Surprise Medical Bills Addressed in 2017 HHS Budget

For the uninsured, seeking medical treatment almost always results in a costly medical bill. But, over the past few years, it's become clear that even if you have health insurance in the U.S., you're still susceptible to receive pricey medical bills—many of which can be a complete surprise.

For the insured, an expensive bill is expected when one visits an out-of-network physician. Lately, bills have been popping up in the least expected places. For these patients, charges roll in even though they did research and, presumably, went to an in-network hospital or saw in-network physicians.

President Obama’s 2017 budget for HHS takes action to eliminate these surprise bills.

Embedded within the 2017 budget is a provision to “eliminate surprise out-of-network healthcare charges for privately insured patients.” The administration would try to solve the problem by requiring physicians who “regularly provide services in hospitals” to accept in-network rates, even if they aren't in the insurer's network. Hospitals would also have to “take reasonable steps” to ensure patients see in-network physicians.

Usually, patients face unexpected charges because of large payment disagreements between insurance companies and physicians. Physicians will refuse to participate in an insurer's network if they believe arguing insurers are low-balling them. But, insurers say doctors ask for unreasonably high rates. Hospitals and patients are often left in the middle. Under President Obama's 2017 budget, patients would be removed from the disputes, and physicians would have to cave to the insurers' rates.

However, American Medical Association President Dr. Steven Stack said last year that he didn't like any approach that would “coerce physicians through yet another way to not receive sufficient payment,” indicated that the budget proposal won’t be popular with physicians.

President Obama's budget for 2017 stands pretty much no chance of moving through Congress, but it does reveal the president's final priorities for his own and future administrations.

The original article by Bob Herman can be found at the following address: http://www.modernhealthcare.com/article/20160211/BLOG/160219975?utm_source=modernhealthcare&utm_medium=email&utm_content=20160211-BLOG-160219975&utm_campaign=am

Omnibus Continues Tax Breaks for Blue Cross and Blue Shield Insurance & Ups Spending to Detect Healthcare Fraud and Abuse

The 2015 Fiscal Year Omnibus Appropriations Bill provides just over $1 trillion in discretionary spending in compliance with the Murray-Ryan budget agreement and funds the majority of the federal government through Sept. 30, 2015. 

Nongermane Riders

The New York Times reports that "Steve Ellis, vice president of Taxpayers for Common Sense, a nonprofit research group that tracks federal spending, said the bill bestowed favors on all sorts of constituencies.

“Authors of the bill and lobbyists behind these provisions know they are in there,” Mr. Ellis said. “But the public will not find out about most of them for weeks or months, if ever.” Congress supposedly forswore spending earmarks several years ago, after federal largess led to several scandals. But lawmakers can still steer money in less conspicuous ways."

One example of a nongermane rider that went into the bill without public debate provides relief to nonprofit Blue Cross and Blue Shield plans, which have special tax breaks that may have been threatened by provisions in the Affordable Care Act. While Blue Cross is not mentioned by name in the legislation, the deduction is only available to Blue Cross and Blue Shield plans. Blue Cross and Blue Shield have been lobbying Congress for a clarification since the Affordable Care Act was signed in 2010.

Fraud Prevention

The Committee on Appropriations executive summary also explains that the bill provides $1.484 billion for cap adjustment funding to prevent waste, fraud, abuse and improper payments in the Medicare, Medicaid and Social Security programs. This is a $560 million increase in funding from last year's level.

A significant portion of those funds, $672 million, are dedicated to the Health Care Fraud and Abuse Control program at the Centers for Medicare and Medicaid Services. That amount more than doubles the level enacted in fiscal year 2014. One reason for the increase is that preventing fraud creates a significant savings for the government. The latest data shows that for every $1 spent on fraud and abuse control, $8.10 is recovered by the Department of Treasury. That recovery ration is the highest three-year average return on investment in the entire 17-year history of the Health Care Fraud and Abuse Control program.

Further Information

For a more comprehensive discussion of nongermane riders passed in the Omnibus see this New York Times article, "In Final Spending Bill, Salty Food and Belching Cows are Winners." The Senate Committee on Appropriations executive summary of the bill can be found here.

Polls Show Number of Uninsured Adults Lowest Since Obama Took Office

The deadline to enroll on the new insurance exchanges is quickly approaching, with just three weeks remaining. The deadline seems to be spurring a dramatic up-tick in the number of adults enrolling in health insurance plans. Acording to the Gallup-Healthways Well-Being Index released Monday the number of Americans with no health insurance has dropped to the lowest levels since President Obama was sworn in. The index found that the percent of uninsured adults dropped from 17.1-percent in the last quarter of 2013 to 15.9-percent in 2014. Experts attribute the increasing number of insured adults to the insurance plans made available by the Affordable Care Act.

The increase in enrollment was found across all demographic groups examined by the index. Hoewver, enrollment throughout the Latino demographic lagged behind other demographic groups. This is notable because the Obama Administration is actively reaching out to the relatively young Hispanic community to encourage enrollment. 

A significant drop in the rate of uninsured adults occurred among African-Americans with a 2.6 percentage point decline. The rate declined 1percentage point among white adults, but only eight-tenths of a percentage point for Latinos. The largest drop in the uninsured rate was a 2.8 percentage point difference for households with an annual income of less than $36,000.

Healthcare Enrollment May Be Stifled By Federal Website Maintenance

Consumers attempting to complete health insurance applications through online healthcare exchanges before the February 15th deadline may be frustrated this weekend. February 15 is the deadline to apply for coverage that will begin on March 1. 

The Department of Health and Human Services (HHS) announced Monday that heavy maintenance to the Social Security Administration's website (SS) will result in the inability of HealthCare.gov to verify Social Security numbers and other personal details required for coverage under the Affordable Care Act. 

The maintenance is expected to begin Saturday, February 15 at 3p.m. and end Tuesday, February 18 at 5a.m. Those consumers that are affected by the website maintenance should phone the federal call center on Tuesday to arrange for coverage March 1. The number to the federal call center is 1-800-318-2596.

Obama Administration Announces Health Insurance Mandate Delay and Reduction of Percentage of Workers Covered Requirements

The Obama Administration announced changes in the implementation of the Affordable Care Act provisions related to the employer mandate for "medium-sized" businesses.  The provisions were originally drafted to go into effect this year. 

The changes in implementation deadlines do not affect most businesses. Companies with fewer than 50 workers remain exempt from the mandate. 

First, the deadline to meet the coverage requirements under the mandate for medium-sized businesses, companies that employ between 50 and 99 workers, has been delayed until January 1, 2016. The delay is conditional and requires companies to promise that the employer will neither cut an employees' hours nor let go of employees for the purpose of making their business qualify as a "medium-sized" business with 50-99 workers. Officials describe the verification process of this promise as "self-attestation" and the IRS has not provided information on how it will determine the companies' veracity. 

White House advisor Phil Schiliro explained the reasoning behind the change, "For the two-percent of American businesses that have between 50 and 99 employees, the Treasury Department concluded that a phase-in was the most common-sense way to implement the law." 

The employer provisions will go into effect for companies that do fall into categories covered by the employer mandate that do not have 50-99 workers. However, the requirement that the employers offer coverage to 95% of their full-time employees by January 1, 2015 has been reduced by 25%. The employers will now be required to offer coverage to 70% of their full-time employees by January 1, 2015. The Treasury Department's final rules state that the requirement for employers to offer coverage to 95% of their full-time employees has been delayed until 2016. 

Other changes affect seasonal workforces, adjunct faculty and volunteer firefighters and paramedics. Seasonal workers that work less than six months will not be considered full-time employees. The changes include a method for estimating the hours of adjunct faculty that accounts for hours spent working outside the classroom. The Administration's promise that volunteer firefighters and paramedics would not be considered full-time employees was formally implemented in the most recent changes. 

Many commentators are suggesting that the adjustments in implementation deadlines and requirements for businesses will increase pressure on the Obama Administration to extend deadlines for individuals so that they are not subject to the $95 or 1% of income fine for failing to purchase health insurance this year. Other experts counter that extending the deadline for individuals would result in fewer healthy individuals signing up now which could drastically shift the ratio of sick-to-healthy individuals enrolled. If too many individuals with significant health problems enroll without the balance of healthy individuals it could make the price of coverage more expensive. 

"Balance Billing" from In-Network Hospitals Leaves Patients Shocked

In emergent situations paperwork is often the last thing on a patient's mind. Patients that have the wherewithal to remember to choose an in-network hospital to avoid large bills for treatment assume that they may be treated by any physician in the hospital and their insurance will cover the treatment. Unfortunately, many find out this is not true several weeks later with the arrival of a hefty "balance bill."

Balance billing is a common practice that bills the patient for the remainder of the cost of treatment that the insurance refused to pay because the treating physician was not out-of-network, even though she practices at a hospital that was in-network.

These unexpected bills can have huge consequences on patients and their families. NBC 5, in Texas, recently ran a story about Melinda Allen, a patient at the Texas Harris Methodist Hospital emergency room. Allen woke up on a Saturday with intense abdominal pain. She had her husband take her a hospital she knew was in-network. Several tests later Allen was diagnosed with an ovarian tumor large enough to require surgery.

The billing was less straightforward than her treatment plan. Allen paid nearly $5,000 out-of-pocket for her treatment, in addition to her $1,500 monthly premium. Allen assumed her insurance would cover the rest since she was treated at an in-network hospital. Allen was shocked when she later received a bill for nearly $700. 

The amount of the bill Allen received  was the balance left over from the price of the treatment charged by the emergency room doctor and the price her insurance company felt was appropriate. 

This practice leaves the patient to sort out the claim with their insurance company. "People are really vulnerable when they go into an emergency room," Stacey Pogue of the Center for Public Policy Priorities explained. "It's unfortunate, again, that we're put in that position because insurance companies and doctors can't decide what is appropriate reimbursement."

In situations like Allen's where does the blame fall? Allen chose an in-network hospital. Physicians, by law, are not allowed to ask about insurance and must treat all patients regardless of their ability to pay. Should the in-take process include a list of in-network and out-of-network physicians?