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Archive for the ‘Healthcare Finances’ Category

Submitting Bills into Evidence

Wednesday, July 20th, 2011

In Illinois in order to submit medical bills into evidence at trial, an opinion is typically required to show that the medical services and charges were usual, customary, and reasonable. An earlier case is often cited Arthur v. Catour, 216 Ill.2d 72 that “to introduce an unpaid bill into evidence, a party must establish that the bill is reasonable for the services of the nature provided.”

Citing a more recent Illinois case, the plaintiff (citing Betty Kunz v. Little Company of Mary Hospital and Health Care Centers, et al., Nos. 1-06-1707 & 1-06-1814) “can establish reasonableness by introducing the testimony of a person having knowledge of the services rendered and the usual and customary charges for such services.”

The skill sets required for this type of analysis include understanding the environment of the services rendered, in addition to healthcare reimbursement.  The method for how healthcare is paid for is complex and layered with components such as understanding ICD (diagnosis codes) and CPT codes (procedure codes). You also have to look at how these services are rendered in the provider environment.  The generation of a provider bill is a multi-layered process. If you have one party that does not stipulate to the bills, then it becomes important to have those bills reviewed by qualified medical auditors.

The following provide some helpful hints of the information you should request:

1.       Provider request list:

  • CMS-1500 claim form for all professional bills and their itemized statement
  • UB claim for all facility claims
  • Any ancillary service, like durable medical equipment or pharmacy charges – ask for an itemized statement
  • Please inform the provider that you are seeking all ICD and CPT codes associated with the services rendered

2.       Obtain relevant medical records representing services rendered.

3.       Have your medical audit specialist review the information and identify any anomalies or bills with insufficient information.

4.       If you hit road blocks such as “this information is only for insurance companies”, please remind the provider that billing information contains protected health information (PHI) and according to HIPAA, the patient is entitled to obtain their entire PHI.

5.       Finally with the right information you will be in a position to have an opinion generated on the bills associated with your case.

Send me a note if you get “stuck” or hit a “road block” in the process!

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

Medical Identity Theft: What is it? How does it happen? How can it affect you or your loved ones?

Friday, May 13th, 2011

Some stats for thought:

  • As many as 500,000 Americans have been victims of medical identify theft, according to the World Privacy Forum.
  • At one medical clinic in Weston, Florida, a front desk clerk downloaded information of more than 1,100 Medicare patients and gave it to a cousin who made $2.8 million in false Medicare claims.
  • Thieves use your identity to buy prescription drugs. They then sell these prescriptions or use them to feed their own addictions.

What does this mean to the average person?

If you find yourself being a victim of medical identity theft, you might receive hospital bills in the mail for services you never received. You might visit an area hospital only to find your records include false or wrong information, like blood type or previous surgeries you’ve never received. You could even have your kids taken away like this unassuming woman almost did during her ordeal with medical identity theft.

Anndorie Sachs, a mother of four from Salt Lake City, has always considered herself a loving, caring mom.  So one can imagine her surprise when a state social worker called Sachs and accused her of having given birth to a baby girl with methamphetamines in her system and abandoning her in the hospital.

Even more unthinkable, according to Sachs, the state told her over the phone she was an unfit mother, and planned to take custody of all her kids.  “I definitely went into shock,” she says.  But, Sachs hadn’t given birth to a baby with meth in its system. In fact, she hadn’t given birth in two years.  Anndorie Sachs was a victim of medical identity theft.”

How can you avoid becoming a victim?

If you don’t monitor your EOBs fraudsters have a better chance of stealing your Medical Identity. This can cause both financial and physical harm – if someone else’s information is included in your medical record you could receive false diagnoses. Take ownership of your healthcare finances and request your medical records and bills once a year.

If your wallet is stolen, notify your insurance company — not just credit-card companies — because your benefit card is like a credit card without a limit.

Be an empowered patient and take charge of your health and healthcare finances.

Thanks for reading!

Your healthcare resource – Rebecca Busch

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.

All Eyes on Compliance with New Whistleblower Laws

Thursday, September 23rd, 2010

With the new laws and incentives reported in the Patient Protection and Affordable Care Act, we are seeing more whistleblowers come forth alleging healthcare fraud. Currently, 90% of health care fraud cases are whistleblower cases — often in which the behavior of the “ethically challenged” directly poses risks to public health.

Regardless of whether whistleblowers are concerned citizens, disgruntled employees or senior executives with a “lottery mentality”, hospitals and other healthcare companies must have strong compliance programs in place to stop fraudulent activity — such as improperly billing Medicare and Medicaid and kickbacks to doctors. A list of healthcare companies that have signed corporate integrity agreements with the OIG can be found here.

With the new incentives, hospitals and other healthcare companies are even more susceptible to whistleblowers. Now is the time to review your current compliance program and develop the necessary internal controls to protect your organization from committing fraud. Below are 4 simple but important considerations to keep in mind when evaluating compliance programs:

1. Periodic comprehensive fraud risk assessments are conducted.
2. Standards of conduct for employees are written and distributed.
3. Educational and training programs are offered to all employees.
4. Audits are conducted to monitor compliance and identify problem areas.

The effectiveness of whistleblowers is also an integral part of the effort to combat healthcare fraud. The first thing people need to do when encountering fraudulent activity in their workplace is to make sure that they understand the reporting framework and seek appropriate legal counsel. As an expert witness, I have seen first-hand the enormous complexity of whistleblower suits.

Top 10 Hospital Stories of 2010

Tuesday, September 14th, 2010

Becker’s Hospital Review recently posted their collection of the top 10 hospital stories of 2010. Many of the topics reflect the major hospital stories of 2010 – a few really delve into the growing problems and concerns for hospitals that are not necessarily on the forefront of discussion.

Here are the top 10 terms/stories for 2010:

1. Healthcare reform
The term “Healthcare reform” was everywhere this year. People are still scratching their heads wondering exactly what that means. 2011 will be a big year along with the next 4 years to see whether healthcare reform will hold up to its hype.

2. Integrating healthcare delivery

3. RACS get rolling

With RACs in full swing, hospitals are developing ways to ensure they meet standards. In the first quarter of 2010, RACs denied a total of $2.47 million in Medicare claims, according to the AHA’s RACTrac Survey of 653 hospitals. In 2011, it will be increasingly important for hospitals to be aware of these audits.

4. For-profits buy up hospitals

5. Ban on physician-owned hospitals

6. Physician fee cuts
With Medicare fees cut by over 20%, some physicians are losing faith in the system. What will this mean for the future of Medicare and physicians and hospitals accepting Medicare? The next 2 years will be key for this.

7. Hospital quality reporting

8. The war against healthcare fraud
One of our favorite topics, the war on healthcare fraud, waste and abuse is continually growing and ever-present. While Congress realizes that there is a need to combat this abuse, we haven’t successfully implemented initiatives to thwart it substantially. The healthcare reform law provides $300 million in funding for fraud investigation and enforcement by over the next 10 years. It will be up to Congress to ensure this money is spent wisely, efficiently and effectively.

9. Big boost for healthcare IT
EHRs, EMRs, Personal Health Records – what does all this mean for Health-IT and e-health? Lots – especially with government investing, beginning in 2011 and lasting for the next six years, $34 billion in incentives for healthcare IT to hospitals and practices.

10. Don Berwick arrives at CMS

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:

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.

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.


Your Money Matters – Rebecca Busch with Tips for Getting Your Personal Healthcare Portfolio In Shape

Tuesday, August 10th, 2010

On July 26, 2010 Medical Business Associates’ CEO Rebecca Busch was featured on Chicago’s own WGN Midday News with Steve Sanders. During the segment, Your Money Matters, Rebecca provided tips for getting your personal healthcare records portfolio in shape.

Rebecca’s appearance highlighted her latest book, Personal Healthcare Portfolio: Your Personal Health & Wellness Record. During the segment she offered viewers valuable time and money saving techniques when it comes to healthcare records and finances.

Tips for Your Personal Healthcare Records

Here are some tips she provided during the interview:

1. Get your records organized and separate medical from financial.

2. Learn the reimbursement lingo in healthcare — start asking your doctor “What CPT codes are you billing me for?” That is a procedure code — patients never see this. Did you know doctors charge in increments of 15/20/45/60 minutes procedure codes? This is why you have to ask what code they are charging.

3. Ask your doctor “What diagnosis code are they billing in MY name?”

4. Ask for itemized copies of your bills as you receive your care.

5. Make sure you collect your health records as you receive your care — or obtain them once per year (ask your provider what their policy is on retention of records).

6. If your insurance company provides you an EOB (explanation of benefits) without procedure codes — ask them annually to print a claim file with the information. This is the best way to avoid being a victim of medical identity theft.

7. Be vigilant — although we have a healthcare crisis there is lots of money floating around.

To view the entire interview please visit WGN’s site here.