Drag to Reposition Photo

Kaiser Health News

Located in United States.
by on November 22, 2021
                                    The ER Charged Him $6,500 for Six Stitches. No Wonder His Critically Ill Wife Avoided the ER.       Blake Farmer, Nashville Public Radio                      November 19, 2021                      Jason and DeeAnn Dean recently relocated to her hometown of Dellrose, Tennessee, where she grew up on a farm. Both in their late 40s, they’re trying to start a green dream business that combines organic farming with a health and wellness consulting company. They want to inspire people to grow their own food in this fertile rolling farmland, just north of the border with Alabama.        Until the business fully launches, Jason is working construction. In May, he was injured on the job site when a piece of sheet metal slipped and caught him on the kneecap. He bled quite a bit. After closing the wound with a butterfly bandage, he thought that might be enough. But on his drive home, he figured it’d be best to have a professional stitch it up. It was late in the day, and the emergency room seemed the best option since his doctor’s office was closed. He and DeeAnn had opted for a health plan with lower monthly payments and a high deductible. So, he knew the cost of care wouldn’t be cheap — and he was right. When the bills for thousands of dollars came, they were shocked. They were in the midst of fighting them in August when DeeAnn started feeling as bad as she’s ever felt. “I haven’t eaten. I’m not drinking. I have a horrible fever. I can’t get out of bed. I’m shaking,” she said. She was pretty sure she had contracted covid-19 — the delta variant was surging across the South. The natural-health fanatic was kicking herself for putting off vaccination. She got tested and the result was negative. She visited a doctor the next day, who said her condition was bad enough to go to the ER — but she regarded that option as financially unacceptable. “That is fear,” said DeeAnn. “If they charged Jason this much, what would they charge me?” She was terrified of a potential bill from the same ER in Pulaski, Tennessee, that had treated her husband. So even though she was deliriously ill, she hit the road in search of cheaper treatment, asking her parents to drive her. They headed south first to an ER in Huntsville, Alabama, but it was so full of covid patients, she would have had to wait all day. Then, they drove north nearly an hour to Maury Regional Medical Center, a public hospital in Columbia, Tennessee, where she was diagnosed with Rocky Mountain spotted fever, a potentially deadly tick-borne infection. She got treatment with appropriate antibiotics and IV fluids. “I would have had organ damage or possibly death in a few days,” she said. And then the bills came. The Patients: Jason and DeeAnn Dean, entrepreneurs and aspiring organic farmers who bought a BlueCross BlueShield of Tennessee insurance plan with a deductible of $8,000. Medical Services: Jason received six sutures for a laceration on his knee and a tetanus shot. DeeAnn received diagnosis and treatment for Rocky Mountain spotted fever. Total Bills: Jason was charged $4,582.77 by the hospital for a Level 4 emergency visit, including $497.40 for a tetanus shot. The ER physicians who treated him sent a separate bill of $2,007, for a total of $6,589.77. The Deans’ share of these bills came to $4,278.05. At a different ER, DeeAnn was charged for a Level 4 emergency and lab tests. BCBST paid a negotiated rate of $1,990.63 and the Deans owed $566.33. Service Providers: Jason received care at Southern Tennessee Regional Health System-Pulaski, part of the LifePoint Health hospital chain. DeeAnn received care at Maury Regional Medical Center, a county-owned hospital in Columbia, Tennessee, about twice as far from her home as the Pulaski hospital. What Gives: The Deans were snagged by a host of major problems in American health care: very high billing, obscure pricing, high-deductible insurance plans and few options for care in rural areas. The net result could have cost DeeAnn her life. When Jason went to the only local ER for stitches, the staff assured him his insurance would cover the treatment. “I’m not versed in medical billing or medical law,” he said. “So I said, ‘Let’s go ahead and stitch it up.’” It took 30 minutes. Despite his questions about coverage, no one ever told him what he would be charged. He guessed no more than $1,000 for the 30-minute visit. Then, a few weeks later, he began receiving bills. The hospital charged a total of $4,582.77, asking him to pay $3,391.25 for his six stitches. Workers’ compensation insurance wouldn’t cover the injury because Jason was working for the company as an independent contractor. LifePoint Health, the hospital’s owner, is a large hospital chain headquartered in Nashville that specializes in rural hospital operations. The ER physicians, who sent a separate bill for $2,007 (discounted to $886.80), are part of TeamHealth, based in Knoxville. His ER visit was coded as Level 4 on the five-level scale. A Level 4 is supposed to require a detailed examination and medical history, along with decision-making of moderate complexity. Both the physicians and the hospital are part of companies recently taken over by private-equity investors. TeamHealth has been sued by the nation’s largest health insurer, UnitedHealthcare, for overusing Level 4 and Level 5 charges on bills. It’s a practice insurance companies refer to as “upcoding.” TeamHealth calls the accusation an attempt at “downcoding” a physician’s expertise. Both companies, through spokespeople, essentially said Jason’s charges are what they are. LifePoint wouldn’t discuss specifics. DeeAnn was still worried about her Maury Regional bill, especially after a battery of tests and being hooked to IV fluids. But, despite the high level of care she received and having the same high-deductible plan as her husband, she’s out only $600 — an amount she said she will gladly pay. As is so often the case with Bill of the Month sagas, the question of responsibility has all sides blaming the others. TeamHealth, the ER staffing firm, which controls billing in an estimated 17% of all emergency rooms, blames insurers for selling high-deductible plans. And patients. “Unfortunately, it is all too common that patients are not knowledgeable about their financial responsibilities under high-deductible plans,” TeamHealth spokesperson Greg Blair said in a written statement. And the high prices do come at a cost for people’s health. For 1 in 10 Americans, according to the Peterson-KFF Health System Tracker, costs cause patients to put off necessary care. Resolution: The Deans spent hours on the phone, asking the hospital and the physicians’ group to review the charges for Jason’s $1,000-per-stitch care. Both companies are sticking by the original bills. But the Deans are still fighting. DeeAnn said they regret gambling on a high-deductible plan. But the difference in monthly premiums was substantial compared with low-deductible plans, especially when they’re launching a business, and the risk seemed minimal given their lack of chronic conditions and focus on healthy living. Pulaski is lucky to still have a hospital, though. Southern states — and Tennessee especially — have seen rural hospitals close faster than anywhere else in the country. It’s a phenomenon routinely blamed on the lack of Medicaid expansion, which leaves many people uninsured. “I get it,” DeeAnn said. “But that doesn’t mean they get to take advantage of the people going through there.” The Takeaway: It is a national tragedy that many Americans avoid or defer needed medical care because of fear of costs. Still, there are steps you can take to protect yourself. Emergency rooms are expensive places, so think twice before using them — although, in many circumstances, they are the only option on nights and weekends, particularly in rural areas. Don’t be reassured by a provider’s insistence that your insurance should cover treatment. If you have a high-deductible plan, “you’re covered” doesn’t mean much because you’re responsible for — in Jason’s case — the first $8,000 in charges. Also, even if your insurer, in theory, covers your medical encounter, you may receive big bills from doctors outside your network or be required to contribute a hefty coinsurance share under the terms of your plan.                  Related Links                                                                                          How Billing Turns a Routine Birth Into a High-Cost Emergency                                                                                                                                                                  A Covid Test Costing More Than a Tesla? It Happened in Texas.                                                                                                                                                                  Jaw Surgery Takes a $27,119 Bite out of One Man’s Budget                                                                                                                                                                                                                                                    You can ask whether the self-pay cash price is an option — thereby waiving your insurance. But many facilities will require those who have insurance to use it — knowing they can bill higher prices that way. If a physician gives you the option of having a lab test, MRI or X-ray on the spot in the ER versus doing it once you’re discharged, choose the latter. Tests run while in the ER are often many times more expensive than elsewhere. After your visit, check how it was coded. If the bill says Level 4 or 5 and the visit was fairly simple, ask more questions. Here’s a handy chart with descriptions of the five CPT (current procedural terminology) codes for the levels of ER service. Finally, it’s worth knowing in advance who staffs the emergency departments of hospitals in your area, especially if you have a high-deductible plan. Are the doctors employed by the hospital or are they employed by a private-equity-owned staffing firm? The latter type of arrangement, research shows, often means high prices and more aggressive billing. Driving a few extra miles could save thousands of dollars. Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it! KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. USE OUR CONTENT This story can be republished for free (details). Subscribe to KHN's free Morning Briefing.                                   Source For more postings by Kaiser Health News, click HERE Website Do you have an exorbitant or baffling medical bill? Join the KHN and NPR ‘Bill of the Month’ Club and tell us about your experience. We’ll feature a new one each month. Bill of the Month 
0 Rating 0 Views 0 likes 0 Comments
Read more
by on November 18, 2021
                                    <h1>Public Opinion Is Unified on Lowering Drug Prices. Why Are Leaders Settling for Less?</h1> <div>    <span class="byline">Elisabeth Rosenthal</span>         <time class="posted-on" datetime="2021-11-18T05:00:00-05:00">             November 18, 2021        </time>         </div> <p>Democrats and Republicans are crystal clear in polls that they want government to be allowed to negotiate down high drug prices. Americans pay <a href="https://www.usnews.com/news/health-news/articles/2021-01-29/compared-to-other-countries-americans-pay-much-more-for-prescription-drugs">nearly three times as much for drugs</a> as patients in dozens of other countries. In the past two years, numerous <a href="https://www.healthaffairs.org/do/10.1377/hblog20190826.689286/full/">Democratic candidates</a> — including <a href="https://joebiden.com/healthcare/">President Joe Biden</a> — have campaigned on enacting such legislation.</p>    <p>This year, <a href="https://www.kff.org/health-costs/poll-finding/public-weighs-in-on-medicare-drug-negotiations/">the polling group at KFF</a> asked respondents about support for drug price negotiations after giving them the commonly offered arguments, pro and con: On the pro side, lower prices mean people can better afford their medicines; on the con side, lower profits mean the possibility of less innovation and fewer new drugs. Large majorities <a href="https://www.kff.org/health-costs/poll-finding/public-weighs-in-on-medicare-drug-negotiations/">supported the idea</a> of Medicare negotiating with pharmaceutical firms to get lower prices for both its beneficiaries and people with private insurance: 83% overall, including 95% of Democrats, 82% of independents and 71% of Republicans.</p><p>Similarly, <a href="https://www.rwjf.org/en/library/research/2021/11/healthcare-affordability--majority-of-adults-support-significant-changes-to-the-health-system.html">in recent polling funded by the Robert Wood Johnson Foundation,</a> 84% of respondents said the government should be allowed to put limits on prices for drugs that save lives and for common chronic illnesses, like diabetes. (Funding from the foundation supports KHN’s journalism.)</p><p>No wonder groups <a href="https://www.rollcall.com/2021/09/30/nonprofit-linked-to-phrma-behind-ads-opposing-drug-pricing-changes/">linked to PhRMA</a>, the pharmaceutical industry’s trade association, are blanketing the airwaves with ads featuring patients with serious illnesses <a href="https://khn.org/news/article/an-ads-charge-that-price-haggling-would-swipe-500-billion-from-medicare-is-incorrect/">who say that price negotiation would mean people would not get vital medicines</a> and could die. Voters aren’t buying it: 93% of Americans and 90% of Republicans said they believe that drugmakers would still make enough money to develop drugs if prices were lowered, the KFF poll found. (KHN is an editorially independent program of the Kaiser Family Foundation.)</p><p>With public opinion so unified in our politically divided society, why are congressional Democrats settling on a menu of weaker, halfway measures to address the problem of sky-high drug prices?</p><p><a href="https://khn.org/news/article/despite-restraints-democrats-drug-pricing-plan-could-still-aid-consumers/">The current proposal</a> on drug prices in Biden’s Build Back Better spending package with support from Congress (so far) contains strong consumer protections — such as limiting out-of-pocket prescription drug payments for Medicare beneficiaries to $2,000 annually and limiting yearly price increases, which have long outpaced inflation.</p><p>But when it comes to allowing the government to negotiate better prices, the provisions are narrow, byzantine and distant. The government would identify 100 high-cost medicines and <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2021/11/02/president-biden-announces-prescription-drug-pricing-plan-in-build-back-better-framework/">choose 10 for price negotiation annually</a>, with those prices first taking effect in 2025. It could negotiate only on medicines that had been on the market for <a href="https://endpts.com/dems-100b-deal-reduced-further-medicare-drug-price-negotiations-pushed-to-13-years-for-biologics/">at least nine to 13 years</a>, depending on the drug type.</p><p>There are many reasons the public’s strong view on this issue hasn’t translated to more forceful law.</p><p>While the idea of drug price negotiations is extremely popular, the benefits of such a program are diffuse — affecting patient pocketbooks here and there. And politicians generally don’t expect to be punished by voters for failing to deliver on this single issue.</p><p>On the other side, PhRMA regards drug price negotiation for Medicare as an existential threat to its business — potentially costing billions. It <a href="https://www.washingtonpost.com/business/2021/11/05/pharmaceutical-industry-drug-price-lobbying/">spent $23 million on lobbying</a> in the first nine months of the year, on pace to surpass the previous record.</p><p>As public support for price negotiations has gained momentum in recent years, PhRMA’s campaign donations have been <a href="https://khn.org/news/article/pharma-campaign-cash-delivered-to-key-lawmakers-with-surgical-precision/">directed with surgical precision</a> to the few sympathetic or moderate Democrats it needed on its side to prevent drug price negotiation being written into law.</p><p>Though Democratic Sen. Kyrsten Sinema of Arizona had made bringing down the cost of prescription drugs <a href="https://www.salon.com/2021/10/21/sinemas-giant-flip-flop-she-once-campaigned-on-issues-she-now-wants-dropped-from-bidens-plan/">a central campaign issue in 2018</a>, she <a href="https://www.azcentral.com/story/opinion/op-ed/laurieroberts/2021/10/28/sen-kyrsten-sinema-delivers-pharmaceutical-companies/6178914001/">helped block</a> a more ambitious House proposal <a href="https://www.washingtonpost.com/health/2021/11/03/reconciliation-drug-price-negotiation-assessment/">from moving forward</a> that would have allowed Medicare to negotiate prices of 250 drugs and extend those prices to those with other types of insurance. She did so even though <a href="https://www.azcentral.com/story/opinion/op-ed/laurieroberts/2021/10/28/sen-kyrsten-sinema-delivers-pharmaceutical-companies/6178914001/">polling in her state showed 94%</a> of Arizonans <a href="https://f.hubspotusercontent40.net/hubfs/7453540/210811_AARP/200811_AARP%20Deck_PR1.pdf?utm_medium=email&_hsmi=169717855&_hsenc=p2ANqtz--HSr-D7hHUTdxgNHJRDqbJg_oOuylIAN83va9W2XG9fNGSiPDsv7hvxlTZoanVBL7teB1AOvhgnyn3gxhrqBI_e7xkuqhu0voGT6HiQ8znByFweis&utm_content=169717855&utm_source=hs_email">support Medicare negotiating cheaper prices</a>. She received about <a href="https://khn.org/news/a-senator-from-arizona-emerges-as-a-pharma-favorite/">$100,000 in campaign contributions</a> from the industry in 2019-20, one of the leading congressional recipients.</p><p>Another hurdle is that Democrats have a thin majority in both houses of Congress and some key Democrats, such as New Jersey’s Sen. Bob Menendez and Rep. Scott Peters of San Diego, represent states or districts with many drug manufacturers. Thirteen of the world’s 20 largest manufacturers <a href="https://www.app.com/story/news/health/2021/09/16/drug-prices-menendez-vote-negotiate-medicare/8258439002/">are located in New Jersey</a>.</p><p>Menendez <a href="https://www.app.com/story/news/health/2021/09/16/drug-prices-menendez-vote-negotiate-medicare/8258439002/">had long declined</a> to say whether he supports Medicare drug price negotiation. He announced earlier this month that he would support the current limited Democratic proposal <a href="https://www.menendez.senate.gov/newsroom/press/menendez-statement-on-prescription-drugs-agreement">in a carefully worded statement</a> that avoided endorsing the practice.</p><p>Finally, the image of the pharmaceutical industry has been at least somewhat burnished by its role in developing covid-19 vaccines and drugs, an accomplishment it has deployed this fall as an argument <a href="https://www.phrma.org/resource-center/Topics/Cost-and-Value/PhRMAs-Steve-Ubl-Says-White-House-Drug-Pricing-Proposal-Not-a-Serious-Plan-to-Lower-What-Patients-Pay">to head off price limitations.</a> “The White House is trying to make it more difficult for our industry to continue the fight against this pandemic and plan for future health crises,” <a href="https://www.phrma.org/resource-center/Topics/Cost-and-Value/PhRMAs-Steve-Ubl-Says-White-House-Drug-Pricing-Proposal-Not-a-Serious-Plan-to-Lower-What-Patients-Pay">Stephen Ubl</a>, president of PhRMA, said in a September statement.</p><p>Politicians and many health experts did their best to see the glass half-full in the plan put forward by the Democrats and the president. “It’s a far cry from what they do in other industrialized countries, but it’s a pretty good first step that would have been unimaginable five years ago,” said Dr. Aaron Kesselheim, a professor at Harvard Medical School, who studies drug costs. Senate Majority Leader Chuck Schumer called it “<a href="https://www.politico.com/news/2021/11/02/dems-drug-pricing-518554">a massive step forward</a>,” though he noted in the same breath that “many of us would have wanted to go much further.”</p><p>So would most voters, public surveys show.</p><p>Instead, the plan allows the Democrats to say they kept a promise, passing drug price negotiation, however meager. And the drugmakers get a distant, narrow program that is unlikely — at least for now — to drastically affect their nice profits.</p><p><a href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p><h3>USE OUR CONTENT</h3><p>This story can be republished for free (<a href="https://khn.org/news/article/surprise-bill-travel-insurance/view/republish/">details</a>).</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1637250115199&cid=72d328fa-f8e1-4044-ab27-43920358e911&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fpublic-opinion-prescription-drug-prices-democratic-plan%2F&el=Public%20Opinion%20Is%20Unified%20on%20Lowering%20Drug%20Prices.%20Why%20Are%20Leaders%20Settling%20for%20Less%3F"/>                                Source For more postings by Kaiser Health News, click HERE Website
0 Rating 0 Views 0 likes 0 Comments
Read more
by on November 11, 2021
                                    <h1>Researcher: Medicare Advantage Plans Costing Billions More Than They Should</h1> <div>    <span class="byline">Fred Schulte, Kaiser Health News</span>         <time class="posted-on" datetime="2021-11-11T05:00:00-05:00">             November 11, 2021        </time>         </div> <p>Switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in original Medicare, a cost that has exploded since 2018 and is likely to rise even higher, new research has found.</p>    <p>Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients.</p><p>Nearly $34 billion of that new spending came during 2018 and 2019, the latest payment period available, according to Kronick. The Centers for Medicare & Medicaid Services made the 2019 billing data <a href="https://www.cms.gov/Medicare/Medicare-Advantage/Plan-Payment/Plan-Payment-Data">public</a> for the first time in late September.</p><p>“They are paying [Medicare Advantage plans] way more than they should,” said Kronick, who served as deputy assistant secretary for health policy in the Department of Health and Human Services during the Obama administration.</p><p>Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies. The health plans have <a href="https://www.ahip.org/7-things-you-need-to-know-about-medicare-advantage/">enrolled</a> nearly 27 million members, or about 45% of people eligible for Medicare, according to AHIP, an industry trade group formerly known as America’s Health Insurance Plans.</p><p>The industry argues that the plans generally offer extra benefits, such as eyeglasses and dental care, not available under original Medicare and that most seniors who join the health plans are happy they did so.</p><p>“Seniors and taxpayers alike have come to expect high-quality, high-value health coverage from MA [Medicare Advantage] plans,” said AHIP spokesperson David Allen.</p><p>Yet critics have argued for years that Medicare Advantage costs taxpayers too much. The industry also has been the target of multiple government <a href="https://www.gao.gov/products/gao-16-76">investigations</a> and Department of Justice <a href="https://www.justice.gov/usao-sdny/pr/manhattan-us-attorney-files-civil-fraud-suit-against-anthem-inc-falsely-certifying">lawsuits</a> that allege widespread billing abuse by some plans.</p><p>The payment issue has been getting a closer look as some Democrats in Congress search for ways to finance the Biden administration’s social spending agenda. Medicare Advantage plans also are scrambling to attract new members by advertising widely during the fall open-enrollment period, which ends next month.</p><p>“It’s hard to miss the big red flag that Medicare is grossly overpaying these plans when you see that beneficiaries have more than 30 plans available in their area and are being bombarded daily by TV, magazine and billboard ads,” said Cristina Boccuti, director of health policy at West Health, a group that seeks to cut health care costs and has supported Kronick’s research.</p><p>Kronick called the growth in Medicare Advantage costs a “systemic problem across the industry,” which CMS has failed to rein in. He said some plans saw “eye-popping” revenue gains, while others had more modest increases. Giant insurer UnitedHealthcare, which in 2019 had about 6 million Medicare Advantage members, received excess payments of some $6 billion, according to Kronick. The company had no comment.</p><p>“This is not small change,” said <a href="https://www.crfb.org/biography/staff/joshua-gordon">Joshua Gordon</a>, director of health policy for the Committee for a Responsible Federal Budget, a nonpartisan group. “The problem is just getting worse and worse.”</p><p>Responding to written questions, a CMS spokesperson said the agency “is committed to ensuring that payments to Medicare Advantage plans are appropriate. It is CMS’s responsibility to make sure that Medicare Advantage plans are living up to their role, and the agency will certainly hold the plans to the standards that they should meet.”</p><p>Making any cuts to Medicare Advantage payments faces stiff opposition, however.</p><p>On Oct. 15, 13 U.S. senators, including Sen. Kyrsten Sinema (D-Ariz.) sent a <a href="https://www.sinema.senate.gov/sinema-and-bipartisan-group-colleagues-commit-protecting-and-strengthening-medicare-advantage">letter</a> to CMS opposing any payment reductions, which they said “could lead to higher costs and premiums, reduce vital benefits, and undermine advances made to improve health outcomes and health equity” for people enrolled in the plans.</p><p>Much of the debate centers on the complex method used to pay the health plans.</p><p>In original Medicare, medical providers bill for each service they provide. By contrast, Medicare Advantage plans are paid using a coding formula called a “risk score” that pays higher rates for sicker patients and less for those in good health.</p><p>That means the more serious medical conditions the plans diagnose the more money they get — sometimes thousands of dollars more per patient over the course of a year with little monitoring by CMS to make sure the higher fees are justified.</p><p>Congress recognized the problem in 2005 and directed CMS to set an annual “coding intensity adjustment” to reduce Medicare Advantage risk scores and keep them more in line with original Medicare.</p><p>But since 2018, CMS has set the coding adjustment at 5.9%, the minimum amount required by law. Boccuti said that adjustment is “too low,” adding that health plans “are inventing new ways to increase their enrollees’ risk scores, which gain them higher monthly payments from Medicare.”</p><p>Some of these coding strategies have been the target of whistleblower lawsuits and government investigations that allege health plans illegally manipulated risk scores by making patients appear sicker than they were, or by billing for medical conditions patients did not have. In one recent case, the Justice Department <a href="https://www.justice.gov/opa/pr/government-intervenes-false-claims-act-lawsuits-against-kaiser-permanente-affiliates">accused</a> Kaiser Permanente health plans of obtaining about $1 billion by inflating risk scores. In a <a href="https://about.kaiserpermanente.org/our-story/news/our-perspective/2021-statement-1">statement</a>, the insurer disputed the allegations. (KHN is not affiliated with Kaiser Permanente.)</p><p>Legal or not, the rise in Medicare Advantage coding means taxpayers pay much more for similar patients who join the health plans than for those in original Medicare, according to Kronick. He said there is “little evidence” that higher payments to Medicare Advantage are justified because their enrollees are sicker than the average senior.</p><p>Kronick, who has <a href="https://publicintegrity.org/health/a-call-for-more-scrutiny-of-private-medicare-advantage-plans/">studied</a> the coding issue for years, both inside government and out, said that risk scores in 2019 were 19% higher across Medicare Advantage plans than in original Medicare. The Medicare Advantage scores rose by 4 percentage points between 2017 and 2019, faster than the average in past years, he said.</p><p>Kronick said that if CMS keeps the current coding adjustment in place, spending on Medicare Advantage will increase by $600 billion from 2023 through 2031. While some of that money would provide patients with extra health benefits, Kronick estimates that as much as two-thirds of it could be going toward profits for insurance companies.</p><p>AHIP, the industry trade group, did not respond to questions about the coding controversy. But a report prepared for AHIP <a href="https://www.ahip.org/wp-content/uploads/09222021-Final-AHIP-Memo.pdf">warned</a> in September that payments tied to risk scores are a “key component” in how health plans calculate benefits they provide and that even a slight increase in the coding adjustment would prompt plans to cut benefits or charge patients more.</p><p>That threat sounds alarms for many lawmakers, according to Kronick. “Under pressure from Congress, CMS is not doing the job it should do,” he said. “If they do what the law tells them to do, they will get yelled at loudly, and not too many people will applaud.”</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1636645080141&cid=51d4d701-a912-46b6-9ec3-4ec34fc73f4c&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fmedicare-advantage-overpayments-cost-taxpayers-billions-researcher-says%2F&el=Researcher%3A%20Medicare%20Advantage%20Plans%20Costing%20Billions%20More%20Than%20They%20Should"/>     Source                           
0 Rating 0 Views 0 likes 0 Comments
Read more
by on November 4, 2021
                                    <h1>Unvaccinated? Don’t Count on Leaving Your Family Death Benefits</h1> <div>    <span class="byline">Michelle Andrews</span>         <time class="posted-on" datetime="2021-11-03T05:00:00-04:00">             November 3, 2021        </time>         </div> <p>These days, workers who refuse to get vaccinated against covid-19 may face financial repercussions, from higher health insurance premiums to loss of their jobs. Now, the financial fallout might follow workers beyond the grave. If they die of covid and weren’t vaccinated, their families may not get death benefits they would otherwise have received.</p>    <p>New York’s Metropolitan Transportation Authority no longer pays a $500,000 death benefit to the families of subway, bus and commuter rail workers who die of covid if the workers were unvaccinated at the time of death.</p><p>“It strikes me as needlessly cruel,” said Mark DeBofsky, a lawyer at DeBofsky Sherman Casciari Reynolds in Chicago who represents workers in benefit disputes.</p><p>Other employers have similar concerns about providing death or other benefits to employees who refuse to be vaccinated.</p><p>In Massachusetts, the New Bedford City Council sought to extend accidental death benefits to city employees who died of covid, but the mayor didn’t sign that legislation because, among other things, it didn’t prohibit payment if the worker was unvaccinated.</p><p>President Joe Biden has leaned hard on businesses to make sure their workers are vaccinated. In September, the <a href="https://www.whitehouse.gov/covidplan/#vaccinate">administration announced</a> all employers with 100 or more workers would be required to either ensure they’re vaccinated or test employees every week for covid.</p><p>Among employers, “there’s a frustration level, particularly at this point when these vaccines are fully approved,” said Carol Harnett, president of the Council for Disability Awareness, an industry group. “You’re trying to protect yourselves and your employees, both from themselves and the general public.”</p><p>The New York transportation authority is the highest-profile employer to take this action. Since the pandemic crisis began in 2020, 173 MTA workers have contracted covid and died. Five of those deaths occurred after June 1 of this year, when the policy changed, according to the MTA.</p><p>“We are not aware they have been vaccinated,” an MTA spokesperson said of the five workers who died since the policy took effect.</p><p>The transit authority’s policy was a shift from an earlier pact with workers. In April 2020, as covid ravaged New York, transit officials and the labor unions representing employees reached agreements that workers who died of covid would be eligible to receive a <a href="http://www.twulocal100.org/story/families-transit-worker-heroes-killed-covid-19-receive-500000-death-benefit-payments">$500,000 lump-sum death benefit</a>, just like payments to which families of MTA workers who have other job-related deaths are entitled. The program will continue through the end of this year.</p><p>But with covid vaccines now widely available and fully approved by the Food and Drug Administration, the MTA Board determined that, starting June 1, workers who died of covid had to have been vaccinated for their families to be eligible for the payment.</p><p>The change comes as the MTA has struggled to improve vaccination rates among its roughly 67,000 workers. More than 70% of transit employees are estimated to be vaccinated, according to MTA officials.</p><p>A spokesperson for the MTA stressed that the program remains in effect, and noted that it has been extended past its original one-year term. The only change is the vaccination requirement.</p><p>“The program is not being revoked,” the MTA spokesperson said in an email. “In fact, the MTA has twice extended it.”</p><p>Local 100 of the Transport Workers Union, which represents roughly 38,000 MTA workers, pushed hard to negotiate the benefit. “No other workforce in the city, probably the country, secured what TWU secured: a $500,000 payment from the employer to the families of workers who died after getting covid,” said Pete Donohue, a union spokesperson. “We look at it that during a terrible time, we got [the benefit] for people.”</p><p>It’s not unusual for employers of workers in risky occupations — such as police, firefighters, utility company workers and transit workers, who could succumb to an industrial accident or get hit by a train on the tracks — to offer extra insurance coverage that pays if they die on the job. The coverage is often provided in addition to a regular life insurance policy.</p><p>These so-called line-of-duty or accidental death and dismemberment policies typically don’t pay out if someone dies of a disease. How can it be proved that someone picked up a deadly infection at work rather than at the supermarket?</p><p>But with covid, some front-line workers have been considered eligible for accidental death benefits because they are <a href="https://www.debofsky.com/articles/covid-brings-disability-accidental-death-coverage-questions/">presumed to have gotten sick on the job</a>, DeBofsky said.</p><p>Workers may be denied death benefits, however, if they didn’t follow established safety protocols, said John Ehrlich, the national lead consultant at Willis Towers Watson on group life insurance. Failing to wear a bulletproof vest, a helmet or other safety equipment, for example, might make their families ineligible for payment under a policy.</p><p>Now that vaccines are widely available, some employers have considered limiting other benefits paid to unvaccinated workers, including reducing short-term disability payments, said Rich Fuerstenberg, a senior partner at benefits consultant Mercer. But Fuerstenberg said he had not heard of other employers eliminating death benefits for unvaccinated workers.</p><p>In the New Bedford case, the City Council unanimously passed a petition in August stating the covid death of any city employee would be considered to have occurred in the line of duty, enabling family members to receive accidental death benefits.</p><p>Mayor Jon Mitchell, however, objected for several reasons — the question of vaccination among them.</p><p>“As I am certain the Council would agree, it would be inappropriate to extend accidental death benefits where the employee refused to take a vaccine that had been found to be nearly 100% effective,” Mitchell said in a letter to the council. The proposal has been tabled for further negotiation, according to a spokesperson for the mayor.</p><p>For more than 17 years, Joseph Fletcher worked for the MTA in Brooklyn, doing body work and other maintenance on buses.</p><p>When he <a href="http://www.twulocal100.org/story/flatbush-bus-maintainer-joseph-fletcher-dies-virus">died of covid</a> on April 11, 2020, at age 60, he left behind his wife, Veronica, a former high school teacher who was disabled after a car accident, and three children, now 9, 13 and 16.</p><p>Coping with his death was hard enough, but looking toward the future has been overwhelming, Veronica said.</p><p>“How am I going to keep afloat financially?” she worried. “Everything about this journey is terrifying.”</p><p>The $500,000 death benefit helped cover the family’s regular bills and pay the mortgage on their Brooklyn home. But she’s aware it will go only so far, and her three children need to go to college.</p><p>If the MTA vaccination requirement had been in place when her husband died, it wouldn’t have been a problem, Fletcher said.</p><p>“I wish that my husband were able to have been vaccinated,” she said. “Knowing my late husband, he would have taken the opportunity to protect himself and his family.”</p><p><a href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p><h3>USE OUR CONTENT</h3><p>This story can be republished for free (<a href="https://khn.org/news/article/new-health-plans-offer-twists-on-existing-options-with-a-dose-of-buyer-beware/view/republish/">details</a>).</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1636038065066&cid=cb6c66e2-5475-4adc-bd45-20c652871f2e&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Funvaccinated-workers-death-benefits%2F&el=Unvaccinated%3F%20Don%E2%80%99t%20Count%20on%20Leaving%20Your%20Family%20Death%20Benefits"/>             For more postings by Kaiser Health News, click Here                   Source Website
0 Rating 0 Views 0 likes 0 Comments
Read more
by on October 28, 2021
                                    <h1>How Billing Turns a Routine Birth Into a High-Cost Emergency</h1> <div>    <span class="byline">Rae Ellen Bichell</span>         <time class="posted-on" datetime="2021-10-27T05:00:00-04:00">             October 27, 2021        </time>         </div> <p>Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn’t prepare her for the resources the conservation biologist would owe after the birth of her second son.</p>    <p>Wells Salerno went into labor on the eve of her due date, in the early weeks of coronavirus lockdowns in April 2020. She and her husband, Jon Salerno, were instructed to go through the emergency room doors at Poudre Valley Hospital in Fort Collins, Colorado, because it was the only entrance open.</p><p>Despite the weird covid vibe — the emptiness, the quiet — everything went smoothly. Wells Salerno felt well enough to decline the help of a nurse offering to wheel her to the labor and delivery department. She even took a selfie, smiling, as she entered the delivery room.</p><p>“I was just thrilled that he was here and it was on his due date, so we didn’t have to have an induction,” she said. “I was doing great.”</p><p>Gus was born a healthy 10 pounds after about nine hours of labor, and the family went home the next morning.</p><p>Wells Salerno expected the bill for Gus’ birth to be heftier than that for her first child, Hank, which had cost the family a mere $30. She was a postdoctoral fellow in California with top-notch insurance when Hank was born, about four years earlier. They were braced to pay more for Gus, but how much more?</p><p>Then the bill came.</p><p><strong>The Patient:</strong> Caitlin Wells Salerno, a conservation biologist at Colorado State University and a principal investigator at Rocky Mountain Biological Laboratory. She is insured by Anthem Blue Cross Blue Shield through her job.</p><p><strong>Medical Service:</strong> A routine vaginal delivery of a full-term infant.</p><p><strong>Total Bill: </strong>$16,221.26. The Anthem BCBS negotiated rate was $14,550. Insurance paid $10,940.91 and the family paid the remaining $3,609.09 to the hospital.</p><p><strong>Service Provider:</strong> <a href="https://www.uchealth.org/locations/uchealth-poudre-valley-hospital/">Poudre Valley Hospital</a> in Fort Collins, Colorado, operated by UCHealth, a <a href="https://www.uchealth.org/give-to-uchealth/#:~:text=UCHealth%20is%20a%20not%2Dfor,health%20care%20professionals%2C%20and%20research.">nonprofit</a> health system.</p><p><strong>What Gives:</strong> In a system that has evolved to bill for anything and everything, a quick exam to evaluate labor in a small triage room can generate substantial charges.</p><p>The total bill was huge, but what really made Wells Salerno’s eyes pop was a line for the highest level of emergency services. It didn’t make any sense. Was it for checking in at the ER desk, as she’d been instructed to? She recalls going through security there on her way to labor and delivery, yet there was a $2,755 charge for “Level 5” emergency department services — as if she had received care there like a patient with a heart attack or fresh from a car wreck. It is the biggest item on the bill other than the delivery itself.</p><p><a href="https://profiles.ucsf.edu/renee.hsia">Dr. Renee Hsia</a>, a professor of emergency medicine and health policy at the University of California-San Francisco and a practicing ER doctor, said Level 5 charges are supposed to be reserved for serious cases — “a severe threat to life, or very complicated, resource-intense cases” — not for patients who can walk through a hospital on their own. Emergency room visits are coded from Level 1 to Level 5, with each higher level garnering more generous reimbursement, in theory commensurate with the work required.</p><p>But over the past 20 years, hospitals and doctors have learned there’s <a href="https://publicintegrity.org/health/how-doctors-and-hospitals-have-collected-billions-in-questionable-medicare-fees/">great profit in upcoding</a> visits. After all, the insurer isn’t in the exam room to know what transpired. An <a href="https://publicintegrity.org/health/hospitals-grab-at-least-1-billion-in-extra-fees-for-emergency-room-visits/">investigation by the Center for Public Integrity</a> found that between 2001 and 2008 the number of Level 4 and 5 visits for patients who were sent homefrom the ER nearly doubled to almost 50% of visits. In Colorado, the Center for Improving Value in Health Care looked at emergency visit billing from 2009 to 2016 and found that the percentage of emergency visits coded as Level 5 <a href="https://civhc.org/wp-content/uploads/2017/07/Data-Byte-ED-Severity-Level-Trends-by-LOB-April-2017.pdf">steadily grew from 23% to 34%</a> for patients with commercial insurance.</p><p>After repeated calls questioning the line item on her bill, Wells Salerno eventually got a voicemail from the billing department, which she shared with KHN, explaining that “the emergency room charge is actually the OB triage little area before they take you to the labor and delivery room.” </p><p>A customer service representative later explained it was for services given there when a nurse placed an IV for antibiotics, and her doctor checked her dilation and confirmed her water had broken — although none of that was performed in the Emergency Department. And those services, performed before every delivery, are traditionally not billed separately — and are routine, not emergency, procedures.</p><p>Some hospitals provide that package of services via an “obstetrical emergency department.” OB-EDs are licensed under the main Emergency Department and typically see patients who are pregnant, for anything from unexplained bleeding to full-term birth. They bill like an ER, even if they aren’t physically located anywhere near the ER.</p><p>Health care staffing company TeamHealth — owned by the investment company Blackstone, and known for <a href="https://www.propublica.org/article/how-rich-investors-not-doctors-profit-from-marking-up-er-bills">marking up ER bills to boost profit</a> — essentially says an OB-ED can be as simple as a rebranded obstetrical triage area. In a <a href="https://www.documentcloud.org/documents/21089863-white-paper-obed-new-innovations-in-womens-care">white paper</a>, the company said an OB-ED is an “entrepreneurial approach to strengthening hospital finances” because with “little to no structural investment” it allows hospitals to “collect facility charges that are otherwise lost in the obstetrical triage setting.”</p><p>The OB Hospitalist Group, which is owned by a <a href="https://www.kohlberg.com/investments/">private equity company</a>, markets a tool to help OB-EDs calculate levels of emergency care. In a case study, OB Hospitalist Group reported that hospitals “<a href="https://www.documentcloud.org/documents/21089862-obhg-case-study-facility-fee_downloaded-oct-19-2021">leave a lot of money on the table</a>” by billing OB-ED visits as Level 1 and 2 emergencies when they could be considered Level 4 emergencies.</p><p>An Arizona facility <a href="https://www.documentcloud.org/documents/21089861-arizona-poster_downloaded-oct-14-2021">said its revenue increased</a> $365,000 per quarter after turning their obstetric triage area into an OB-ED. Poudre Valley <a href="https://www.uchealth.org/locations/uchealth-poudre-valley-hospital/">Hospital’s website</a> doesn’t list “OB-ED” as part of the facility’s offerings, though UCHealth documents do reference OB-ED beds in other facilities.</p><p>KHN spoke with four other women who, after giving birth at Poudre Valley in 2020 and 2021, received ER charges on their bills after healthy births. They had no clue they had received emergency services. One wrote a warning note on Facebook to other area moms after getting a whopping charge — for the 10 minutes she spent in the triage room, while fully dilated and in active labor.</p><p>In Wells Salerno’s case, UCHealth and her insurer have an agreement that Anthem BCBS pays a lump sum for vaginal delivery, rather than paying for line items individually. “Being seen there in OB-ED did not impact this bill whatsoever,” said Dan Weaver, a spokesperson with UCHealth.</p><p>But in one of the other moms’ cases, it did: The hospital received $1,500 from the insurer for that charge, and the mom was on the hook for an additional $375 for coinsurance.</p>        <h4>        Related Links    </h4>            <ul><li>                    <a href="https://khn.org/news/article/pricey-covid-test-costs-more-than-tesla-surprise-billing-texas/">                                                    A Covid Test Costing More Than a Tesla? It Happened in Texas.                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/surprise-medical-bill-jaw-surgery-takes-bite-out-of-budget/">                                                    Jaw Surgery Takes a $27,119 Bite out of One Man’s Budget                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/olympic-dream-dashed-after-bike-crash-and-nightmare-medical-bill-over-200k/">                                                    Olympic Dream Dashed After Bike Crash and Nightmare Medical Bill Over $200K                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/surprise-bill-iv-push-hospital-unbundling/">                                                    A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.                                            </a>                </li>                    </ul><p><a href="https://carey.jhu.edu/faculty/faculty-directory/ge-bai-phd">Ge Bai</a>, a professor of accounting and health policy at Johns Hopkins University, said it’s a “questionable” billing practice, and one that can matter to those who don’t have the same <a href="https://www.verywellhealth.com/how-does-a-drg-determine-how-much-a-hospital-gets-paid-1738874">kind of insurance</a> as Wells Salerno, or have none at all.</p><p>Dr. Mark Simon, chief medical officer with OB Hospitalist Group, said OB-EDs can help women avoid being admitted to the hospital too early in labor, ensuring timelier, more appropriate care.</p><p>UCHealth’s Weaver said they can also help pregnant patients with actual emergencies like preterm labor, preeclampsia or vaginal bleeding get quick care from specialists available 24/7, often without having to be admitted to the hospital. But at hospitals like Poudre Valley, healthy women having healthy births also get routine “OB-ED” treatment, without their knowledge.</p><p>Weaver said the only time someone in labor would not go through the OB-ED — and therefore the only time they would not receive the emergency charge — is if they have a scheduled induction or cesarean section or are directly admitted from a provider’s office.</p><p>Hsia, the UCSF researcher and ER doctor, is unconvinced: “If they’re actually going to charge a special fee that you didn’t get directly admitted from your physician, that’s absolutely ridiculous.”</p><p>Wells Salerno’s “OB-ED” exam was performed by her clinician, but the OB-ED charge still showed up on her bill.</p><p><strong>Resolution:</strong> After trying to determine that the charge wasn’t a mistake, Wells Salerno eventually threw in the towel and paid the bill.</p><p>“I was at a very vulnerable time during pregnancy and immediately postpartum,” she said. “I just felt like I had kind of been taken advantage of financially at a time when I couldn’t muster the energy to fight back.”</p><p>The fact that two healthy brothers could come with such different price tags isn’t surprising to <a href="https://chrt.org/bio/michelle-moniz-m-d-ms-c-facog/">Dr. Michelle Moniz</a>. “There is no clinical reason that we have this level of variation,” said Moniz, assistant professor of obstetrics and gynecology at the University of Michigan and its Institute for Healthcare Policy and Innovation. Her <a href="https://pediatrics.aappublications.org/content/148/1/e2021050552">research shows</a> that people with private insurance pay anywhere from nothing to $10,000 for childbirth.</p><p>“You don’t get what you pay for,” said Wells Salerno, who maintains that — despite their price difference — both of her children are equally “awesome.”</p><p>Data from the Colorado Division of Insurance <a href="https://doi.colorado.gov/colorado-hospital-price-report">shows</a> that Poudre Valley typically received about $12,000 for similar births in 2020, about 43% more than the typical Colorado hospital. So the more than $14,000 Wells Salerno and her insurer paid is very high.</p><p><strong>The Takeaway:</strong> Anything in our health system labeled as an emergency room service likely comes with a big additional charge.</p>    <p>Expectant parents should be aware that OB-EDs are a relatively new feature at some hospitals. Ask whether your hospital has that kind of charge and how it will affect your bill. Ahead of time, ask both the hospital and your insurer how much the birth is expected to cost. In Colorado, the Center for Improving Value in Health Care offers a <a href="http://www.civhc.org/shop-for-care/">price comparison tool</a> for common medical procedures, including vaginal delivery.</p><p>If you do require a genuine ER encounter, look at your bill to see how it was coded, Levels 1 to 5 — and protest if your visit was misrepresented. Ask, “Has this bill been upcoded?” You are the only one who knows how much time you spent with a medical provider and how much care was given. Here’s <a href="https://www.bcbsnd.com/providers/policies-precertification/reimbursement-policy/coding-and-billing-guidelines-for-emergency-department">a chart</a> that will help with the proper definition of each level.</p><p>Know that victory is possible. At least one mom won the battle and got the emergency charge removed from her Poudre Valley Hospital birth bill. It took hours on the phone with UCHealth, a lot of confidence and countless repetitions of the birth story — and how an emergency charge for a routine delivery just didn’t, and doesn’t, make sense.</p><p><em>Bill of the Month is a crowdsourced investigation by <a href="https://khn.org/news/tag/bill-of-the-month/">KHN</a> and <a href="https://www.npr.org/sections/health-shots/2018/02/16/585549568/share-your-medical-bill-with-us">NPR</a> that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? <a href="https://khn.org/send-us-your-medical-bills/">Tell us about it</a>!</em></p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1635434886812&cid=83994b65-7d2c-40c5-b582-f7a7ee41e7e1&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fhow-billing-turns-a-routine-birth-into-a-high-cost-emergency%2F&el=How%20Billing%20Turns%20a%20Routine%20Birth%20Into%20a%20High-Cost%20Emergency"/>                  Source          For more postings by Kaiser Health News, click Here Website:  https://khn.org/ Do you have an exorbitant or baffling medical bill? Join the KHN and NPR ‘Bill of the Month’ Club and tell us about your experience. We’ll feature a new one each month. Bill of the Month                
0 Rating 0 Views 0 likes 0 Comments
Read more
by on October 26, 2021
                                    <h1>Analysis: A Procedure That Cost $1,775 in New York Was $350 in Maryland. Here’s Why.</h1> <div>    <span class="byline">Elisabeth Rosenthal</span>         <time class="posted-on" datetime="2021-10-26T05:00:00-04:00">             October 26, 2021        </time>         </div> <p>For the past 18 months, while I was undergoing intensive physical therapy and many neurological tests after a complicated head injury, my friends would point to a silver lining: “Now you’ll be able to write about your own bills.” After all, I’d spent the past decade as a journalist covering the often-bankrupting cost of U.S. medical care.</p>    <p>But my bills were, in fact, mostly totally reasonable.</p><p>That’s largely because I live in Washington, D.C., and received the majority of my care in next-door Maryland, <a href="https://www.healthcarevaluehub.org/advocate-resources/publications/hospital-rate-setting-promising-challenging-replicate">the one state</a> in the nation that controls what hospitals can charge for services and has a cap on spending growth.</p><p>Players in the health care world — from hospitals to pharmaceutical manufacturers to doctors’ <a href="https://www.axios.com/why-the-ama-doesnt-support-federal-drug-price-controls-1513305977-18f6ace5-9d10-4caf-b1fc-4a8099a1f458.html">groups</a> — act as if the sky would fall if health care prices were regulated or spending capped. Instead, health care prices are determined by a dysfunctional market in which providers charge whatever they want and insurers or middlemen like pharmacy benefit managers negotiate them down to slightly less stratospheric levels.</p><p>But for decades, an independent <a href="https://hscrc.maryland.gov/Pages/About-Us.aspx">state commission</a> of health care experts in Maryland, appointed by the governor, has effectively told hospitals what each of them may charge, with a bit of leeway, requiring every insurer to reimburse a hospital at the same rate for a medical intervention in a system called “all-payer rate setting.” In 2014, Maryland also instituted a global cap and <a href="https://www.npr.org/sections/health-shots/2015/10/23/451212483/in-maryland-a-change-in-how-hospitals-are-paid-boosts-public-health">budget for each hospital </a>in the state. Rather than being paid per test and procedure, hospitals would get a set amount of money for the entire year for patient care. The per capita hospital cost <a href="https://www.nejm.org/doi/full/10.1056/nejmp1314868">could rise only a small amount annually</a>, forcing price increases to be circumspect.</p><p>If the care in the Baltimore-based Johns Hopkins Medicine system ensured my recovery, Maryland’s financial guardrails for hospitals effectively protected my wallet.</p><p>During my months of treatment, I got a second opinion at a similarly prestigious hospital in New York, giving me the opportunity to see how medical centers without such financial constraints bill for similar kinds of services.</p><p>Visits at Johns Hopkins with a top neurologist were billed at $350 to $400, which was reasonable, and arguably a bargain. In New York, the same type of appointment was $1,775. My first spinal tap, at Johns Hopkins, was done in an exam room by a neurology fellow and billed as an office visit. The second hospital had spinal taps done in a procedure suite under ultrasound guidance by neuroradiologists. It was billed as “surgery,” for a price of $6,244.38. The physician charge was $3,782.</p><p>I got terrific care at both hospitals, and the doctors who provided my care did not set these prices. All the charges were reduced after insurance negotiations, and I generally owed very little. But since the price charged is often the starting point, hospitals that charge a lot get a lot, adding to America’s sky-high health care costs and our rising insurance premiums to cover them.</p><p>It wasn’t easy for Maryland to enact its unique health care system. The state imposed rate setting in the mid-1970s because hospital charges per patient were rising fast, and the system was in financial trouble. Hospitals supported the deal — which required a federal waiver to experiment with the new system — because even though the hospitals could no longer bill high rates for patients with commercial insurance, the state guaranteed they would get a reasonable, consistent rate for all their services, regardless of insurer.</p><p>The rate was more generous than Medicare’s usual payment, which (in theory at least) is calculated to allow hospitals to deliver high-quality care. The hospitals also got funds for teaching doctors in training and taking care of the uninsured — services that could previously go uncompensated.</p><p>In subsequent decades, however, hospitals did end runs around price controls by simply <a href="https://www.nytimes.com/2013/08/28/business/economy/lessons-in-maryland-for-costs-at-hospitals.html?searchResultPosition=">ordering more</a> hospital visits and tests. Spending was growing. Maryland risked losing the federal waiver that had long underpinned its system. Also, under the waiver’s terms, Maryland’s hospitals were at risk for paying a hefty penalty to the federal government for the excessive growth in cost per patient.</p><p>That’s why in 2014 the state worked with the federal Centers for Medicare & Medicaid Services to institute the global cap and budget system in place today. Dr. Joshua Sharfstein, who was the state’s health and mental hygiene secretary, met skeptical hospital administrators to “sell the concept,” as he described it, assuring them the hospitals would still get reasonable revenue while gaining new opportunities to improve the health of their communities with money to invest in preventive services.</p><p>Studies show the program, which was further revised in 2019, generally <a href="https://pubmed.ncbi.nlm.nih.gov/30994523/,">worked</a> at keeping costs down and generated savings of<a href="https://innovation.cms.gov/data-and-reports/2021/md-tcoc-imp-eval-report"> $365 million</a> for Medicare in 2019 and over $1 billion in the prior four years. What’s more, working with a fixed budget has provided incentives for hospitals to keep patients out, resulting in programs like better outpatient <a href="https://www.healthaffairs.org/do/10.1377/hblog20170131.058550/full/">efforts to manage chronic illnesses</a> and putting <a href="https://www.modernhealthcare.com/article/20141206/MAGAZINE/312069983/global-budgets-pushing-maryland-hospitals-to-target-population-health">doctors in senior housing</a> to keep residents out of hospitals through on-site care.</p><p>Instituting this type of plan may be politically unacceptable statewide in other places today, given the much greater power now of hospital trade groups and large consolidated hospital networks. “Where hospitals are making money hand over fist, it’s a hard sell to switch,” Sharfstein said. “But where hospitals are facing economic pressure, there is much more openness to financial stability and the opportunity to promote community health.”</p><p>Sharfstein thinks the Maryland approach can be especially attractive for financially strapped rural and urban hospitals that treat mostly people on Medicaid and the uninsured.</p><p>Though Maryland is an oddity in the United States (the few other states that tried price controls in the 1970s <a href="https://www.nashp.org/wp-content/uploads/sites/default/files/1995.May_.decline.state_.based_.hospital.rate_.setting.pdf">abandoned the experiment</a> <a href="https://www.urban.org/urban-wire/promise-and-performance-all-payer-rate-setting-just-what-doctor-ordered">long ago</a>), <a href="https://www.oecd.org/health/health-systems/OECD-WHO-Price-Setting-Summary-Report.pdf">many countries successfully use price guidelines</a> and budget limits to control medical spending. Notable among them is Germany, whose health system is otherwise similar to the United States’, with multiple insurers. <a href="https://www.ncbi.nlm.nih.gov/books/NBK231470/">A landmark 1994</a> <a href="https://www.nap.edu/catalog/9218/changing-the-health-care-system-models-from-here-and-abroad#toc">study</a> comparing efforts here and abroad did find that the German system, for example, can be stingier at providing care that is expensive or elective.</p><p>But, referring in part to that issue, the study’s author concluded that costs are so high in the United States that the country “could probably lower our expenditures and see none of the problems that we found in our study for a number of years.”</p><p>Data also shows that operating margins, a measure of profit, are generally slimmer in Maryland than those of big health systems in the rest of the country. Johns Hopkins’ margin was 1.2% in fiscal year 2019, compared with 6.9% at the Mayo Clinic in Minnesota and 5.8% at the University of Pennsylvania Health System; Stanford Health Care’s was 7.1%.</p><p>But those margins can also reflect how much of its income a hospital chooses to spend on things like amenities and executive pay. Living with financial constraints may be at least partly why Johns Hopkins Hospital’s main entrance is pleasant but functional, lacking the elegant art-filled marble lobbies I often encounter at its peer hospitals.</p><p>My experience demonstrates that excellent care can be delivered to patients by a system that works within financial limits. And that’s something America needs.</p><p><a href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p><h3>USE OUR CONTENT</h3><p>This story can be republished for free (<a href="https://khn.org/news/article/understaffed-state-psychiatric-facilities-leave-mental-health-patients-in-limbo/view/republish/">details</a>).</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1635262238877&cid=be9fdc25-4342-49ac-a124-596c93e2384b&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fanalysis-a-procedure-that-cost-1775-in-new-york-was-350-in-maryland-heres-why%2F&el=Analysis%3A%20A%20Procedure%20That%20Cost%20%241%2C775%20in%20New%20York%20Was%20%24350%20in%20Maryland.%20Here%E2%80%99s%20Why."/>                                Source            For more postings by Kaiser Health News, click Here Website:  https://khn.org/
0 Rating 0 Views 0 likes 0 Comments
Read more
by on October 15, 2021
                                    <h1>How to Crush Medical Debt: 5 Tips for Using Hospital Charity Care</h1> <div>    <span class="byline">Emily Pisacreta</span>         <time class="posted-on" datetime="2021-10-15T05:00:00-04:00">             October 15, 2021        </time>         </div> <p>What if a law passed but no one enforced it? That’s essentially what has happened with one small but helpful rule about hospitals and financial assistance for medical bills.</p><p>The Affordable Care Act, the health law also known as Obamacare, requires nonprofit hospitals to make financial assistance available to low-income patients and post those policies online. Across the U.S., <a href="https://www.kff.org/other/state-indicator/hospitals-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">more than half of hospitals are nonprofit </a>— and in some states all or nearly all hospitals are nonprofit. But many people who qualify for financial assistance — or “charity care,” as it is sometimes known — never apply.</p><p>Jared Walker is helping get the word out. He founded <a href="https://dollarfor.org/">Dollar For</a>, an organization that directly helps people use hospital financial assistance policies to overcome unaffordable medical bills. Walker earned the public’s attention early this year through a viral TikTok he made on a lark, late one night.</p><p>In the <a href="https://www.tiktok.com/@dollarfor/video/6972020772843965702?is_copy_url=1&is_from_webapp=v1">60-second video</a>, Walker outlines the basics of applying for hospital financial assistance, in response to a prompt that asks TikTokers to share “something you’ve learned that feels illegal to know.”</p><p>“Most hospitals in America are nonprofits, which means they have to have financial assistance or charity care policies,” he says in the video. “This is going to sound weird, but what that means is if you make under a certain amount of money the hospital legally has to forgive your medical bills.”</p><p>The video outlines the basics of applying for hospital charity care, which he says he uses to “crush” medical bills.</p><p>“<a href="https://armandalegshow.com/">An Arm and a Leg</a>,” a podcast about the cost of health care, has been covering Walker and his <a href="https://armandalegshow.com/episode/wait-that-was-legal/">organization’s work</a> since the video’s viral moment, as well as the decades-long fight to establish charity care rules that preceded it.</p><p>Here are five strategies Walker endorses and shares during monthly volunteer training sessions:</p><p><strong>1. How do you find the policy?</strong></p><p>Walker’s trick for finding a hospital’s financial assistance policy is as straightforward as it gets: Google it. Enter the hospital’s name, followed by “financial assistance policy” or “charity care policy.” The first search results are likely to be an outline of the policy and an application to submit.</p><p>Your first instinct might be to go to your hospital’s home page. But that’s likely a mistake. Policies tend to be hidden from hospital website menus, according to Walker. In many states, charity care laws are more specific than what’s outlined in the ACA, and hospitals may be required to display their financial assistance policies prominently.</p><p>It’s rare for the policies not to be available online at all, but in some cases, Walker said, you may need to call the hospital and ask for an application.</p><p /><p><strong>2. Who qualifies?</strong></p><p>Most hospital charity care policies are income-based, using percentages of the <a href="https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines">federal poverty guidelines</a> to define eligibility. In an example, Walker showed the guidelines for <a href="https://www.saintlukeskc.org/locations/saint-lukes-hospital-kansas-city">St. Luke’s Hospital of Kansas City</a>, where patients earning 200% of the federal poverty guidelines were responsible for 0% of their bill. That figure was just over $2,000 a month in 2021. Those making 201% to 300% were eligible for certain discounts.</p><p>Not sure how your income compares to the federal poverty guidelines? <a href="https://home.mycoverageplan.com/fpl.html">Here’s one of many helpful online calculators.</a> Remember, your household is you, plus your spouse, plus anyone you claim as a dependent on your taxes. Roommates don’t count.</p><p>Applications typically require documentation to prove your income. Hospitals ask for things like recent pay stubs, proof of unemployment, Social Security award letters and tax returns, according to Walker. Exactly which documents the hospital may ask for can vary. But a hospital can’t deny you for failing to provide a document that isn’t spelled out in the application.</p><p><strong>3. In collections? You may still have time.</strong></p><p>The <a href="https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6">IRS</a> requires nonprofit hospitals to give patients a grace period of 240 days (about eight months) from the initial billing date to apply for financial assistance. But hospitals are allowed to send bills to collection agencies much earlier than that — often after just 120 days.</p><p>At that point, patients often feel as though they’re being hounded by notifications from collection agencies. Still, patients may have months remaining to apply for financial assistance, and alerting the collection agents that an application with the hospital is in process can sometimes stop the letters.</p><p>“The hospital can take you out of collections just as easily as they put you there,” Walker said.</p><p>In some cases, hospitals will forgive bills that are much older than 240 days. When in doubt, applying may be worth it even for bills that are several years old, Walker said. It does not hurt to ask for help.</p><p><strong>4. Looks like you won’t qualify? Write a letter.</strong></p><p>If you don’t qualify on income alone but you still can’t afford your hospital bills, don’t rule yourself out. The same applies if the hospital’s financial aid policy specifies that only uninsured people qualify; you might have insurance but are still looking at giant bills you can’t pay.</p><p>Walker said a letter of financial hardship attached to an application can help. In fact, he encourages each patient to attach a letter, no matter how strong their application seems.</p><p>“These are real people reading these and the letters go a long way,” he said. Ultimately, each hospital is making a judgment call about who gets the assistance it is legally obligated to provide. Make your case.</p><p><strong>5. Yes, you may need to fax it in.</strong></p><p>While many hospitals have digital portals to enable online bill-paying, there’s usually no equivalent for applying for financial assistance. Many applications offer only a mailing address. But Walker and his team have found that applications sent by mail frequently get lost.</p><p>Instead, they recommend either walking the application into the hospital and delivering it by hand or faxing it. Public libraries, packaging stores like FedEx and certain online services make faxing possible even if, like most people, you haven’t used a fax machine since the late 1990s.</p><p>When it comes to accessing charity care, “you’re gonna have to jump through a lot of hoops,” Walker said, “but it’s worth it.”</p><p><em>Emily Pisacreta is a reporter and producer with “</em><a href="https://armandalegshow.com/"><em>An Arm and a Leg</em></a><em>,” a podcast about the cost of health care that is co-produced with KHN.</em></p><p><a href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p><h3>USE OUR CONTENT</h3><p>This story can be republished for free (<a href="https://khn.org/news/article/virtual-first-insurance-plans-telemedicine/view/republish/">details</a>).</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1634315663021&cid=f5e355d3-3f3b-418d-8ee8-acb8ca2b6213&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fhow-to-crush-medical-debt-5-tips-for-using-hospital-charity-care%2F&el=How%20to%20Crush%20Medical%20Debt%3A%205%20Tips%20for%20Using%20Hospital%20Charity%20Care"/>          Source For more postings by Kaiser Health News, click Here Website:  https://khn.org/                       
0 Rating 0 Views 0 likes 0 Comments
Read more
by on October 11, 2021
                                    <h1>Look Up Your Hospital: Is It Being Penalized By Medicare?</h1> <div>    <span class="byline">Jordan Rau, Kaiser Health News</span>     <time class="posted-on" datetime="2021-02-18T05:00:40-05:00">         February 18, 2021    </time>     </div> <p>Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the <a href="https://khn.org/news/medicare-eases-readmissions-penalties-against-safety-net-hospitals/">readmission penalties</a>, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The <a href="https://khn.org/news/medicare-trims-payments-to-800-hospitals-citing-patient-safety-incidents">patient safety penalties</a> cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.</p><p>Below are look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year.</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1633970459880&cid=2da0b915-d0dc-40ac-950e-6f73f614b456&ea=https%3A%2F%2Fkhn.org%2Fnews%2Fhospital-penalties%2F&el=Look%20Up%20Your%20Hospital%3A%20Is%20It%20Being%20Penalized%20By%20Medicare%3F"/>              For more postings by Kaiser Health News, click Here Website:  https://khn.org/                
0 Rating 0 Views 0 likes 0 Comments
Read more
by on October 1, 2021
                                    <h1>A Covid Test Costing More Than a Tesla? It Happened in Texas.</h1> <div>    <span class="byline">Aneri Pattani</span>     <time class="posted-on" datetime="2021-09-30T05:00:00-04:00">         September 30, 2021    </time>     </div> <p>When covid-19 struck last year, Travis Warner’s company became busier than ever. He installs internet and video systems, and with people suddenly working from home, service calls surged.</p>    <p>He and his employees took precautions like wearing masks and physically distancing, but visiting clients’ homes daily meant a high risk of covid exposure.</p><p>“It was just like dodging bullets every week,” Warner said.</p><p>In June 2020, an employee tested positive. That sent Warner and his wife on their own hunt for a test.</p><p>Because of limited testing availability at the time, they drove 30 minutes from their home in Dallas to a free-standing emergency room in Lewisville, Texas. They received PCR diagnostic tests and rapid antigen tests.</p><p>When all their results came back negative, it was a huge relief, Warner said. He eagerly got back to work.</p><p>Then the bill came.</p><p><strong>The Patient:</strong> Travis Warner, 36, is self-employed and bought coverage from Molina Healthcare off the insurance marketplace.</p><p><strong>Medical Service: </strong>Two <a href="https://www.npr.org/sections/health-shots/2020/05/01/847368012/how-reliable-are-covid-19-tests-depends-which-one-you-mean">covid tests</a>: a diagnostic <a href="https://www.genome.gov/genetics-glossary/Polymerase-Chain-Reaction">PCR</a> test, which typically takes a few days to process and is quite accurate, and a rapid antigen test, which is less accurate but produces results in minutes.</p><p><strong>Total Bill:</strong> $56,384, including $54,000 for the PCR test and the balance for the antigen test and an ER facility fee. Molina’s negotiated rate for both tests and the facility fee totaled $16,915.20, which the insurer paid in full.</p><p><strong>Service Provider:</strong> SignatureCare Emergency Center in Lewisville, one of more than a dozen free-standing ERs the company owns across Texas.</p><p><strong>What Gives:</strong> Throughout the pandemic, <a href="https://www.nytimes.com/2020/06/16/upshot/coronavirus-test-cost-varies-widely.html">stories of shockingly high prices</a> for covid tests have abounded. A <a href="https://www.ahip.org/covid-19-test-prices/?_zs=mdLtl&_zl=U88x1">recent report from an insurance trade association</a> noted that “price gouging by certain providers continues to be a widespread problem.”</p><p>But Warner’s PCR bill of $54,000 is nearly eight times the most notable charge previously reported, at $7,000 — and his insurer paid more than double that highest reported charge. Health policy experts KHN interviewed called Warner’s bill “astronomical” and “one of the most egregious” they’d seen.</p><p>Yet it’s perfectly legal. For covid tests — like much else in American health care — there is no cap to what providers can charge, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.</p><p>Covid testing has been in a special category, however. When the pandemic hit, lawmakers worried people might avoid necessary testing for fear of the cost. So they passed bills that <a href="https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/for-patients/index.html">required insurers to pay for covid tests</a> without copays or cost sharing for the patient.</p><p>For in-network providers, insurers can negotiate prices for the tests, and for out-of-network providers, they’re generally required to pay whatever price the providers list publicly on their websites. The free-standing ER was out of network for Warner’s plan.</p><p>While the policy was intended to help patients, health experts say, it has <a href="https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/04/09/how-the-cares-act-affects-covid-19-test-pricing/">unintentionally given providers leeway</a> to charge arbitrary, sometimes absurd prices, knowing that insurers are required to pay and that patients, who won’t be billed, are unlikely to complain.</p><p>“People are going to charge what they think they can get away with,” said Niall Brennan, president and CEO of the Health Care Cost Institute, a nonprofit that studies health care prices. “Even a perfectly well-intentioned provision like this can be hijacked by certain unscrupulous providers for nefarious purposes.”</p><p>A <a href="https://www.healthsystemtracker.org/brief/covid-19-test-prices-and-payment-policy/">report from KFF</a> published earlier this year found that hospital charges for covid tests ranged from $20 to $1,419, not including physician or facility fees, which can often be <a href="https://www.propublica.org/article/how-a-covid-19-test-led-to-charges">higher than the cost of the tests themselves</a>. About half the test charges were below $200, the report noted, but 1 in 5 were over $300.</p><p>“We observed a broad range of COVID-19 testing prices, even within the same hospital system,” the authors wrote.</p><p>Realistically, the cost of a covid test should be in the double digits, Brennan said. “Low triple digits if we’re being generous.”</p><p>Medicare pays $100 for a test, and at-home tests are sold for as little as $24 for an antigen test or $119 for a PCR test.</p><p>Warner’s charges were fully covered by his insurance.</p><p>But insurance policy premiums reflect how much is paid to providers. “If the insurance company is paying astronomical sums of money for your care, that means in turn that you are going to be paying higher premiums,” Adler said.</p><p>Taxpayers, who subsidize marketplace insurance plans, also face a greater burden when premiums increase. Even those with employer-sponsored health coverage feel the pain. Research shows that each increase of $1 in an employer’s health costs is <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/hec.3452">associated with a 52-cent cut</a> to an employee’s overall compensation.</p><p>Even before the pandemic, wide variability in the prices for common procedures like cesarean sections and blood tests had been driving up the cost of health care, Brennan said. These discrepancies “happen every single day, millions of times a day.”</p>        <h4>        Related Links    </h4>            <ul><li>                    <a href="https://khn.org/news/article/surprise-medical-bill-jaw-surgery-takes-bite-out-of-budget/">                                                    Jaw Surgery Takes a $27,119 Bite out of One Man’s Budget                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/olympic-dream-dashed-after-bike-crash-and-nightmare-medical-bill-over-200k/">                                                    Olympic Dream Dashed After Bike Crash and Nightmare Medical Bill Over $200K                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/surprise-bill-iv-push-hospital-unbundling/">                                                    A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/enough-to-wreck-their-rest-10322-for-a-sleep-study/">                                                    Enough to Wreck Their Rest: $10,322 for a Sleep Study                                            </a>                </li>                    </ul><p><strong>Resolution:</strong> When Warner saw that his insurance company had paid the bill, he first thought: “At least I’m not liable for anything.”</p><p>But the absurdity of the $54,000 charge gnawed at him. His wife, who’d received the same tests the same day at the same place, was billed $2,000. She has a separate insurance policy, which settled the claim for less than $1,000.</p><p>Warner called his insurer to see if someone could explain the charge. After a game of phone tag with the ER and the ER’s billing firm, and several months of waiting, Warner received another letter from his insurer. It said they’d audited the claim and taken back the money they had paid the ER.</p><p>In a statement to KHN, a spokesperson for Molina Healthcare wrote, “This matter was a provider billing error which Molina identified and corrected.”</p><p>SignatureCare Emergency Centers, which issued the $54,000 charge, said it would not comment on a specific patient’s bill. However, in a statement, it said its billing error rate is less than 2% and that it has a “robust audit process” to flag errors. At the height of the pandemic, SignatureCare ERs faced “unprecedented demands” and processed thousands of records a day, the company said.</p><p>SignatureCare’s website now <a href="https://ercare24.com/">lists the charge</a> for covid tests as $175.</p><p><strong>The Takeaway:</strong> Covid testing should be free to consumers during the public health emergency (currently extended through mid-October, and likely to be renewed for an additional 90 days). Warner did his insurer a big favor by looking carefully at his bill, even though he didn’t owe anything.</p>    <p>Insurers are supposed to have systems that flag billing errors and prevent overpayment. This includes authorization requirements before services are rendered and audits after claims are filed.</p><p>But “there’s a question of how well they work,” Adler said. “In this case, it’s lucky [Warner] noticed.”</p><p><a href="https://journals.sagepub.com/doi/abs/10.1177/1471082X16685020?journalCode=smja">At least one estimate</a> says 3% to 10% of health care spending in the U.S. is lost to overpayment, including cases of fraud, waste and abuse.</p><p>Unfortunately, that means the onus is often on the patient.</p><p>You should always read your bill carefully, experts say. If the cost seems inappropriate, call your insurer and ask them to double-check and explain it to you.</p><p>It’s not your job, experts agree, but in the long run, fewer overpayments will save money for you and others in the American health care system.</p><p><em>Bill of the Month is a crowdsourced investigation by <a href="https://khn.org/news/tag/bill-of-the-month/">KHN</a> and <a href="https://www.npr.org/sections/health-shots/2018/02/16/585549568/share-your-medical-bill-with-us">NPR</a> that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? <a href="https://khn.org/send-us-your-medical-bills/">Tell us about it</a>!</em></p><p><a href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p><h3>USE OUR CONTENT</h3><p>This story can be republished for free (<a href="https://khn.org/news/article/a-colorado-town-is-about-as-vaccinated-as-it-can-get-covid-still-isnt-over-there/view/republish/">details</a>).</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1633105979792&cid=ab3807a0-7c93-4b19-93ee-eec69c3ef10b&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fpricey-covid-test-costs-more-than-tesla-surprise-billing-texas%2F&el=A%20Covid%20Test%20Costing%20More%20Than%20a%20Tesla%3F%20It%20Happened%20in%20Texas."/>                                Source
0 Rating 0 Views 0 likes 0 Comments
Read more
by on September 28, 2021
                                    An Ad’s Charge That Price Haggling Would ‘Swipe $500 Billion From Medicare’ Is Incorrect     Victoria Knight              September 28, 2021              “These guys [insurance companies and Washington bureaucrats] are working together to swipe $500 billion from Medicare to pay for Pelosi and Schumer’s out-of-control spending spree.”   Video advertisement from the 60 Plus American Association of Senior Citizens The advertisement opens with a doctor sitting across from his patient and holding a prescription drug pill bottle. “You want to continue with this medication?” the doctor asks while an older patient nods. The doctor then explains that he can no longer provide the medicine to her because insurance companies and Washington bureaucrats “are working together to swipe $500 billion from Medicare to pay for [House Speaker Nancy] Pelosi and [Senate Majority Leader Chuck] Schumer’s out-of-control spending spree.”      “They’re calling it Medicare negotiation, but, really, it’s just a way to cut your benefits and no longer pay for lifesaving medicines,” the doctor says. Medicare negotiation refers to the federal government bargaining directly with pharmaceutical companies on the price of prescription drugs. Currently, Medicare is prohibited from using its vast market-share muscle to set prices. But supporters of Medicare drug negotiations eye the Democratic-backed budget reconciliation bill now being discussed in Congress as a means to reverse the policy. This ad, seen on television and online, is part of a multiplatform campaign by the 60 Plus American Association of Senior Citizens, a conservative group that lobbies on senior issues and brands itself as the “right alternative to AARP.” It’s one example of a swath of ads that have popped up in the past month about Medicare drug price negotiations. Since drug pricing is a hot topic and a critical piece of the broad, politically charged debate in Congress, we thought it was important to dig into the ad’s messages. The $500 Billion Number First, the ad claims that Medicare drug price negotiation will take “$500 billion from Medicare.” All five of the Medicare and drug pricing experts we consulted said that was a misleading way to frame this policy. The reference to $500 billion most likely comes from a Congressional Budget Office estimate of a provision in H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act. It’s an estimate of how much the government would save over 10 years if drug price negotiations were enacted. That is, the government would be paying pharmaceutical companies $500 billion less for prescription drugs. And, in that bill, $300 billion to $400 billion of the savings were to be used to expand benefits to include dental, hearing and vision coverage, said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. Right now, Medicare doesn’t provide that coverage to seniors. If this policy were to make it into the pending budget reconciliation, some of the savings would also likely address other Democratic health care priorities, such as permanently closing the Medicaid coverage gap and improving Affordable Care Act coverage and subsidies. So the ad’s charged language — that Pelosi and Schumer are planning to “swipe” this money from Medicare — is incorrect. That $500 billion in savings would be slated for reinvestment in the program. And some experts said the changes to drug pricing could also translate into lower premiums and out-of-pocket costs for seniors. The point of negotiations is “to spend less on the drugs we’re already buying and put the money back into the health system,” said Rachel Sachs, a law professor and expert on drug policy at Washington University in St. Louis. But what about the ad’s other main point — that Medicare negotiation will result in seniors no longer being able to get their medications? Since 60 Plus did not return requests for comment, it’s hard to know exactly what it is asserting will come between seniors and their medication. It’s possible the ad is implying that drugmakers may walk away from the negotiating table if they don’t like the prices the government promotes. But experts said it’s likely a financial penalty would be in place to motivate the companies to work with the government. H.R. 3 proposed an escalating excise tax. The U.S. has the world’s largest prescription market, so it seems unlikely companies would stop selling drugs here completely, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. And the number of drugs subject to negotiation would probably be a small subset of all drugs on the market, based on the negotiation method that was proposed in H.R. 3. In real life, the scenario shown in the ad is unlikely to happen, said Joseph Antos, senior fellow in health care policy at the American Enterprise Institute. “The question of whether a drug would be taken off the market — it’s always a little hard to say and, clearly, that is a possibility,” said Antos. “But it’s much more plausible to say this is the kind of policy that would lead to some new drugs not coming out to the market.” That’s an argument often wielded by the pharmaceutical industry. Evidence suggests there’s a grain of truth in the assessment that lower industry profits results in less research and development, said Paul Van de Water, a senior fellow in health care policy at the Center on Budget and Policy Priorities. But only a grain. For the most part, the drug industry overstates the effect of lost profits. “A lot of these drugs are what’s known as ‘me-too’ medicines, which means the drugmakers are making small innovations on existing drugs,” said Van de Water. “The loss to Medicare beneficiaries of those types of drugs would be relatively small.” In a separate analysis, the CBO examined to what extent negotiated drug prices could squeeze the pharmaceutical industry’s R&D capacity. The agency, using a 30-year window, estimated that 59 drugs wouldn’t come to market. That’s against a baseline of about 900 drugs being released per year, said Sachs, which means it would stymie only a tiny fraction of otherwise expected drugs. Still, some experts say the CBO report can’t precisely predict the future and a loss in profits would have a larger effect on smaller, start-up pharmaceutical companies. “At the small operations, a scientist thinks they have an insight into some biological process and they attract venture capitalists to develop a drug,” said Antos. “But drug development is a complicated business, and the drug might not make it to market. With less funds for that type of research, that is the part of the drug business most directly affected by the drug pricing policy.” Why It Matters The political stakes surrounding the Medicare drug price negotiations are high. Currently, the idea is seen as a way to help pay for the Democratic-backed health initiatives being discussed as part of the reconciliation bill. And, a recent poll from KFF shows that almost 90% of the public supports the government’s ability to negotiate for lower drug prices. But allowing Medicare to bargain on drugs is controversial, even among Democrats, some of whom say they don’t want to stifle drug companies’ innovation, especially if it’s a big industry in the area of the country they represent. Meanwhile, PhRMA, the powerful pharmaceutical industry trade group, announced Sept. 15 it would be launching a seven-figure ad campaign against the drug pricing proposals, according to The Hill. Our Rating The 60 Plus Association ran an advertisement that claimed Medicare drug price negotiations were “swiping” $500 billion from Medicare and going to be used as a way to “cut benefits and no longer pay for lifesaving medicines.” While the $500 billion number is based on facts, everything else this ad says is misleading. If Congress approves a plan to let Medicare negotiate drug prices, Democrats are calling for most of the savings to be funneled directly back into the Medicare program to provide vision, dental and hearing benefits. So, it’s not true that the plan for the money is to steal from Medicare. Experts also agreed it is specious to say seniors could no longer get the medications they’re currently taking. We rate this claim False. Sources 60 Plus American Association of Senior Citizens, “Our Mission,” accessed Sept. 22, 2021 60 Plus American Association of Senior Citizens, “Protecting Medicare,” accessed Sept. 22, 2021 Center on Budget and Policy Priorities, Build Back Better Legislation Would Close the Medicaid Coverage Gap, Sept. 13, 2021 Congressional Budget Office, CBO’s Simulation Model of New Drug Development, August 2021 Congressional Budget Office, H.R. 3, Elijah E. Cummings Lower Drug Costs Now Act Cost Estimate, Dec. 10, 2019 Congress.gov, H.R.3 — Elijah E. Cummings Lower Drug Costs Now Act — 116th Congress (2019-2020), accessed Sept. 22, 2021 Email interview with Stacie Dusetzina, associate professor of health policy at Vanderbilt University, Sept. 21, 2021 Fierce Pharma, “Advocates Roll Pricey Ad Campaigns as Biden, Congress Push for Medicare Drug Negotiations,” Aug. 17, 2021 The Hill, “PhRMA Launches 7-Figure Ad Campaign Against Democrats’ Drug Pricing Measures,” Sept. 15, 2021 KFF, What’s the Latest on Medicare Drug Price Negotiations?, July 23, 2021 KFF, Public Opinion on Prescription Drugs and Their Prices, June 15, 2021 KHN/PolitiFact, “Pharma’s Take on the Pelosi Drug-Pricing Bill: Fair Warning or Fearmongering?” Dec. 5, 2019 KHN/PolitiFact, “Biden Promise Tracker — Promise: Lower Cost of Prescription Drugs,” updated July 15, 2021 Open Secrets, “Pharmaceutical Industry Backs Democratic Holdouts on Drug Pricing Plan,” Sept. 17, 2021 Politico, “House Leadership Looks to Jam Holdouts on Drug Pricing,” Sept. 21, 2021 Phone interview with Juliette Cubanski, deputy director of the program on Medicare policy at KFF, Sept. 21, 2021 Phone interview with Joseph Antos, senior fellow and Wilson H. Taylor Scholar in health care and retirement policy at the American Enterprise Institute, Sept. 21, 2021 Phone interview with Paul N. Van de Water, senior fellow at the Center on Budget and Policy Priorities, Sept. 21, 2021 Phone interview with Rachel Sachs, Treiman professor of law at Washington University in St. Louis School of Law, Sept. 21, 2021 The Washington Post, “Three Democrats Say They’ll Oppose Party’s Drug-Price Plan, Creating Roadblock for Larger Package,” Sept. 14, 2021 YouTube, 60 Plus Association Official Account, “Doctor’s Visit,” Sept. 10, 2021 Subscribe to KHN's free Morning Briefing.         Source                          
0 Rating 0 Views 0 likes 0 Comments
Read more
by on September 1, 2021
                                    <h1>Jaw Surgery Takes a $27,119 Bite out of One Man’s Budget</h1> <div>    <span class="byline">Phil Galewitz, Kaiser Health News</span>     <time class="posted-on" datetime="2021-08-27T05:00:00-04:00">         August 27, 2021    </time>     </div> <p>For years, Ely Bair dealt with migraine headaches, jaw pain and high blood pressure, until a dentist recommended surgery to realign his jaw to get to the root of his health problems.</p>    <p>The fix would involve two surgeries over a couple of years and wearing braces on his teeth before and in between the procedures.</p><p>Bair had the first surgery, on his upper jaw, in 2018 at Swedish Medical Center, First Hill Campus in Seattle. The surgery was covered by his Premera Blue Cross plan, and Bair’s out-of-pocket hospital expense was $3,000.</p><p>He changed jobs in 2019 but still had Premera health insurance. In 2020, he had the planned surgery on his lower jaw at the same hospital where he’d been treated the first time. The surgery went well, and he spent one night in the hospital before being discharged. He was healing well and beginning to see the benefits of the surgeries.</p><p>Then the bill arrived.</p><p><strong>The Patient:</strong> Ely Bair, 35, a quality assurance analyst. He has a Premera Blue Cross health plan through his job at a biotech firm in Seattle.</p><p><strong>Total Bill:</strong> Swedish Medical Center billed Bair $27,119 for the second surgery in July 2020. This was Bair’s share of the negotiated rate, after the hospital took $14,310 off the charge. His insurer paid $5,000. Bair owed additional bills to the surgeon and the anesthesiologist.</p><p><strong>Service Provider:</strong> <a href="https://www.swedish.org/locations/first-hill-campus">Swedish First Hill Campus</a> in Seattle, part of the largest nonprofit health system in the Seattle area, which is affiliated with <a href="https://www.providence.org/about">Providence</a>, a major Catholic health care network.</p><p><strong>What Gives:</strong> Bair hit two maddening health system pitfalls here: He expected his new plan to behave like his previous one from the same insurer — and he expected his mouth to be treated like the rest of his body. Neither commonsense notion appears true in America’s health system.</p><p>Typically, large companies, such as Bair’s employers, “self insure,” meaning they pay their workers’ health costs but use insurance companies to maintain provider networks and handle claims. When Bair changed jobs, his insurance coverage changed even though both employers used Premera. Bair paid $3,000 for his first surgery because that was the out-of-pocket maximum under his plan from his previous employer, which covered oral and maxillofacial surgery.</p><p>Bair expected that using the same hospital and the same insurance carrier would mean his costs would be similar for part two of his treatment. Bair’s oral and maxillofacial surgeon — the same doctor who performed the first procedure — checked Bair’s benefits through his insurer’s online portal and thought it would be covered. Premera also sent his doctor confirmation agreeing that the second procedure was medically necessary.</p><p>About three months after the surgery, Bair was shocked to get the large hospital bill — about $24,000 higher than he expected.</p><p>When he called Premera, he learned his new plan had a $5,000 lifetime limit on coverage for the reconstructive jaw procedure known as orthognathic surgery, which is sometimes regarded as a dental rather than a medical intervention. His doctor said that information was not noted in Bair’s benefits when the practice reviewed them through an online portal. Premera told Bair he should have known about the limit because it was listed in his detailed, hard-copy, 86-page member-benefit booklet.</p><p>The Affordable Care Act in 2014 eliminated lifetime and annual caps on insurance coverage for categories of treatment such as prescription drugs, laboratory services and mental health care. While the ACA lists broad categories about what is considered an “essential health benefit,” each state decides which services are included in each category and the scope or duration that must be offered. Bariatric surgery, physical therapy and <a href="https://www.kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans/">abortion</a> are examples of care for which insurance coverage can vary a lot by state under <a href="https://www.everycrsreport.com/reports/R44163.html">this ACA provision</a>. Orthognathic surgery is not considered an <a href="https://www.insurance.wa.gov/benefits-health-plans-must-cover-under-washington-state-law">essential health benefit in Washington</a>. It is sometimes performed for cosmetic purposes only. Also, plans sometimes regard the surgery as part of orthodontia — which frequently involves limits on coverage. But for Bair, it was a clear medical necessity.</p><p>Without an ACA requirement for orthognathic surgery, Premera and self-insured plans are allowed to provide various levels of benefits and can impose annual and lifetime caps.</p><p>Premera spokesperson Courtney Wallace said Bair transferred from a plan with his former company that did not have a lifetime maximum to a plan with a $5,000 lifetime maximum benefit.</p><p>Martine Brousse, a patient advocate and owner of <a href="https://advimedpro.com/">AdvimedPro</a>, which helps patients with health care billing disputes, said Bair acted appropriately by using a doctor and hospital in his health plan’s network and checking with his doctor about his insurance coverage.</p><p>She said Swedish should have told him before the surgery — which was planned weeks ahead of time — how much he would have to pay. “That is a failure on part of the hospital,” she said.</p><p>Sabrina Corlette, co-director of the Georgetown University Center on Health Insurance Reforms, said it doesn’t seem fair that his first employer covered the cost of his surgery but the second employer did not. She said the $27,000 bill seemed excessive and the $5,000 lifetime limit very low. “Essential health benefits serve a really important function, and when there are gaps or holes people can really get hurt,” she said.</p><p><strong>Resolution: </strong>Bair’s doctor told him the hospital charge was at least three times the amount Swedish charges uninsured patients for the same surgery. Bair said Swedish offered to let him pay the bill over two years but did not make any other concessions.</p><p>Swedish would not say why it did not verify Bair’s insurance benefits before the surgery or let him know he would face an enormous bill even though he was insured.</p><p>“Hospital pricing is complex and nuanced,” Swedish officials said in a statement. Bair’s bill “was inclusive of all the care he received, which included specialized services and expertise, equipment and the operating room time. He had a jaw procedure that had a maximum benefit from his insurer of $5,000. He was billed the balance not covered by his insurer.”</p><p>The hospital system said it also has an <a href="https://www.swedish.org/locations/first-hill-campus/pricing-transparency">online tool</a> that generates estimates tailored to patients’ coverage and choice of hospital.</p><p>The online tool did not come up with anything on the term “orthognathic surgery,” however.</p>        <h4>        Related Links    </h4>            <ul><li>                    <a href="https://khn.org/news/article/olympic-dream-dashed-after-bike-crash-and-nightmare-medical-bill-over-200k/">                                                                            Olympic Dream Dashed After Bike Crash and Nightmare Medical Bill Over $200K                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/surprise-bill-iv-push-hospital-unbundling/">                                                                            A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/enough-to-wreck-their-rest-10322-for-a-sleep-study/">                                                                            Enough to Wreck Their Rest: $10,322 for a Sleep Study                                            </a>                </li>                            <li>                    <a href="https://khn.org/news/article/after-accident-patient-crashes-into-700000-bill-for-spine-surgery/">                                                                            After Accident, Patient Crashes Into $700,000 Bill for Spine Surgery                                            </a>                </li>                    </ul><p>Bair appealed three times to Premera to reconsider its decision to cover only $5,000 of the cost of his procedure. But the insurer rejected each one saying he had exhausted his lifetime orthognathic surgery benefit and he was responsible for any additional care. When Swedish wouldn’t lower his cost, he filed a complaint in December 2020 with the state attorney general’s office.</p><p>A few months later, Swedish reduced Bair’s bill from over $27,000 to $7,164.</p><p>“Because neither the patient nor his provider was aware of this limitation in coverage prior to the procedure, the surgeon advocated on the patient’s behalf to get the bill lowered,” the hospital told KHN in a statement.</p><p>Bair agreed to pay the lower amount. “The bill is at least a much more manageable number than the financial ruin $27,000 would have been,” he said. “I am just looking forward to closing this chapter and moving on.”</p><p>His surgeon, who helped him fight the hospital bill and limited insurance coverage, reduced his bill to $5,000 from $10,000, Bair said.</p><p>Bair said his employer, Adaptive Biotechnologies, is looking into eliminating its $5,000 lifetime limit for the procedure when it is medically necessary.</p><p>Since the surgery, Bair said he gets far fewer migraine headaches and his high blood pressure has been reduced. “I feel way more energized,” he said.</p><p><strong>The Takeaway: </strong>When facing a planned surgery, talk to your hospital, doctor and insurer about how much of the bill you will be responsible for — and get it in writing before any procedure.</p>    <p>“In theory, you should be able to rely on your provider to confirm your coverage but, in practice, it is in your best interest to call your insurer yourself,” Corlette said.</p><p>Even though the ACA eliminated lifetime and annual caps on coverage, that applies only to services deemed essential in a patient’s state. Be aware that certain surgeries — like jaw surgery — lie in a gray area; insurers might not consider them a necessary medical intervention or even a medical procedure at all. Corlette said health plans should notify patients when they are closing in on lifetime or annual limits, but that doesn’t always happen.</p><p>Also, be aware that even though your insurance carrier may stay the same after switching jobs, your benefits could be quite different.</p><p>Kudos to Bair for being a proactive patient and appealing to the state attorney general — which got him a positive result.</p><p><em>Stephanie O’Neill contributed the audio profile with this report.</em></p><p><em>Bill of the Month is a crowdsourced investigation by <a href="https://khn.org/news/tag/bill-of-the-month/">KHN</a> and <a href="https://www.npr.org/sections/health-shots/2018/02/16/585549568/share-your-medical-bill-with-us">NPR</a> that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? <a href="https://khn.org/send-us-your-medical-bills/">Tell us about it</a>!</em></p><p><a href="https://khn.org/about-us">KHN</a> (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at <a href="https://www.kff.org/about-us/">KFF</a> (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.</p><h3>USE OUR CONTENT</h3><p>This story can be republished for free (<a href="https://khn.org/news/article/how-rape-affects-memory-and-why-police-need-to-know-about-that-brain-science/view/republish/">details</a>).</p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1630509271864&cid=aad86c03-999d-4633-9c72-e6f376b4ec22&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Fsurprise-medical-bill-jaw-surgery-takes-bite-out-of-budget%2F&el=Jaw%20Surgery%20Takes%20a%20%2427%2C119%20Bite%20out%20of%20One%20Man%E2%80%99s%20Budget"/>                               
0 Rating 1 view 0 likes 0 Comments
Read more
by on August 4, 2021
                                    <h1>Olympic Dream Dashed After Bike Crash and Nightmare Medical Bill Over $200K</h1> <div>    <span class="byline">Samantha Young</span>     <time class="posted-on" datetime="2021-07-29T05:00:00-04:00">         July 29, 2021    </time>     </div> <p>It was a race in Pennsylvania that could have sent cyclist Phil Gaimon to the Tokyo Olympics; instead, a serious crash landed the Californian in two hospitals on the East Coast.</p>    <p>Gaimon knows accidents are, unfortunately, part of the sport. He had retired from competitive road cycling three years earlier, but a recruiting call came in spring 2019 from a coach of the USA Cycling track team.</p><p>The coach needed speed for a four-man event. At the time, Gaimon was making a name for himself, and money, by mountain racing, and he was setting records.</p><p>“It was a dream come true,” said Gaimon, 35. “A chance at a second career in racing.”</p><p>But his Olympic dreams were short-lived. In a <a href="https://thevelodrome.com/wp-content/uploads/2019/06/19.6.14-Mens-UCI-Omnium.pdf">sprint</a> with a pack of riders at the velodrome track in eastern Pennsylvania, Gaimon sailed over his handlebars after colliding with a fellow racer. Gaimon hit the ground hard. The result: a fractured collarbone, five broken ribs, a partially collapsed lung and a broken scapula — his worst injuries in the 10 years he had raced on pro road teams in the United States and Europe.</p><p>An ambulance whisked him to Lehigh Valley Hospital in Allentown, Pennsylvania, which is part of the health system that <a href="https://thevelodrome.com/wp-content/uploads/2019/06/19.6.14-Men-UCI-Team-Pursuit.pdf">sponsored</a> the cycling event. Emergency doctors admitted the athlete and he underwent surgery on his collarbone. He needed surgery on his scapula, too, which he said felt “like a collapsed taco.” But that surgery would happen days later, after he was discharged from the Pennsylvania hospital and a friend helped him find a surgeon in New York.</p><p>He chronicled the whole ordeal on his social media channels, and soon he was recuperating — painfully, but successfully — back home. And then the bills came.</p><p><strong>The Patient:</strong> Phil Gaimon, 35, a former professional cyclist, YouTuber and blogger who earns most of his income through sponsorships. He paid about $500 a month for his insurance policy with Health Net through Covered California, the state’s health insurance exchange. He also had a secondary health insurance policy with USA Cycling.</p><p><strong>Total Bills:</strong> $151,804 from <a href="https://www.lvhn.org/">Lehigh Valley Health Network</a>, and $49,526 from the <a href="https://www.hss.edu/">Hospital for Special Surgery</a>. He had additional bills from various physicians. Health Net has paid approximately $27,000 to Lehigh Valley, according to Gaimon. His secondary insurance, USA Cycling, paid $25,000 to the Hospital for Special Surgery and his surgeon there.</p><p><strong>Service Providers:</strong> Lehigh Valley Hospital-Cedar Crest in Allentown, Pennsylvania, part of the not-for-profit Lehigh Valley Health Network. The Hospital for Special Surgery, an academic medical center, in Manhattan.</p><p><strong>Medical Procedure: </strong>Surgery for a fractured collarbone at Lehigh Valley Hospital and surgery for a broken scapula at the Hospital for Special Surgery.</p>    <p><strong>What Gives:</strong> Gaimon collided with three health system dangers in this physically and financially painful crash: an out-of-state emergency, out-of-network care and gold-plated prices from both hospitals that treated him. Gaimon said he could sell his house and pay these bills, “but I shouldn’t have to. I have insurance.”</p><p>His situation is a scenario many patients have encountered when they need emergency care outside of their provider’s network. It’s known in medical jargon as “balance billing.” Hospitals and insurance companies without mutual contracts often don’t agree on the price of services, and the patient is left to pay the difference.</p><p>While at least <a href="https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections">33 states</a> have enacted laws intended to protect consumers from balance billing, many don’t apply to out-of-state patients, said <a href="https://gufaculty360.georgetown.edu/s/contact/0033600001KrSvJAAV/maanasa-kona">Maanasa Kona</a>, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.</p><p>For example, in Gaimon’s home state of California, state law protects enrollees of state-licensed health plans from balance billing, but their authority is limited to California doctors and hospitals.</p><p>“These state laws depend upon the state having jurisdiction over the providers involved,” Kona said. “So, nothing is going to stop out-of-state providers from sending bills and hounding the patient. It’s a major gap.”</p><p>In Gaimon’s case, the validity of the hospital charges was also questionable. Lehigh Valley Health Network is notorious for big markups on care for out-of-network patients, said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide. “There’s no rhyme or reason as to how they’re charging compared to their costs,” Quarum said.</p><p>WellRithms reviewed Gaimon’s bills in detail at the request of KHN and determined that a reasonable reimbursement for the care he received would have been $21,000. That’s $6,000 less than what Health Net had already paid.</p><p>In an email to KHN, Lehigh Valley Health Network spokesperson Brian Downs called the calculations by WellRithms “flawed,” and said it is not appropriate to use Medicare-based rates to determine medical costs because they “are not reflective of the actual cost incurred by a provider in rendering any specific medical service.” WellRithms didn’t use Medicare rates, however. It looked up the amounts Lehigh told Medicare it costs the health system to perform a wide range of services.</p><p>One reason cited by WellRithms for Gaimon’s high bill: Lehigh Valley Hospital charged him $25,915 for a night in the intensive care unit and $29,785 for a night in the burn unit, according to an explanation of benefits sent to Gaimon by Health Net in January 2020. Gaimon understood he was placed in these specialty units because of a lack of space in other parts of the hospital. But Downs, in his statement, said Gaimon needed the burn unit because of his abrasions and the ICU after his collarbone surgery.</p><p>Still, the charges are big markups compared with the costs Lehigh reports to Medicare: $13,038.82 for an ICU patient night and $18,036.92 for a burn ICU patient night, according to WellRithms.</p><p>“$25,000 a day for a charge for an ICU is absolutely ridiculous,” Quarum said.</p><p>Gaimon’s $49,526 bill from the Hospital for Special Surgery posed other patient-billing land mines.</p><p>He recalled representatives from the hospital and his insurance plan telling him he would be billed as an out-of-network patient, but they assured him he could file an appeal because of the extenuating circumstances. And he had secondary insurance offered by USA Cycling that would cover $25,000 for the shoulder surgery, which it did, according to billing records.</p>    <p>He expected his primary insurer, Health Net, to pay some of the cost, too.</p><p>But in an Oct. 19, 2019, letter, Health Net denied Gaimon’s appeal because he “self-referred” himself to a surgeon in New York. They also described the surgery as “outpatient” even though he spent the night at the hospital. The letter went on to say the Hospital for Special Surgery had categorized the surgery as elective.</p><p>Given his level of pain and the fact surgeons at the first hospital didn’t perform the scapula surgery during his stay, he figured there was nothing “elective” about it. “I needed this surgery and no one else could do it,” Gaimon said.</p><p>Health Net spokesperson Darrel Ng declined to comment, saying it doesn’t comment on specific member cases, even though Gaimon gave written permission for his case to be discussed.</p><p>A reasonable reimbursement for Gaimon’s out-of-network scapula surgery should have been $13,908, according to WellRithms. Historically, the hospital’s average charge for that surgery was nearly $11,000 even though it cost only $3,094 to perform in the year Gaimon had his surgery, WellRithms found in the 2019 annual cost report the hospital submitted to the federal government.</p><p><strong>Resolution:</strong> Battling these bills became Gaimon’s full-time job as he recovered from surgery. And, almost two years after the crash, he still faces huge bills from both hospitals despite both hospitals having been paid tens of thousands of dollars through Gaimon’s insurance coverage.</p><p>After a reporter made inquiries, a representative from the Hospital for Special Surgery called Gaimon, offering to help him apply for financial assistance based on his income.</p><p>In a statement, HSS spokesperson Noelle Carnevale said, “We regret Mr. Gaimon’s dispute with his insurance provider’s classification of the surgery as elective.” And she added, “We are optimistic for an easy resolution, and look forward to celebrating his continuing achievements.”</p><p>Gaimon spent months calling and writing letters to Health Net to persuade them to cover the emergency room visit and the collarbone surgery. So far, he has been unsuccessful.</p><p>Congress last December passed <a href="https://khn.org/news/article/surprise-congress-takes-steps-to-curb-unexpected-medical-bills/">legislation</a> intended to protect patients like Gaimon against unexpected bills from out-of-network providers. Starting next year, when the law takes effect, patients can be charged only up to the amount of their deductible or copayment when receiving emergency care at any hospital.</p><p><strong>The Takeaway:</strong> The federal protections against unforeseen medical bills for emergency care kick in Jan. 1, 2022. So, if you travel out of state this year, you should be aware that many state-based insurance plans might not cover you fully or at all in another state.</p><p>If you’re in possession of a surprise or balance bill for out-of-state emergency care, contact your health insurance plan and make sure representatives understand it was an emergency. Call the hospital and ask about financial assistance or charity care.</p><p>And be aware that the new federal law doesn’t cover everything. <a>Should you be taken to the hospital by a ground ambulance service that’s not in your insurance plan’s network, for example, you could still be on the hook for a large bill.</a></p><p>“There will always be some surprises, because the hospital or the doctors are going to find a way to get you uncovered by the law,” said <a href="http://www.jhsph.edu/faculty/directory/profile/1278/Anderson/Gerard">Gerard Anderson</a>, director of the Center for Hospital Finance and Management at Johns Hopkins University Bloomberg School of Public Health. “It’s always a game of whack-a-mole.”</p><p><em>Stephanie O’Neill contributed the audio profile with this report.</em></p><p><em>Bill of the Month is a crowdsourced investigation by </em><a href="https://khn.org/news/tag/bill-of-the-month/"><em>KHN</em></a><em> and </em><a href="https://www.npr.org/sections/health-shots/2018/02/16/585549568/share-your-medical-bill-with-us"><em>NPR</em></a><em> that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? </em><a href="https://khn.org/send-us-your-medical-bills/"><em>Tell us about it</em></a><em>!</em></p><p><em>This story was produced by <a href="https://khn.org/">KHN</a>, which publishes <a href="http://www.californiahealthline.org/">California Healthline</a>, an editorially independent service of the <a href="http://www.chcf.org/">California Health Care Foundation</a>.</em></p><p><a href="https://khn.org/morning-briefing/">Subscribe</a> to KHN's free Morning Briefing.</p><img src="https://ssl.google-analytics.com/collect?v=1&t=event&ec=Republish&tid=UA-53070700-2&z=1628087678142&cid=28645e52-83ae-496e-bc7b-581d8e53bf8f&ea=https%3A%2F%2Fkhn.org%2Fnews%2Farticle%2Folympic-dream-dashed-after-bike-crash-and-nightmare-medical-bill-over-200k%2F&el=Olympic%20Dream%20Dashed%20After%20Bike%20Crash%20and%20Nightmare%20Medical%20Bill%20Over%20%24200K"/>           Do you have an exorbitant or baffling medical bill? Join the KHN and NPR ‘Bill of the Month’ Club and tell us about your experience. We’ll feature a new one each month. Bill of the Month                       
0 Rating 1 view 0 likes 0 Comments
Read more