn't reveal the particular virus that was to blame for the cold. The results were all negative.)
 
CHDeac, if you had to guess, how much of all US medical spending is straight up provider fraud? 5%? 10%?
 
TownieDeac said:
https://www.npr.org/sections/health...9/for-her-head-cold-insurer-coughed-up-25-865

For Her Head Cold, Insurer Coughed Up $25,865

Alexa Kasdan had a cold and a sore throat.

The 40-year-old public policy consultant from Brooklyn, N.Y., didn't want her upcoming vacation trip ruined by strep throat. So after it had lingered for more than a week, she decided to get it checked out.

Kasdan visited her primary care physician, Roya Fathollahi, at Manhattan Specialty Care just off Park Avenue South and not far from tony Gramercy Park.

Do you have a medical bill you'd like us to investigate? You can tell us about it and submit it here.

The visit was quick. Kasdan got her throat swabbed, gave a tube of blood and was sent out the door with a prescription for antibiotics.

She soon felt better, and the trip went off without a hitch.

Then the bill came.

Patient: Alexa Kasdan, 40, a public policy consultant in New York City, insured by Blue Cross and Blue Shield of Minnesota through her partner's employer.

Total bill: $28,395.50 for an out-of-network throat swab. Her insurer cut a check for $25,865.24.

Service provider: Dr. Roya Fathollahi, Manhattan Specialty Care.

Medical service: lab tests to look at potential bacteria and viruses that could be related to Kasdan's cough and sore throat.

What gives: When Kasdan got back from the overseas trip, she says there were "several messages on my phone, and I have an email from the billing department at Dr. Fathollahi's office."

The news was that her insurance company was mailing her family a check — for more than $25,000 — to cover some out-of-network lab tests. The actual bill was $28,395.50, but the doctor's office said it would waive her portion of the bill: $2,530.26.

"I thought it was a mistake," she says. "I thought maybe they meant $250. I couldn't fathom in what universe I would go to a doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill."

The doctor's office kept assuring Kasdan by phone and by email that the tests and charges were perfectly normal. The office sent a courier to her house to pick up the check.

How could a throat swab possibly cost that much? Let us count three reasons.

First, the doctor sent Kasdan's throat swab for a sophisticated smorgasbord of DNA tests looking for viruses and bacteria that might explain Kasdan's cold symptoms.

Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine, says such scrutiny was unnecessary.

"In my 20 years of being a doctor, I've never ordered any of these tests, let alone seen any of my colleagues, students and other physicians order anything like that in the outpatient setting," she says. "I have no idea why they were ordered."

The tests might conceivably make sense for a patient in the intensive care unit or with a difficult case of pneumonia, Mishori says. The ones for influenza are potentially useful, since there are medicines that can help, but there's a cheap rapid test that could have been used instead.

"There are about 250 viruses that cause the symptoms for the common cold, and even if you did know that there was virus A versus virus B, it would make no difference because there's no treatment anyway," she says.

(Kasdan's lab results didn't reveal the particular virus that was to blame for the cold. The results were all negative.)
Click to expand...

You would think the insurance company would care that they were paying $25k for a throat swab. But nope, not when they can just jack up premium costs next year.
 
The whole provider network thing is a scam built upon severe price gouging. Using in-network providers spares you the price gouging. Make a mistake and use an out of network provider and get gouging rates. Price fixing, or capping, fixes this.
 
Having private insurance companies in charge of basic services is the problem.
 
Providers are gouging patients, must be the insurance companies fault. That is quite a leap. Please connect those dots.
 
"She may not be paying anything on this particular claim," says Richelle Marting, a lawyer who specializes in medical billing at the Forbes Law Group in Overland Park, Kan., who looked into this case for NPR. "But overall, if the group's claims and costs rise, all the employees and spouses paying into the health plan may eventually be paying for the cost of this."

Marting says this is a common problem for insurance companies. Most claims processing is completely automated, she says. "There's never a human set of eyes that look at the bill and decide whether or not it gets paid."

Kasdan did pay her usual $25 copay for the office visit and a $9.61 fee to LabCorp for a separate set of lab tests.

After a reporter started asking questions about the bill, Blue Cross and Blue Shield of Minnesota stopped payment on the check it issued and is now investigating.

Jim McManus, director of public relations for BCBS of Minnesota, says the company has a process to flag excessive charges. "Unfortunately, those necessary reviews did not happen in this case," he wrote in an email.
 
awaken said:
Providers are gouging patients, must be the insurance companies fault. That is quite a leap. Please connect those dots.
Click to expand...

Insurance companies don’t do due diligence on inflated charges because they know they can pass on the costs to consumers.
 
An insurance mechanism (public or private or both) is necessary.

Inadequately regulated is the problem.
 
TownieDeac said:
CHDeac, if you had to guess, how much of all US medical spending is straight up provider fraud? 5%? 10%?
Click to expand...

It sorta depends on how you define fraud. Usually, its gets lumped in as "fraud, waste and abuse"....But pure, true fraud? Id guess in that 5-10% range.
 
DistrictDeacon said:
Insurance companies don’t do due diligence on inflated charges because they know they can pass on the costs to consumers.
Click to expand...

Just simply not the case in how it really works. Are there cases were this happens, sure. But in an overwhelming # of these cases, a set fee schedule is used for OON services. In MA, the OON rates are capped by law. And self funded employers would sue insurers if they did this with any regularity. Also, in a competitive insurance market (which we largely have), not sure this would occur. I'd love for my competitors to do this as it would give me a huge pricing advantage.

BTW, I think OON utilization is less than 5% of claims spend.
 
CHDeac said:
Just simply not the case in how it really works. Are there cases were this happens, sure. But in an overwhelming # of these cases, a set fee schedule is used for OON services. In MA, the OON rates are capped by law. And self funded employers would sue insurers if they did this with any regularity. Also, in a competitive insurance market (which we largely have), not sure this would occur. I'd love for my competitors to do this as it would give me a huge pricing advantage.

BTW, I think OON utilization is less than 5% of claims spend.
Click to expand...

If it happened in this case, what’s stopping it from happening regularly?
 
DistrictDeacon said:
If it happened in this case, what’s stopping it from happening regularly?
Click to expand...

Good business practice. Competitive forces. Keeping Palma employed. As I said there are errors that happen for a host of goofy esoteric reasons. But they aren't common and suggesting that insurers don't care as they simply pass along the costs in higher rates is inaccurate.
 
CHDeac said:
Good business practice. Competitive forces. Keeping Palma employed. As I said there are errors that happen for a host of goofy esoteric reasons. But they aren't common and suggesting that insurers don't care as they simply pass along the costs in higher rates is inaccurate.
Click to expand...

Insurers don’t pass on higher costs in the form of rate increases?
 
You must log in or register to reply here.
Back
Top