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One of the biggest claim issues we are now dealing with is our clients getting bills from out of network providers and labs even though they used an in network facility. In the past this rarely happened but it seems some doctors have found out they can make more money by not contracting with an insurance companies PPO network. Even more worrysome is hospitals and out patient surgery centers knowingly allow these providers to work on their patients even though they know the problems it will create.
In the past insurance companies were more tolerant of this abuse and providers thought they had found a loophole to higher reimbursements. Because it became so common, the group insurance companies began following the legal contracts they have in place which allows them to not pay for these procedures as in network benefits. Most policies have a separate deductible for out of network claims which is where these claims get filed. That creates a separate bill for the insured and unfortunately there are no in-network discounts so the provider can bill whatever they want for their services.
Congress and President Trump have promised to create legislation to stop this abusive practice. Of course, they have also promised price transparency and lower prescription costs. We have yet to see those changes and in an election year they need all the Super Pac money they can get.
It is estimated that 20% of all surgeries and hospital stays now have out of network charges with an average cost of $2,011. The scary thing is we are seeing it regardless of which insurance carrier they have and it seems most hospitals are allowing it to happen as well. Even worse, there is very little you can do as a patient on the front end to avoid this from happening.
It is very important for you to understand, this is not the insurance companies fault. This is the hospitals fault loud and clear. They are allowing non contracted doctors to knowingly work on their patients and bill their patients huge amounts they should not owe.
For more information click here
A new survey by JD Power compares the low adoption of Telehealth programs to mobile banking. Remember when you did not check bank balance or make deposits on your cellphone? Today mobile banking applications are the third most used apps nationally and they expect the same with Telehealth.
Here are some of their findings;
- Customer satisfaction is very high at 851 out of 1000. For reference, only direct banking is higher at 855.
- Word of mouth is the best advertisement, 65% of new users tried it after talking with a friend or relative.
- Telehealth works - 84% of users said they were able to completely resolve their medical concern.
- 79% did not experience any issues or problems during their service
- 87% said the enrollment process was somewhat/very easy
- 49% said there were no barriers making the Telehealth service difficult
- Fast and easy - The average amount of time spent was 44 minutes for a first visit: 17 minutes for the enrollment process, 9 minutes waiting for a callback and 18 minutes for the actual consultation.
For more information about the 2019 Telehealth Satisfaction Study visit www.jdpower.com/business/resource/us-telehealth-study
That is my opinion and I am extremely frustrated because Mark and I are on the frontline of healthcare costs spiraling out of control while we increase deductibles to levels never imagined. For example, diabetes is one of the oldest and most common ailments with an estimated 9.4% of Americans affected by this awful disease. After all these years and all the medications created, why does insulin cost $500 per month (Reuters)?
I am writing this because a story just came out that Nancy Pelosi and the Democratically controlled House of Representatives is expected to pass legislation that would allow Medicare to negotiate drug prices with the pharmaceutical companies. The Republican controlled Senate is expected to oppose it and not pass the bill. This is expected to save tax paying Americans $500 billion dollars over the next 10 years. More importantly, private insurance companies would be able to piggy back on the discounted prices.
The Republicans say it's best left to the private insurance companies to negotiate the prices. What we need to remember is private insurance companies pay on average 40% more for all healthcare than Medicare. It is going to take the Government to intervene to get any kind of price control in place. Unfortunately, because of the strong Pharmaceutical lobby and political donations to super PACs, I don't much changing in the short term.
Did you ever think you would see a $500 monthly employee premium for a $5,000 deductible HSA qualified plan? Welcome to 2020, it's going to be a challenging year for employers and employees. The Affordable Care Act is really not all that affordable for most. Yes, it has provided much needed protection for groups who have employees with serious medical conditions, unfortunately there are a lot of other companies paying more for it.
While the $500 monthly premium is what we have see for companies with older employees everyone is seeing higher premiums regardless of who your insurance carrier is. Most of our groups with 50 or fewer employees use BlueCross BlueShield of Tennessee. They have the pricing advantage the S Network provides making them the lowest cost option if you want a HSA qualified plan. Unfortunately, our most popular plan last year, the Silver 40 is seeing 20-30% increases and the options to reduce costs dramatically reduce the benefits.
One option that has helped a few of our groups is using a strategy called "Level Funding". These are self-insured plans that allow them to avoid the costly "community rating" provision of the ACA. These policies require you to go through medical underwriting so only the healthiest groups qualify. We have successfully used Level Funded plans with Aetna, Cigna, Humana and United HealthCare.
Hold on, because of high cost specialty prescriptions and the commonality of high cost procedures like joint replacement we don't see a slowdown in rate increases.
Want to see if your company can save money with a Level Funded group health insurance plan? Give us a call and hopefully we can help you like we have many of our great clients.
This is even worse that I had believed true. Rand Corporation conducted a nationwide study of hospital claims from 2015 - 2017 to understand the disparity in pricing of private health insurance verses Medicare reimbursement rates. The results are astounding. In middle Tennessee the average reimbursement by our hospital systems are: Williamson Medical Center 160%, Vanderbilt Hospital 208%, St. Thomas Health Systems 192% and HCA Tri-Star 303%.
What that means is, if Medicare charged $1,000 for a procedure Vanderbilt has been paid $2,008 for that same procedure from our commercial insurance carriers. That is the type of insurance most of us have individually or through our employers. We wonder why health insurance costs so much, it's because we subsidize the government policies to keep our healthcare providers afloat.
Think about that, HCA Hospitals are charging on average 300% more than the amount the government is paying for the same services. What can be done? That's the $100 billion dollar question that needs to be answered to get healthcare costs and medical premiums under control. I don't have the answers, just want to give you some information to think about.
Want to read the study, click here
The payment amounts above are referenced in the national map, zoom into Tennessee and you can view the hospitals individually for their specific payment amounts. It's very interesting and very disappointing.
Good news, the annual HSA contribution limits continue to increase (a little bit). For 2020 a person with employee only coverage will be able to contribute $3,350, up from $3,500 in 2019. If you cover dependents on your medical plan you can put $7,100 away on a pre-tax, tax free basis. This is a $100 increase from 2019.
One of the challenges I have with HSA rules is why a person has to have a $2,800 deductible to be eligible to contribute. I understand if you have a "shared" deductible it's only $1,400 but those are the exception to the rule. I am a huge HSA fan and encourage everyone who is eligible to try it because there is nothing to lose.
Many financial experts are saying an HSA even without a match is a better long-term retirement strategy than your 401-k (traditional or Roth). The reason is that you can put in tax deductible dollars on the frontend, your money grows tax-free and if taken out for qualified expenses comes out tax-free. That is a fantastic program, get on board, set up your account and fund it as heavily as possible.
Have an excellent day, we appreciate your business. Have questions or need group insurance help in Tennessee, call me. David Moore 615-724-1701
Good news for those getting their individual policies through Healthcare.gov. BCBST will be offering individual plans in Nashville and Memphis in 2020. Additionally, Cigna and Oscar Health will be reducing rates for their individual policies. Although the proposals are not final, it appears Tennesseans will have more options at hopefully lower costs next year.
There are five insurance companies currently offering individual health insurance in TN. Here are the proposed increases/decreases for 2020.
BCBST will expand into Nashville and Memphis and is asking for an average increase of 1.4%.
Bright Health offers coverage in Knoxville, Nashville and Memphis and is asking for an average 2.9% increase.
Celtic is expanding into Nashville and Knoxville and proposes to reduce rates by an average of 1.6%.
Cigna is expanding into Chattanooga, Jackson is proposing a 5.7% decrease in premiums.
Oscar Health will continue to offer coverage in Nashville and Memphis and proposes an 8.3% decrease in premiums.
This information is from Kevin Walters, a spokesman for the Tennessee Department of Commerce and Insurance.
Unfortunately the insurance carriers no longer allow agents and brokers to help individual customers with these policies. You will have to do all the research and customer service on your own.
In the summer of 2018 Amazon purchased PillPack a mail order prescription company that packages all your prescriptions in individual daily packets. PillPack had an amazing concept and Amazon wants to scale it worldwide. The nearly $1,000,000,000,000 ($1 Trillion) pharmaceutical industry has long been controlled by Pharmacy Benefit Managers. These are the middle men between those who manufacture the medicines and the individuals, insurance companies or Medicare who pay for them.
PBMs create very confidential and secretive pricing practices where no one really knows the actual cost of a medicine especially the end user. What happens many times is a prescription has a retail price the customer pays but behind the scenes the insurance company receives a cash rebate or credit for that prescription reducing their actual cost. How much is the rebate you ask? Only the PBM and insurance company know and they claim it is used to keep health care prices lower for everyone.
Congress is working hard to create more transparency in drug pricing and do away with behind the scenes rebates and discounts. There is of course a lot of pushback from the pharmacy lobby in Washington so time will tell if this does in fact lower pharmacy costs.
Amazon on the other hand could do to prescriptions what they have done to buying pretty much anything else. It seems they are already talking with insurance companies about working directly with them and cutting out the PBMs or middle men. This is not welcome news to the decades old pharmaceutical industry and they are pushing back. While it may take years it seems, we may soon be getting lower cost medications delivered to our doors with just the push of a button.
Here is a very interesting article and videos that better explain how this disruption could take place. These are of course my thoughts and opinions but I have worked in the health insurance industry for 25 years.
Before the ACA, small employers had the option to "reimburse" employees with tax-free dollars for their individual health insurance policies. The Affordable Care Act wanted all policies to go through the healthcare.gov exchanges and businesses to offer ACA compliant plans to their employees so Health Reimbursement Arrangement's for individual policies were eliminated.
As President Trump and his administration look for ways to create affordable health insurance options they are re-allowing employers to reimburse employees who have individual policies. This is great news except there are no longer any affordable individual policies available. Without qualifying for a subsidy, small group policies are less expensive and offer the same qualified benefits. Some are saying short-term policies could work in this situation but too are costly and the benefits are quite limited.
So what's the point? I believe it is about talking points and "trying" to find solutions. If the carriers are unable to offer policies that can have "pre-existing" conditions and medical underwriting we will not see low cost medical plans again and HRA's won't make much sense.
Here is a very good article from Forbes about this issue.
I am reading a summary of the American Medical Associations recommendations to improve healthcare in America. Some democrats are pushing Medicare for All, the AMA is more concerned about those who are unable to afford basic health insurance rather than the millions who have access through their employers. This study says 82% of the uninsured fall below the 400% of the Federal Poverty Level “FPL” with 20% of those falling below the poverty line. More than three-quarters have at least one full-time worker in their family.
The crux of the affordability issue stems from the high cost of healthcare in the US. In 2017 we spent $3.5 trillion on healthcare, an average of $10,739 per person. This was up 3.9% from 2016 and makes up 17.9% of the gross domestic product.
Who doesn’t have insurance? A lot of eligible people. Here in Tennessee because we did not expand Medicaid or Tenncare there are the working poor who earn less than 133% of the FPL so they don’t qualify for a premium subsidy through Healthcare.gov Across the county there are 8.2 million individuals who are eligible for premium tax credits but still have not signed up for coverage. Another serious problem is those who have a working spouse who has access to affordable, credible coverage through work but the dependent premiums are not affordable. Because coverage is available at work, they are not eligible for a subsidy for their dependents leaving many uninsured. Then of course there are those who are “bullet proof” and because the individual mandate penalty is no longer effect have decided not to pay for insurance regardless of the cost.
What can be done to fix some of these issues? There are many suggestions in the report, many of which make total sense but unfortunately, we need our politicians to cross the isle and agree to make or change the laws. There are also many industries who will lose business and revenue if some of the changes were to happen and they have very strong political ties and contributions to try and prevent change from happening or water down the things that have the greatest impact to reduce costs.
Because Medicaid and Medicare reimbursements to doctors and hospitals are so low, commercial insurance reimbursements are exceedingly high to make up for the losses. If everyone were moved to Medicare level reimbursements the healthcare system would collapse financially. Just one more reason it’s so difficult to make serious changes and improvements to our healthcare system.
This is a fascinating report you can read it here