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We Have a New Secretary of HHS

On February 10, 2017
By: Brady Bizarro, Esq.

In a rare overnight session, the Senate voted 52-47 (along party lines) to confirm Tom Price (R-GA) as Secretary of HHS. He will be managing a department with a $1 trillion budget and have the authority to rewrite ACA rules. Price is the author of perhaps the most extensive replacement healthcare bill; the Empowering Patient Frist Act, which provides age-adjusted tax credits for the purchase of health insurance. It’s a good bet that whatever congressional Republicans come up with in the near future, Price’s proposal will serve as the infrastructure.

It’s Tax Time – Do You Know Your 6056 Deadlines?

On February 10, 2017
By: Kelly Dempsey, Esq.

The tax season is officially upon us. Reporting requirements under ACA Section 6055 and 6056 are still in effect for the 2016 calendar year. For Applicable Large Employers (ALEs),  Forms 1094-C and 1095-C for the 2016 calendar year are required to be filed with the IRS by February 28, 2017 if filing on paper (March 31, 2017 if filing electronically).  The IRS did extend the due date for furnishing 1095-C forms to individuals from January 31, 2017, until March 2, 2017. Take note that transition relief for ALEs is limited, but affordability safe harbors are still applicable.

From the Waiting Room: Health Insurance

On February 9, 2017
By: Ron Peck. Esq.

I recently found myself in a doctor’s waiting room.  I overheard another patient arguing with the office administrator.  The gist of it was that he was being balance billed for an amount exceeding what insurance paid.  His anger was directed at the insurance.  “How can they say what is medically necessary?  Only the doctor can say what’s necessary.” A nurse emerged, and to her credit, I heard her explain that insurance defines medical necessity as the least costly option likely to resolve the medical issue.  She then explained that the doctor provided the patient with options, and he chose the option that was more intensive. That another, less thorough treatment might have resolved the issue. Well done, I thought. Yet, to my horror, the patient screamed, “Insurance!  Crooks!  How dare they decide what’s necessary!  They aren’t my doctor.”

No News Is Good News For Healthcare Providers

On February 9, 2017
By: Garrick Hunt

While Super bowl LI was exciting, the commercials were far more revealing. The political motivations for most of the commercials were clear, be it Coke’s America the Beautiful sung in 5 languages to promote inclusiveness or  the American Petroleum Institute’s Many Uses of Oil commercial. Much like a pendulum, there is a swing from right to left with different sides trying to tell their message and incite a reaction; a swing not seen on such a public scale in our own Health Care Industry. Where are these messages? There are stories of families going bankrupt due to medical bills, a small employer plan that implements new ways to contain costs, or a copy of medical bill that reveals all. They exist, so where are the prime time commercials telling these stories? Buried. No news is good news for a provider looking to continue the practice of egregious billing.

Overpayment Success Story: Dialysis Claim

On February 9, 2017
By: Michael Branco

A dialysis claim was adjudicated at the regular out-of-network rate instead of the dialysis carve-out rate of 130% of Medicare. After unsuccessful attempts to recover the overpayment, the TPA, with expectations dashed, asked The Phia Group to attempt to make an attempt at recovery. After four months of arguing, back-and-forth correspondence, and what seemed like an endless amount of repetition, the provider finally agreed to refund the $137,500 overpayment based on the language in the plan document.

Self-Funded Employers Beware the Network!

On February 8, 2017
By: Jennifer McCormick, Esq.

Self-funded employers should be careful when selecting networks. In some cases,  low discounts, anti-audit clauses, unseen provider agreements, and upside-down DRGs can cause more problems than the network access is worth. That’s especially true with wrap networks!

The Details of Your Coverage Plan Matter

On February 8, 2017
By: Brady Bizarro, Esq.

Employers face many, many regulatory burdens. There is an ever-increasing number of federal regulations to abide by (although that might change), and each state maintains its own set of regulations. This can get very complicated. The family and medical leave laws are a prime example of this. In Oregon, for example, an employee can be eligible for up to 36 weeks of leave under certain specific conditions. It is essential that employers understand the eligibility criteria involved to avoid coverage gaps with a stop-loss carrier.

A Canadian Pays Cash for Care – Part One

On February 8, 2017
I have personally experimented with paying cash for healthcare. I had sustained a rather nasty cyst/lesion on my chin (basketball accident – I named it Jermaine for the guy that accidently hit me) and I was on the waiting list in Canada to see a plastic surgeon (I am Canadian BTW, if you did not already know, and coverage does not equate access). I had already waited two uncomfortable months when I decided to take matters into my own hands and wallet. As I was speaking at a conference nearby, I called Surgery Center of Oklahoma (SCO), which had recently made the national news for shunning networks and offering transparent pricing, which they post online (what a concept). I will admit that I was a little nervous about the price because I had a claim on my desk from New York City for a similar procedure and it was billed at $24,000. I did some research and estimated that the average charges for my procedure would be about $8,000. Finally, I spoke with SCO, and my cash price was $800. I paid for the procedure, had no claim to worry about, and the care was excellent.  BTW – 1 year later I am still on the waiting list…

Mental Health Parity and Claim Negotiation

On February 8, 2017
By: Jon Jablon, Esq.

When choosing claims to have negotiated, don’t worry about mental health parity. While it’s an important set of laws, it primarily protects patients from having higher responsibility; as long as the SPD is compliant with the Mental Health Parity and Addiction Equity Act, negotiating claims will not cause a violation, since the patient’s liability won’t decrease.

Call Me Corny: Discussion on Healthcare

On February 6, 2017
By: Ron Peck, Esq.

So; call me corny, but as I watched my favorite football team miraculously pull forth victory from the jaws of despair, I was inspired.  No – I wasn’t inspired by their excellence in the face of adversity.  I was inspired by everyone other than the New England Patriots.  I was inspired by my family, my friends, people on social media, and even myself.  We all counted them out, and assumed it was over.  We assumed they couldn’t do something because it had never been done before.  I’d love to say they proved us wrong by “doing the impossible…” but the truth is, it was possible.  Very difficult; sure.  But possible.  Healthcare in our country is too expensive.  The money is being spread around, and wasted.  Is there greed?  Sure.  But there is also inefficiency.  If we target this waste, and spend funds only where needed… If we ensure the proper people pay for the proper items in the proper order… I believe we can start moving the ball in the right direction.