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Unexpected Large Medical Bills: Balance Billing is Not Prohibited in Many States

Imagine that you receive a medically necessary surgery from an out-of-network specialist. You pay your co-insurance or co-pay and your health insurance authorizes the surgery agreeing to pay the remaining cost. Then, a month later, you receive a bill from the specialist for the difference between what they charged and what your insurance company paid them. The specialist charged an above-average rate and the health insurance did not cover all of the charge. Now you are stuck with a massive bill that you never saw coming. To make matters worse, you are threatened with being placed in debt collections by the specialist if you do not pay! This is called balance billing, or sometimes extra billing, and is not only legal but also common in 37 states.

Balance billing is really a dispute between physicians and health insurance plans but it is the patient that gets stuck in the middle of it and ends up financially responsible. The main cause of the dispute is that the physician, usually an out-of-network physician, does not have any contract with the health plan and thus, is not bound by a pre-negotiated charge for the service. The health insurance companies usually pay a rate that is a little higher than the Medicare rate for the particular service. Then the unsatisfied physician will bill the patient to recover the difference for the service performed. Many physicians do not like the low reimbursement rates of the various health insurance plans and choose to be out-of-network.

The Affordable Care Act does not require all healthcare plans or managed care organizations to cover non-emergency balance billing amounts nor does it prohibit balance billing for non-emergency services. However, this does not give a free reign for providers because not all kinds of balance billing are allowed in the United States. Balance billing beneficiaries of TRICARE is prohibited. The Centers for Medicare and Medicaid Services (CMS) also prohibits balance billing of all qualified Medicare beneficiaries and Medicaid members. Furthermore, balance billing is not allowed for emergency out-of-network service under the 2010 patient protection amendments to the Public Health Service Act. And for virtually all in-network providers, i.e. providers who have contracts with managed care organizations, there are provisions in their contracts that prohibit them from balance billing the patient. Yet, this still allows balance billing of patients with private health insurance by out-of-network providers. Consequently, some states have tried to address this gap with legislation.

Thirteen states led by New York, Maryland, and California have enacted statutes prohibiting balance billing by out-of-network providers. Under the patient-protection oriented state laws of Maryland, New York, and California, providers cannot balance bill patients and this restriction applies across the board to all situations including in-network, out-network, HMOs, and PPOs. The District of Columbia and the Commonwealth of Virginia only prohibit balance billing of in-network HMO patients but allow balance billing for patients with out-of-network health plans and PPO plans.

When these disputes occur, a lot of patients end up taking their frustrations on their health insurance company. Therefore, some health insurance companies, like Aetna, seek to protect their members by taking legal action against the out-of-network providers who balance bill, especially when it involves unreasonable and uncustomary charges for a particular service.

Patients would be wise in making efforts to avoid unexpected bills by making sure beforehand that their specialist does not balance bill. Patients should also keep up-to-date with the state laws regarding balance billing. In the event that balance billing occurs and is not prohibited in a given state, patients should avoid debt collection by negotiating with the provider.

 

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Defensive Medicine Impeding the Medical Profession with Liability

The thought of malpractice for many doctors begins as soon as a patient walks into the door. The subsequent fear and actions that follow are known as defensive medicine. Defensive medicine, “occurs when doctors order tests, procedures, visits, or avoid high-risk patients or procedures, primarily (but not necessarily or solely) to reduce their exposure to malpractice liability.”
Defensive medicine can benefit patients. Concerned about malpractice liability, doctors encourage patients to attain more testing and second opinions even if the expected benefits are minimal. These efforts decrease the risk of negligence while allowing patients to feel secure in their doctor’s opinion. Therefore, defensive medicine can prove beneficial.
On the other hand, defensive medicine is problematic for patients and physicians. Malpractice is the most challenging issue for physicians and the cost to fight them continues to rise. However patients face a different problem, access to medical treatment or certain specialists becomes difficult. They are subject to exorbitant costs because of the amount of secondary exams necessary before a high-risk procedure is provided. As a result, there is an unnecessary amount of health care spending because doctors fear being sued for malpractice. In 2010, defensive medicine accounted for 45.6 billion out of the total 2.3 trillion national health care cost.
However, the cost of defensive medicine was not always this high. Some researchers and doctors have been able to connect cesarean sections to defensive medicine. Cesarean sections increased from 4.5 percent in 1965 to 30 percent in 2010. Today, obstetricians are more likely to pose cesarean sections to patients at the first sight of a complication. Therefore, the prevalence of cesarean sections is a good indicator of the increase of defensive medicine over the years. In lieu of lawsuits resulting from the increase in defensive medicine, how are doctors supposed to practice medicine with the fear of being sued for negligence?
The American Medical Association (AMA) has proposed a solution called safe harbor. This proposal would prevent doctors from being sued for failing to order a test, if the doctor followed guidelines that indicate a test was unnecessary. This idea provides benefits to both the doctor and the patient. The patient is protected because there is an established standard of care that the doctor must uphold or face liability. Also, doctors are protected because they are given the opportunity to be doctors and make the best decision for their patients while using a readily applicable standard.
Studies have shown that defining medical malpractice liability by a nationwide regime would reduce local variation in care and provide a national standard that doctors could easily follow. In states that have chosen to adopt the AMA safe harbor proposal, the amount of medical malpractice has decreased by 30 to 50 percent in conjunction to the rest of the nation. By decreasing the incentive to follow local customary practices, which are less likely to be supported by clinical evidence, decreased variations in clinical care that commonly leads to malpractice and defensive medicine.
In sum, although defensive medicine has increased there are solutions. The advocates at the AMA have proposed one that has changed the amount of medical malpractice suits in states through providing a nationwide standard for doctors supported by clinical evidence. I believe this decrease will lead to more doctors being able to practice without the fear of lawsuits and decrease defensive medicine.

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The push for IT advancements in health related fields in the wake of technological breaches

For over twenty-five years, health related industries have increased the use of technology hoping to make healthcare more accessible, affordable, and efficient. As early as the 1990s, medical providers have slowly migrated to electronic health records (EHRs) from traditional paper record keeping systems. With the adoption of legislation like the HITECH Act, HIPAA, and the Patient Protection and Affordable Care Act of 2010, the Federal government has supported the trend of advancing technological innovations in the realm of the health care.

With increased reliance on EHRs, the issue of patient privacy is more prevalent. Medical providers must ensure, more than ever, that electronic record keeping will not jeopardize patient privacy. Providers bear the same burden in regard to online platforms, which provide virtual medical services to consumers. Especially, in the wake of recent technological breaches, how can healthcare providers ensure that the steady trend of IT innovations in health related industries does not experience similar issues with security and breaches occurring as of late?

In a recent article in the healthcare section of InformationWeek, Alison Diana outlined several pros and cons of technological advances in healthcare over the past twenty-five years. Making the top of the ‘cons’ lists was privacy. Diana noted that although medical providers take numerous precautions and implement safety measures to prevent breaches, there are also factors that are more difficult to control that can lead to leaks. Diana specifically noted that human error and criminal activity are two factors that often contribute to privacy mishaps.

Do the benefits outweigh the downfalls?

The Office of the National Coordinator for Healthcare IT, an office within HHS, believes that healthcare IT has its benefits despite its shortcomings. Proper implementation of healthcare IT programs can lead to decreased healthcare costs, increased access to healthcare, provide various forums for patients to have access to personal medical records, and create a simplified efficient system for recording sharing amongst healthcare providers. However, some legislators feel that more can be done to ensure that privacy is in fact protected.

On September 18, 2014, Rep. Robert Hurt, R-Va. and Rep. John Barrow, D-Ga., introduced a bi-partisan bill in the House, proposing additional privacy rights for potential consumers of insurance plans pursuant to the ACA. The bill would allow individuals who do not opt-in to the Federal healthcare program to remove any personal information from the site that they provided in the application process. Currently that option is not available to potential consumers. After, a potential consumer provides his or her personal medical information on healthcare.gov, it cannot be removed even if that individual does not decide to purchase a plan. Rep. Hurt explained to Information Security Media Outlet that he was prompted to introduce the bill after a constituent expressed concern with his inability to remove his profile from Healthcare.org, which contained a myriad of personal information and health history, after deciding not to purchase healthcare from the site. Rep. Hurt explained that he had not received an explanation about the policy of keeping consumer information after contacting the Agency several times to inquire why the data was kept if insurance was not purchased. Rep. Hurt also attributes studies from the Government Accountability Office highlighting breaches to healthcare.gov as motivation to create the bill.

The bill will offer all consumers, potential and realized, increased security when using healthcare.gov, a concern that is prevalent with consumers. Having the ability to remove highly private, personal medical information from a government controlled website can help decrease the feeling that “big brother” is watching. As of yet, HHS has not taken any steps to address the concerns Rep. Hurt outlines in his bill. However, addressing the concerns raised in the bill could be beneficial for HHS to lure individuals in who may be on the fence about healthcare.gov.

 

 

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The United States Obesity Rate is Still Too High

The Robert Wood Johnson Foundation (RWJF) and the Trust for America’s Health (TFAH) released their September 2014 report on the current state of obesity in the United States. TheHill. As defined in the report, obesity is “an excessively high amount of body fat or adipose tissue in relation to lean body mass.” StateofObesity. Although obesity rates are plateauing, the rates remain high, leading to increased health problems for millions of Americans. StateofObesity. Adult obesity rates are now above 35 percent in two states, at or above 30 percent in 20 states, above 25 percent in 42 states, and above 20 percent in every state. StateofObesity. Rates of severe obesity apply to children as well, as more than one-in-ten children become obese between the ages of two and five. StateofObesity. This report projects that the United States’ general obesity rate will rise to 44 percent by 2030. NBC.

As recently as 1980, no state had obesity rates above 15 percent; in 1991, no state had obesity rates above 20 percent; in 2000, no state had obesity rates above 25 percent; and, in 2007, Mississippi was the only state above 30 percent. StateofObesity. As of 2011, more than 34.9 percent of adults were obese, and more than 68.5% of adults were overweight or obese as of 2011 to 2012. StateofObesity. Between 2011 and 2012, around 16.9 percent of children (ages two to nineteen) were obese, and 31.8 percent were overweight or obese. StateofObesity.

There are many preventable causes of obesity such as physical inactivity and limited or no access to healthy food. Eighty percent of adults in the United States do not meet the aerobic and muscle strengthening standards for physical activity. StateofObesity. In cases of child inactivity, all fifty states have adopted physical education standards that schools must follow; however, the scope of these requirements and the degree to which they are enforced and funded fluctuates. StateofObesity. Additionally, the types of foods available make it difficult to maintain a healthy weight. Besides general limited access to healthy foods, low-income families are unable to afford such products as they are generally higher priced than lower quality foods. Further, those who live in rural areas tend not to have access to a grocery store closer than ten miles away. StateofObesity.

Moreover, insurance coverage does not cover community health workers and obesity counselors. Medicare does not include medicine for obesity in its Part D drug benefit, nor does it give beneficiaries access to many lifestyle programs, which makes it even more difficult for those in need to attain the proper help in preventing serious health illnesses due to obesity. In turn, these chronic diseases are consuming a shocking amount of time and money throughout our healthcare system. StateofObesity.

It is highly important and beneficial to address these causes of obesity to prevent the serious health risks obesity poses. Overweightness and obesity have been shown to lead to the following health conditions: (1) type two diabetes; (2) heart disease; (3) hypertension; (4) risks before, during, and after childbirth; (5) cancer; (6) kidney disease; (7) arthritis; (8) dementia; (9) Alzheimer’s; and (10) mental health conditions. In the past twenty years, diabetes rates have almost doubled, and over eighty percent of diabetes patients are overweight or obese. Additionally, individuals who are overweight are more prone to developing high blood pressure, high blood fats levels, and high cholesterol, leading to heart disease and stroke. StateofObesity. According to the National Cancer Institute, around 84,000 cancer diagnoses per year are related to obesity. It has also been shown that extra fat affects how cancer treatments process. Wptv

What can America do to fix this? Our nation has been recently progressing by increasingly producing healthier foods. Coke, Pepsi, and Dr. Pepper proposed that they would aim to reduce the calories Americans obtain from beverages by twenty percent over the next ten years by marketing smaller sized drinks. WashingtonPost. The United States Department of Agriculture also updated the nutrition standards for school meals, snacks, and drinks for the first time in years. StateofObesity. In order to help the low-income community, food stamps have started including healthier foods as required by Obama’s enactment of the Farm Bill. StateofObesity.

To further combat obesity, agencies should implement policies where they can, for example, with child inactivity. Children are recommended to get sixty minutes of moderate to vigorous physical activity per day, which is not being considered in many school districts. Additionally, insurance plans should consider including obesity combatting treatment within their plans so that more individuals have a higher chance in solving this health issue.

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