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From the Waiting Room: Health Insurance
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.”

10 Things to Know About Athena Health
By Jessica Kim Cohen

Here are 10 things to know about Watertown, Mass.-based athena health, one of the largest publicly traded companies in the world providing medical record, revenue cycle, patient engagement, care coordination and population health services.

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For Some, the Affordable Care Act Is a Lifesaver. For Others, a Burden.
By SONA PATEL and FAHIMA HAQUE

After President Trump and the Republican-controlled Congress vowed to repeal and replace the Affordable Care Act, millions of Americans have been left wondering about the future of their health care. We asked readers to tell us how they would be affected if the law were repealed. These are some of their stories, condensed and edited for clarity.

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Diabetes patients sue 3 drug companies over alleged fraudulent insulin pricing
By Kelly Gooch

Eleven diabetes patients are suing several drug companies for alleged collusion on insulin pricing, reports The Washington Post.

The lawsuit was filed Monday in U.S. District Court in Massachusetts against Indianapolis-based Eli Lilly, French pharmaceutical company Sanofi and Danish drugmaker Novo Nordisk. The suit claims the companies systematically increased insulin list prices for years in an alleged fraudulent-pricing scheme that left patients with “crushing out-of-pocket expenses,” according to the article. The companies, the lawsuit says, increased the insulin list prices to expand their discounts without lowering the overall price tag, according to the report.

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Beth Israel, Lahey in advanced merger talks
By Jessica Bartlett

Beth Israel Deaconess Medical Center and Lahey Health have announced plans to combine forces for the fourth time, a move that would create an entity rivaling the size of Partners HealthCare.

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What is ‘Repeal and Replace?’ A Guide to Trump’s Health Care Buzzwords
By Benjy Sarlin

President Donald Trump and GOP lawmakers have yet to come up with a plan to repeal and replace the Affordable Care Act. But in the meantime, there’s already a complicated vocabulary to describe the process and its goals.

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Want to improve health care? Focus on hospitals
By Rich Lesser & Barry Rosenberg

(CNN) As Congress and the Trump administration debate the future of America’s health care system, they should go beyond the issues of access and cost and recognize an equally important priority: that patients come first, so health reform should also focus on quality of care.

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HHS nominee Dr. Tom Price’s 2nd confirmation hearing: 5 things to know
By Emily Rappleye

Rep. Tom Price, MD, R-Ga., faced another four hours of cross-examination Tuesday, this time with the Senate finance committee.

Grilled by Democrats and lauded by Republicans, Rep. Price’s second hearing comes ahead of a vote that will determine his nomination. The committee recessed and will reconvene to vote “promptly,” according to Sen. Orrin Hatch, R-Utah.

Here are five things to know about the second hearing.

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The Gap Trap
By: Jon Jablon, Esq.

So how ‘bout those stop-loss carriers?! We work closely with some excellent carriers that look for reasons to pay claims and are a pleasure to interact with – but there are also carriers and MGUs out there that will do whatever they can to deny claims. Make sure you and your clients read policy proposals carefully! Don’t fall into the stop-loss “gap trap.”

GOP on ACA replacement: Who wants what?
By Emily Rappleye

Republicans in Congress have already laid the foundation for an ACA repeal through the reconciliation process, but what will replace the law still remains uncertain.

And while Republicans agree the ACA needs to go, they have not coalesced around a single plan yet. To provide some clarity around the replacement ideas out there right now, we pulled highlights from statements and plans put forth by President Donald Trump and several Republican leaders.

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