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Archive for the ‘Health Insurance’ Category

Attention Employers: Medical Identity Theft Concerns You, Your Bottom Line, and the Health of Your Employees!

Friday, April 6th, 2012

Opportunity for crime comes in many forms, from an open window for a burglar to a victim’s lack of information to avoid a fraudster.  At one point or another, many of us have fallen victim to a theft or have even just lost a wallet, but something that doesn’t often come to the forefront of our minds is protecting our medical identity in such a situation.

A patient in South Carolina, an ex-marine in good health, lost his wallet when he left boot camp back in 2005.  He went back home to California.  Over a year later he received a call from his mother informing him that he was the lead suspect in a string of auto thefts in South Carolina!  The man who found his wallet used his military ID and driver’s license to test-drive cars that he would never return to the dealership – grand-theft auto in our patient’s name.

This in itself is a tough resolution, but what’s even worse is that this man’s problems weren’t over; they also included medical identity theft.

The man who found his wallet and test drove those cars also racked up a $20,000 medical bill treating kidney stones and an injured wrist.  The ex-marine never thought to call and inform his insurance carrier, so he was on the hook for those bills.  He was hounded by collection agencies and the government even withheld his tax return!  These issues were finally resolved, but it took over a year of appeals, phone calls, withheld income, and finally the intervention of the US Secret Service to pinpoint the man who stole his identity – Arthur Watts. Not all of us would be afforded that luxury (the Secret Service was brought in by the US attorney’s office to help in this investigation).

When someone loses a credit card, the process is simple:  call your credit card company and notify them.  Any reputable company will refund your money – they investigate the claim, and within about a week you will have a resolution that will cost no more than $50 by law, and often nothing at all.  When someone loses their healthcare benefits card in that same wallet, there is no course of action that takes place regarding the benefit card, and most people don’t realize something is wrong until they start getting collection calls or run a credit report months or even years later.

This doesn’t just happen one victim at a time when wallets are lost either.  The implementation of Electronic Health Records in hospitals and doctors’ offices increases the scale of these problems.  The wrong person gaining access to the system can mean tens, hundreds, or even thousands of Social Security numbers and benefit profiles at risk.  Lax technological security is another issue with this type of information.  Earlier this month, BlueCross-BlueShield of Tennessee agreed to pay $1.5 million for a 2009 breach in which over 50 hard drives holding over 1 million patient profiles were stolen.[1]

This is a dangerous lapse by BCBS, who is entrusted by its patients to guard their most personal and valuable information, including names, SSN’s, and policy numbers.  It was an inside job that could happen again. This tells us two things: a person’s medical identity is a coveted asset in fraud, and there is significant opportunity due to the lack of detection and prevention.

The reality is that healthcare fraud occurs at a lower instance rate than credit card fraud, but with higher dollar amounts per instance.  This translates into less public awareness and education on the risks, and much more financial risk and discomfort for those afflicted by medical identity theft. The laws protecting medical identity theft are not the same as those protecting victims of credit card theft – it is harder to recover the money, it takes longer, and the money might not be totally recoverable.  Possibly the most devastating implication of medical identity theft, though, is the impact it can have on your medical record.

The changes to a medical record can impact insurance coverage and treatment by providers.  A legitimate healthcare claim for an emergency surgery can turn into a nightmare when it is denied by a carrier because the patient has “reached the maximum on benefits” thanks to this undetected fraud.  Even more difficult to resolve is being denied benefits, or even being dropped from coverage, all due to a medical condition that you don’t have, yet someone else has reported under your name.

Electronic medical records can be amended, but it’s much more work to have things deleted, because of the implications your medical condition has on insurance coverage and pricing.

This begs the attention of employers in protecting their employees.  Carriers need to dutifully encrypt information and protect their customers.  And, most importantly, patients must educate themselves and advocate for their own well-being. The Federal Trade Commission [FTC] agrees (http://www.ftc.gov/bcp/edu/pubs/consumer/idtheft/idt10.shtm).

  • Read your EOB’s and know what you are being charged for
    • Check the name of your provider, date of service, & service provided
    • Discrepancy? – call your healthcare provider
  • Review a copy of each credit report – annually verify the integrity of ALL information listed
  • Patient tracking of personal health and ideally annual comparison to medical records provided by insurance carrier

The next steps to take if fraud is suspected include filing a complaint with the FTC and a report with local police, exercising HIPAA patient rights and correcting any errors on your medical record, and activating a fraud alert and security (credit) freeze with the individual credit agencies (Experian, Equifax, Transunion). http://health.usnews.com/health-news/family-health/articles/2008/02/29/medical-identity-theft-turns-patients-into-victims.

Fight for Your Rights – Patient Advocacy at Its Best

Monday, August 29th, 2011

Recently an employee came to me terribly worried about her child. Her daughter had been finally diagnosed with a severe lactose allergy after months of testing, countless doctors’ visits, and numerous theories of the cause for her tiredness, chronic hives, and other symptoms. However, my employee’s daughter wasn’t out of the gate yet. She takes a few medications to help with her allergies and her Attention Deficit Disorder.

Lactose in Drugs Can Affect Allergies

Now, here is the problem. What happens when these necessary medications contain lactose or eggs – two ingredients the child is allergic to? First, you need to ask your doctor or pharmacists what ingredients are in your medications – all the ingredients. Many medications use lactose as a filler. You also need to be aware of vaccines as well – many (including the flu vaccine) contain lactose.

For my employee, she asked her pharmacist if her child’s medication could contain lactose. Her pharmacist firmly replied that is takes too long to look up the ingredients of drugs. (Subsequent calls to other pharmacies did not pose this same problem, so hopefully in her case it was a moody pharmacist). However, if you receive this reply, first indicate that your child has a severe allergy and could be seriously harmed or even die if the product contains any milk (or peanuts, eggs, etc.). Second, ask to speak with another pharmacist. If you don’t receive an adequate answer find a pharmacy that will accommodate your questions and go directly to the drug manufacturer’s site to look up the ingredients in your child’s medication.

The good news is, that with most lactose allergies, many people can continue taking medication that includes milk. According to Walgreens, “Most people who are lactose intolerant can tolerate the lactose in oral medication because it usually takes around 12 to 18 gm of lactose—about the amount in 8 to 12 oz of milk—to cause the symptoms that include gas, bloating, diarrhea, and abdominal pain. Most oral medications contain far less than this amount. However, some individuals may still experience those symptoms from very small amounts of lactose. In these cases, lactase enzyme supplementation may help. These supplements, available over the counter, help by breaking down lactose. Probiotics, which contain beneficial bacteria that may help break down lactose, are another possible remedy.” So for those of you that only have a mild lactose intolerance, medications including milk might be fine for you to take (please consult your physician or pharmacist before doing so).

Again, be the informed patient. Most people might not think that the medication that is supposed to be helping them, might actually be severely hurting them. Keeping a Personal Health Record will help you keep control of your allergies and inform your healthcare providers on changes in your health condition.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Healthcare Reform and Businesses

Tuesday, June 14th, 2011

Current Healthcare Statistics:

•          Small businesses on average pay about 18% more than big businesses for the same health insurance policies

•          Small business health insurance premiums have risen 113% over nine years, a growth rate of nearly 9% annually

•          99% of large firms offer healthcare coverage, while 78% of firms with 10 to 24 workers offer coverage; that drops down to just 49% among firms with fewer than 10 workers

•          Of the 45 million uninsured Americans in 2007, 22.3 million (about half) were self-employed or worked for small businesses

Healthcare Reform Changes that Affect Your Business Right Now:

•          If you have 25 or fewer employees with annual wages of less than $50,000, you can get tax credits of up to 35% of the premiums paid under the new healthcare reform.

•          Catch: Employers need to cover at least 50% of the total premium cost for their employees

•          The credit will go up to 50% in 2014 and can be used for two consecutive years after that.

•          Businesses with 10 or fewer employees and annual wages of less than $25,000 will receive full access to the tax credit.

•          Small businesses that are tax-exempt are eligible for tax credits of up to 25% of the amount they contribute toward an employee’s health insurance premium.

•            4 million businesses are expected to be eligible for the credit this year

•          Holes: The IRS form that small business owners will fill out next year to claim the tax credit for 2010 is in draft form, and the IRS has not yet created instructions for how to use it

•          The Congressional Budget Office estimates that the credit could save small businesses $40 billion by 2019

What Can You Do to Trim Costs Right Now?

1.       Add a wellness or health management program

2.       Change plan design

3.       Perform a dependent eligibility audit

4.       Give incentives for employees to participate in wellness programs to improve the overall wellness of the group

Thanks for reading!

Your healthcare resource – Rebecca Busch

Avoiding Fraud, Medical, and Billing Errors in the Healthcare Arena

Monday, March 21st, 2011

A HealthGrades report indicates that there have been between 400,000-1.2 million error-induced deaths during 1996–2006 in the United States. On top of that, $60 to $80 billion is lost each year in the healthcare system due to fraud, waste, and abuse. How can you protect yourself from these alarming numbers?

As a patient you have many resources at your fingertips. Before you even visit a healthcare facility or provider, perform a due diligence check on both the facility and the provider.

How to Research a Doctor

First, confirm your physician’s NPI number – all physicians are required to have a NPI number for Medicare billing. Even if a physician is not billing Medicare, they need to have a NPI number to refer patients to other physicians.

Here is a free site to find your physician’s and facilities’ (where you will be receiving the treatment) NPI number.

Second, authenticate your physician’s and facilities’ information with the NPI registry. Here you will be able to confirm the provider’s legal business name and/or location, contact information, and NPI number. The NPI Registry is a free service located here.

Third, research the background history of your provider to see whether he/she has been disciplined, fined, or has had a suspended license. The State of Illinois License Lookup allows you to confirm all licenses distributed by the State of Illinois including MD, RN, PharmD, DO, etc.

Finally, a simple Internet search on the provider/facility may garner surprising results. Oftentimes, pending lawsuits and court filings appear at the top of Internet searches if the provider/facility is involved.

If you suspect anything, remember to request a copy of your medical records and billing statements. By performing your own mini-investigation you will be able to determine if your provider is supplementing or omitting information from your medical records or billing statements.

Useful sites:

NPI Registry

NPI Number Lookup

State of Illinois License Lookup

Can Health & Wellness Programs Fight Obesity?

Friday, January 21st, 2011

According to a recent report titled, “Obesity and its Relation to Mortality and Morbidity Costs” almost 30% of the adult population is overweight, obese, or morbidly obese.

  • Overweight – 19.2% (Body Mass Index of 25.0 to 29.9)
  • Obese – 7.4% (Body Mass Index of 30.0 to 39.9)
  • Extremely Obese – 4.2% (Body Mass Index of 40.0 +)

Some other shocking finds concerning obesity and health from the New York Times:

  • Obese Americans spend about 42% more on health care than normal-weight Americans
  • Obese Americans spend about $1,429 more on health care each year than the roughly $3,400 spent by normal-weight Americans
  • The average American consumes 250 more calories per day than just two decades ago
  • Medical spending on obesity-related conditions is estimated to have reached $147 billion a year in 2008. A figure that represents almost 10% of all medical spending

How can health and wellness programs curb this epidemic? First, group programs and working with others on a common goal keep people on track (think Weight Watchers). If employees are accountable for their actions to others, they will more likely stay on task. This also builds comradery and teamwork skills.

Second, you can show your employees that you care for their well-being and want them to be healthy. You can also reduce absenteeism, increase employee loyalty and witness a major decrease in health insurance costs by offering health and wellness services.

What are some services you can offer? Weight management, healthy eating, healthcare financial services, patient advocate services, concierge visits, gym memberships, group fitness programs, counseling, etc. to name a few.

The major thing is to show your employees you care about their well-being and want them to be healthy and feel great. We can fight obesity by re-learning healthy eating/living habits and decrease healthcare spend exponentially.

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.

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.

Healthcare 101: Explanation of Benefits (EOB)

Wednesday, September 1st, 2010

An Explanation of Benefits (EOB) is a document sent by an insurance provider to an enrollee and the enrollee’s healthcare provider.  An EOB is produced in response to a claim for healthcare service.  It contains important information regarding the payment responsibilities of both the insurance company and the patient.  Unless they cover the entire cost, an insurance company is required to send an EOB to both the patient and the provider.

An EOB usually includes:

  1. Identification of service rendered*
  2. Date of service (DOS)
  3. Name and address of subscriber
  4. Name of patient
  5. Name of healthcare provider who rendered service
  6. Provider’s tax identification number
  7. Provider’s charge/ total billed services
  8. Allowed amount
  9. Total patient responsibility amount
  10. Total payment made and to whom
  11. The amount payable (in dollars or percentage of total) after deductibles, co-payment, and any other reduction have been made
  12. An explanation of for any reason for not providing full reimbursement for the amount claimed
  13. Point of contact (telephone number or address) by which an enrollee may inquire regarding payment
  14. Information on the appeal process of a denial of benefits and timeline of the process

The first item, identification of service provided (marked with *) is the most important item on an EOB.  It is the reason for receiving healthcare and should be communicated via ICD (diagnosis) or CPT (procedure) codes. If you receive an EOB that is missing this, call your insurance company and ask for this information.  Keep track of the code – it represents what you received and why you received it.  Imagine that your EOB is a receipt from a store and that the ICD and CPT codes are the items you purchased.  Wouldn’t you want to know what you bought?

Unfortunately, EOBs are not standardized and can be difficult to read, especially after switching insurance providers.  In addition, an EOB is sent to both the provider and the patient, and it attempts to convey different information to each recipient.  This often produces a very confusing document.

When reading an EOB, don’t be hesitant to look for guidance.  Your insurance company may have an example EOB and accompanying information on their website.  And, of course, be sure to look at our Healthcare How To: Read an Explanation of Benefits (EOB).

Other Resources:
http://www.healthlink.com/tech_tip_eob.asp
http://www.ins.state.ny.us/website1/inshelp/c_eob.htm
http://www.cigna.com/customer_care/member/forms/explanationofbenefits.html

What is a Prior Approval Law?

Thursday, August 26th, 2010

As the news of expected and enacted premium increases spreads across the country, these state-level legislative measures are receiving more and more attention. Elected officials proudly tout them and insurance companies are already suing states in response to them. Most people, however, don’t know much about prior approval laws.

The term “prior approval law” refers to legislation that grants the officials of a state the power to review and approve health insurance premium increases before they take effect. These laws are passed at the state level and usually give the authority to the State Insurance Department. Without prior approval laws, states are restricted in their ability to regulate premium increases and, de facto or de jure, the insurance industry self-regulates.

Prior approval laws have gained attention as a result of the recent healthcare reform, which affords the federal government limited power to curtail premium increases. Although the federal reform includes provisions such as that which requires insurers to justify “unreasonable” rate increases, much of the power necessary for premium moderation has been left outside the reach of the national government.

Regulating premiums has traditionally been the responsibility of the states, and now, as we continue to see double digit premium increases during this economic crisis, it is more important than ever for states to fulfill this responsibility. It is the disappointing truth that only 19 states currently have prior approval legislation on the books. Of those 19, however, some states are making great progress by enforcing these laws. For example, Oregon officials have modified or dismissed 20 of 71 proffered premium increases in the individual and small group markets since April 2009.

Some consumer advocates and politicians support granting prior approval authority to all states. Doing so would likely end many current lawsuits between insurance companies and states. But the effectiveness of such legislation in suppressing premium increases would depend on politicians’ willingness to resist the influence of the insurance industry.

It is well known that the healthcare insurance industry aggressively lobbies federal officials and helped pen much of the recent healthcare reform. Few realize, however, that the industry exerts significant pressure at the state level as well. Much of that pressure comes from over $42 million in contributions since 2003. Jim Duffett, executive director of the Illinois-based Campaign for Better Health Care, describes the result of excessive lobbying: “State government here has basically been a wholly owned subsidiary of the insurance industry.”

Apparently, insurance companies already know what many of us are just learning; as Washington State Insurance Commissioner Mike Kreidler warns, “The battle has shifted to the states.”

Look for more on this and other healthcare legislation in future posts.

Sources:
EconomicCollapseBlog
L.A. Times
N.Y. State Government

Rising Healthcare Cost to Employers Passed on to Employees

Thursday, August 19th, 2010

A recent survey by the National Business Group on Health shows that large employers expect their healthcare expenses to increase significantly next year. It also shows that they plan to diffuse the cost increase by extending it to their employees.

Large employers are projecting a healthcare cost hike of 8.9 percent in 2011, a significant leap from the previously projected 7 percent increase for 2010. Healthcare reform was partly, although not entirely, credited with the increase.

The new regulation, which takes effect September 23rd, will affect costs in accordance with each company’s current healthcare practices. About 70 percent of the companies currently have “lifetime cap” or total dollar limits that they will have to eliminate. Around 25 percent will have to end annual limits on benefits. And 13 percent will now have to extend coverage to children suffering from expensive preexisting medical conditions to whom they had previously denied coverage. Many employers reported that they intend to cover these increases by requiring greater employee contribution.

Although the changes might be seen in different places, most employees will be affected by them. 63 percent of employers indicated that they planned to increase employee contribution to premiums. 46 percent of employers intend to increase employee out-of-pocket contributions.

Some companies also report that they plan to reduce costs through other means. Company-directed wellness programs have become more popular. Also on the rise are consumer-directed health plans, which allow employees more say in how they spend their healthcare dollars.

Employers and consultants are hinting –if not warning- that employees should be prepared to pay more for their health insurance in coming years. In fact, employers indicate that they intend to encourage employees to restrict healthcare spending in order to slow these rising costs.

If this is true for big businesses, are small businesses or the self-employed doing any better? As it turns out, no. No one, it seems, is able to dodge the rising healthcare costs. New legislation has raised costs to insurance companies who are ready and willing to pass those costs onto consumers via huge increases (sometimes 50%!) in premiums. Although some states are fighting back, the federal government and most states are helpless to perturb premium increases. Look for a future post about the changing healthcare costs that are being felt by those employed at small companies and the self-employed. Until then, look here for further reading.

The National Business Group on Health represents large employers’ health policy interests. The NBGH surveyed 72 companies, each with over 5,000 employees. These companies provide their own health insurance and hire a health insurer to administer the coverage.

Sources:
businessgrouphealth.org
theeconomiccollapseblog.com
ibnlive.in.com
kiplinger.com
msnbc.msn.com