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Archive for December, 2010

More on Employers Pushing the Rising Cost of Healthcare onto Employees, Families

Friday, December 31st, 2010

The Kaiser Family Foundation and the Health Research and Educational Trust (HRET) perform an annual survey regarding the nature of employer-sponsored health benefits at nonfederal private and public companies nationwide. This is the twelfth such survey. The results are grim, for employees at least.

It’s no longer news that healthcare costs are on the rise. Most have begun to brace themselves for cost increases as a result of healthcare reform. In our recent blog post on the NNNN survey we reviewed the plans of large employers to pass the cost increase onto employees in 2011. For the most part, we are prepared to see our healthcare costs rise after the reform takes effect. But we don’t have to wait to feel these increases. Across the board, the average employee has already seen these increases. The survey certainly shows increases- especially in premiums for family and individual plans. The most notable increase may be that seen in the employee contribution.

Historically, employers and employees have shared the burden of rising premium costs. In 2010, however, employers did not increase their dollar-amount contribution. As a result, employee contribution rose 14% from 2009. Employer contribution did not rise.

The survey reports that 27% of employees have deductibles of $1,000 or more for single coverage. This is up from 22% in 2009. The average deductible is considerably less for workers with PPOs or HMOs. Prescription drugs, physicians visits, and preventative care are usually covered (with, of course, a co-pay or coinsurance) before a deductible is met. The out-of pocket maximum varies considerably for workers and plans.

Where are you better off, a large firm or a small firm? For the most part, it’s hard to tell. But, if you’re hoping to pay less of your premium, start sending your resume to small companies. 35% of employees at small firms pay nothing towards single coverage premium and 13% pay nothing towards family coverage. Only 6% at large firms pay nothing for single coverage and 1% towards family coverage.

Employers were not shy about reporting the changes nor the reasons for them.  Increased cost sharing, reduction in the scope of coverage, and increased employee contribution were all responses to the poor economy.

Keep in mind that this survey was conducted from January to May 2010. After our previous post on Large Employers passing rising health costs onto employees, we can only imagine what the survey will show in 2011.

Attention Patients: Be Aware of Medical Errors this Holiday Season

Friday, December 24th, 2010

With the holidays right around the corner, many of us will be rushing around, finishing up holiday shopping, attending parties, eating too much… the list goes on.

However, people still get hurt and sick around the holidays and are in the hospital. Hospital staff is lighter around the holidays, giving providers some much needed family time. On the other hand, less providers and tired staff can lead to medical errors.

A recent article by Dr. Bialek of www.covermd.com looks at the top ten most common medical errors in the United States.

1. Technical medical error
Ex: Provider cutting the wrong artery in a heart surgery, leading to complications or death.

2. Failure to use indicated tests
Ex: Patient having chest pains, but doctor failing to perform an EKG and patient has a heart attack.

3. Avoidable delay in treatment
Ex: Patient complains of stomach pains, isn’t seen quickly by ER attendees because of more urgent manners, patient’s appendix erupts causing severe internal bleeding.

4. Failure to take precautions
Ex: Patient is weak and has a history of falling. Nurse takes patient from the bed to the bathroom, unaware of patient’s weakness. Patient falls and fractures hip.

5. Failure to act on test results
Ex: Patient feels dizzy and sick. Doctor orders blood test, believes it’s an infection and sends the patient off with antibiotics. Test results come back, but doctor fails to look at them thinking she just has an infection. Patient ends up in a diabetic comma.

6. Inadequate monitoring after a procedure
Patient has a routine surgery. After surgery, patient is on narcotics. Nurses fail to monitor the patient, although patient’s parents are in the room. They do not realize that the patient has stopped breathing.
Another important list is errors with serious consequences. These occur mostly in intensive care units, operating rooms, and emergency departments.

7. Inadequate patient preparation before a procedure
Patient goes in for surgery. The provider fails to check with the patient to see what medications the patient is taking before surgery is performed. The patient is currently taking a blood thinner. During surgery and bleed occurs and the patient dies.

8. Inadequate follow-up after treatment
Patient has surgery. After surgery the doctor tells the patient to call for any changes in temperature, feeling, etc. Patient feels drowsy and nauseous from anesthesia and blames it on that. When the patient calls the doctor, the doctor tells the patient to wait 24 hours. Patient comes down with a deadly infection.

9. Avoidable delay in diagnosis
Patient comes in after blacking out after being assaulted. Provider waits 12 hours for a CT scan. Patient’s brain is bleeding and never wakes up.

10. Improper medication dose and/or method of use
Ex: A drug mix up causes a patient to take 10 times the normal dose. Patient dies a result.

Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting

Friday, December 10th, 2010

On Wednesday, Rebecca participated in a Webinar for an Illinois Workers’ Compensation Association. She presented on the topic “Tips to Identify Healthcare Fraud in a Workers’ Compensation Setting.” In front of an audience of case managers, attorneys, human resource personnel and other healthcare professionals, Rebecca had a lively discussion on many aspects of healthcare fraud in a Workers’ Compensation setting.

Some highlights include:
Overall numbers –
The Insurance Information Institute estimates that all property/casualty insurance fraud cost insurers $30 billion annually.

Workers’ Compensation fraud accounts for approximately 25% or $7.2 billion a year, according to the National Insurance Crime Bureau (NICB).

The NICB characterizes Workers’ Compensation fraud as the “fastest growing segment of insurance fraud” in the nation.

Most studies indicate that the three parties primarily driving the cost of workers’ comp fraud are employers, medical providers, and employees.

Tips on spotting fraud:
Worker Claim Fraud
• Number of days worked and amount of salary inconsistent with occupation
• Injured worker disputes average weekly wage due to additional income (i.e., per diem and/or 1099 income)
• Cross-outs, white-outs and erasures on documents
• Injured worker files for benefits in a state other than principle location of the alleged industrial injury or occupational disease
• Injured worker-listed occupation is inconsistent with employer’s stated business
Employer Fraud
• Business displays or presents a Certificate of Coverage that contains inaccurate data, such as an implausible period of coverage
• Cross-outs, white-outs and/or erasures on documents, such as the Application for Ohio Workers’ Compensation Coverage (U-3) or Payroll Report (DP-21)
• Business name is not consistent with type of work being performed
• Number of employees, classifications and payroll are inconsistent
Provider Fraud
• Injured worker does not recall having received the billed service
• Provider’s medical reports read almost identically even though they are for different patients with different conditions
• Much higher healthcare costs than expected for the allowed injury type
• Frequency of treatments or duration of treatment period is greater than expected for allowed injury type, especially for older (non-catastrophic) claims

When investigating workers’ compensation fraud, always request detailed medical records and records of the injury. If all the facts don’t add up – you might be looking at fraudulent activity.

Employers Reining in Costs: Cutting Ineligible Dependents Cuts Healthcare Spend

Wednesday, December 8th, 2010

A recent Wall Street Journal article explained that employers are taking new initiatives to decrease healthcare costs. One simple solution employers are turning to – dependent eligibility audits. Dependents costs employers around $2,100 per year and an average of 2 – 10% of all dependents are ineligible.

Typically employers do not require employees to submit documents to confirm the eligibility of dependents – many currently use the honor system, entrusting that employees aren’t out the cheat their employers. However, times are tough and employers are viewing these dependent eligibility audits as an easy way to cut cost without laying off employers or decreasing health benefits.

So how do the audits typically work? Medical Business Associates, Inc. conducts electronic audits using a secure sever and email communication. Typically, there is an amnesty period for employees to drop dependents without penalty. Then employers receive information about required documents for each dependent. Employees then upload, mail or fax the required information to keep their dependents on the plan.

According to a CNN article, removing ineligible dependents could save companies between 4% to 6% of their annual healthcare costs. With Medical Business Associates, Inc. electronic solution, all required documents are stored, so if a company decides to conduct a follow up audit, employees will not be required to submit duplicate birth or marriage certificates if dependents status hasn’t changed.

For more information on MBA’s audit solution visit here.