Archive for the ‘Blog’ Category

After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion

Adam Woodrum was out for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed.

“He cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum.

Because they were on bikes, he called the fire department in Carson City, Nevada.

“They were great,” said Woodrum. “They took him on a stretcher to the ER.”

Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.

Then the denial letter came.

The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program

Total Bill: $18,933.44, billed by the hospital

Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health

Medical Service: Stitches and anesthesia during an emergency department visit

What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.

This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.

The legal name for the process of determining which type of insurance is primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?

Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.

Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.

About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.

The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.

The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”

Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.

The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.

“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”

When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.

The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”

Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”

Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.

“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”

Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.

Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.

That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.

Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.

“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.

After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.

His child just fell off his bicycle.

HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.

The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.

The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.

It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.

But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.

Don’t panic.

If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.

And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.

“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”

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! COPY HTML

Medicare Open Enrollment Is Complicated. Here’s How to Get Good Advice As Kaiser Health News Explains.

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in Californiado not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.” 

Trump Administration’s Rule Ending Drug Rebates in Medicare Nears Final Approval

The Trump administration’s revived rule to end rebates that drugmakers give to middlemen in Medicare is awaiting approval from the Office of Management and Budget and a final rule could be imminent, according to a person familiar with the matter.

The administration has said the rule would drive down the prices consumers pay for prescription drugs. An earlier version of the rule, a signature part of President Trump’s plan to lower drug prices, was withdrawn in 2019 because some White House advisers raised concerns that it could increase Medicare premiums. Mr. Trump in July signed an executive order that revived the rule and added a requirement that it not raise premiums or increase federal spending.

Ending the annual rebates would spare drug companies from paying billions of dollars to middlemen in Medicare, the federal health-insurance program for seniors and the disabled. Health plans had fought against the proposal because they would then have to cover higher drug costs. The rule was revised because of the requirements on premiums imposed by the executive order, the person said.

The Department of Health and Human Services’ decision to submit the rule to the OMB shows the administration plans to continue making health-related rules and regulations before Jan. 20, when President-elect Joe Biden is scheduled to be inaugurated.

Trump officials preparing to move forward with major step to lower Medicare drug prices

The Trump administration is preparing to move forward with a major proposal to lower drug prices and rulemaking could come as soon as this week, according to people familiar with the effort.

The move, fiercely opposed by the pharmaceutical industry, would implement President Trump’s “most favored nation” proposal and lower certain Medicare drug prices to match prices in other wealthy countries.

Trump issued an executive order in September calling for steps to that effect, but it was unclear whether the administration would still go forward with implementing the proposal, especially given the election and a coming change in administration.

Sources said that while plans can always change at the last minute, the administration is preparing to take the regulatory steps to implement the idea as soon as this week and that it is likely to take the form of an interim final rule, meaning it will skip some of the steps in the regulatory process and go forward faster.

Asked about the plans, a spokesperson for the Department of Health and Human Services said “we don’t have any announcements at this time.” A White House spokesperson did not immediately respond to a request for comment.

Trump’s actions would be sure to set off a backlash from drug companies, possibly including lawsuits to try to stop the rule.

Many congressional Republicans also oppose the proposal, warning that it veers from traditional GOP free-market principles and instead constitutes “price controls.”

In a twist, though, the proposal is similar to ideas proposed by Democrats to lower drug prices, increasing the odds that the incoming Biden administration would choose to continue the program if it’s implemented.

Trump has long railed against high drug prices, but none of his major proposals have taken effect. This proposal would be his most sweeping move on drug prices.

“Just signed a new Executive Order to LOWER DRUG PRICES!” Trump tweeted in September. “My Most Favored Nation order will ensure that our Country gets the same low price Big Pharma gives to other countries. The days of global freeriding at America’s expense are over and prices are coming down FAST!”

While the details of the regulation remain to be seen, the executive order proposed lowering Medicare drug prices to more closely match the lower prices in other wealthy countries that make up the Organization for Economic Cooperation and Development. It is also unclear whether the rules will apply to drugs in just Medicare Part B or Medicare Part B and Part D.

On a separate drug pricing front, a rule to eliminate rebates that drugmakers pay to pharmacy benefit managers, in a bid to simplify the pricing system and lower out of pocket costs for patients, could also come before President-elect Joe Biden takes office. The rule went to the Office of Management and Budget for review on Friday, an online government dashboard shows.

That proposal is supported by the pharmaceutical industry but opposed by pharmacy benefit managers, the companies that negotiate prices with drugmakers and receive the rebates. The Pharmaceutical Care Management Association (PCMA), which represents those companies, pointed to projections that eliminating rebates could increase premiums and government spending, and threatened to sue. 

“If this rule is finalized as originally proposed, PCMA will explore all possible litigation options to stop the rule from taking effect and destabilizing the Medicare Part D program that millions of beneficiaries and people living with disabilities rely on,” the organization said.

The combination of the two different possible drug pricing rules in the closing days of the Trump administration would mean that officials are going out with a burst of moves on a front where action was stalled for much of Trump’s presidency.

Trump first announced a version of the most favored nation proposal in 2018, shortly before the midterm elections, but the proposal went nowhere.

But the approach taken by the administration could open the proposed rule to legal challenges.

Fast-tracking the proposal through an interim final rule, rather than the normal process of first doing a proposed rule and gathering comments, could make it easier for drug companies to win their lawsuits seeking to stop the proposal.

“In the last weeks of the administration, [Health and Human Services] Secretary [Alex] Azar seems inclined to try to move this and other rules forward in a way that creates much more legal jeopardy for them than is necessary,” tweeted Rachel Sachs, a health law professor at Washington University in St. Louis.

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Five Important Questions About Pfizer’s COVID-19 Vaccine As reported By Kaiser Health News

Pfizer’s announcement on Monday that its COVID-19 shot appears to keep nine in 10 people from getting the disease sent its stock price rocketing. Many news reports described the vaccine as if it were our deliverance from the pandemic, even though few details were released.

There was certainly something to crow about: Pfizer’s vaccine consists of genetic material called mRNA encased in tiny particles that shuttle it into our cells. From there, it stimulates the immune system to make antibodies that protect against the virus. A similar strategy is employed in other leading COVID-19 vaccine candidates. If mRNA vaccines can protect against COVID-19 and, presumably, other infectious diseases, it will be a momentous piece of news.

“This is a truly historic first,” said Dr. Michael Watson, the former president of Valera, a subsidiary of Moderna, which is currently running advanced trials of its own mRNA vaccine against COVID-19. “We now have a whole new class of vaccines in our hands.”

But historically, important scientific announcements about vaccines are made through peer-reviewed medical research papers that have undergone extensive scrutiny about study design, results and assumptions, not through company press releases.

So did Pfizer’s stock deserve its double-digit percentage bump? The answers to the following five questions will help us know.

1. How long will the vaccine protect patients?

Pfizer says that, as of last week, 94 people out of about 40,000 in the trial had gotten ill with COVID-19. While it didn’t say exactly how many of the sick had been vaccinated, the 90% efficacy figure suggests it was a very small number. The Pfizer announcement covers people who got two shots between July and October. But it doesn’t indicate how long protection will last or how often people might need boosters.

“It’s a reasonable bet, but still a gamble that protection for two or three months is similar to six months or a year,” said Dr. Paul Offit, a member of the Food and Drug Administration panel that is likely to review the vaccine for approval in December. Normally, vaccines aren’t licensed until they show they can protect for a year or two.

The company did not release any safety information. To date, no serious side effects have been revealed, and most tend to occur within six weeks of vaccination. But scientists will have to keep an eye out for rare effects such as immune enhancement, a severe illness brought on by a virus’s interaction with immune particles in some vaccinated persons, said Dr. Walt Orenstein, a professor of medicine at Emory University and former director of the immunization program at the Centers for Disease Control and Prevention.

2. Will it protect the most vulnerable?

Pfizer did not disclose what percentage of its trial volunteers are in the groups most likely to be hospitalized or to die of COVID-19 — including people 65 and older and those with diabetes or obesity. This is a key point because many vaccines, particularly for influenza, may fail to protect the elderly though they protect younger people. “How representative are those 94 people of the overall population, especially those most at risk?” asked Orenstein.

Both the National Academy of Medicine and the CDC have urged that older people be among the first groups to receive vaccines. It’s possible that vaccines under development by Novavax and Sanofi, which are likely to begin late-phase clinical trials later this year, may be better for the elderly, Offit noted. Those vaccines contain immune-stimulating particles like the ones contained in the Shingrix vaccine, which is highly effective in protecting older people against shingles disease.

3. Can it be rolled out effectively?

The Pfizer vaccine, unlike others in late-stage testing, must be kept supercooled, on dry ice around 100 degrees below zero, from the time it is produced until a few days before it is injected. The mRNA quickly self-destructs at higher temperatures. Pfizer has devised an elaborate system to transport the vaccine by truck and specially designed cases to vaccination sites. Public health workers are being trained to handle the vaccine as we speak, but we don’t know for sure how well it will do if containers are left out in the Arizona sun too long. Mishandling the vaccine along the way from factory to patient would render it ineffective, so people who received it could think they were protected when they were not, Offit said.

4. Could a premature announcement hurt future vaccines?

There’s presently no way to know whether the Pfizer vaccine will be the best overall or for specific age groups. But if the FDA approves it quickly, that could make it harder for manufacturers of other vaccines to carry out their studies. If people are aware that an effective vaccine exists, they may decline to enter clinical trials, partly out of concern they could get a placebo and remain unprotected. Indeed, it may be unethical to use a placebo in such trials. Many vaccines will be needed in order to meet global demand for protection against COVID-19, so it’s crucial to continue additional studies

5. Could the Pfizer study expedite future vaccines?

Scientists are vitally interested in whether the small number who received the real vaccine but still got sick produced lower levels of antibodies than the vaccinated individuals who remained well. Blood studies of those people would help scientists learn whether there is a “correlate of protection” for COVID-19 — a level of antibodies that can predict whether someone is protected from the disease. If they had that knowledge, public health officials could determine whether other vaccines under production were effective without necessarily having to test them on tens of thousands of people.

But it’s difficult to build such road maps. Scientists have never established correlates of immunity for pertussis, for example, although vaccines have been used against those bacteria for nearly a century.

Still, this is good news, said Dr. Joshua Sharfstein, a vice dean at the Johns Hopkins Bloomberg School of Public Health and a former FDA deputy commissioner. He said: “I hope this makes people realize that we’re not stuck in this situation forever. There’s hope coming, whether it’s this vaccine or another.” COPY HTML

HOW I ESCAPED HOSPITAL BILLING ERROR PRISON

The team at Escaping the Healthcare Prison is dedicated to showing how healthcare consumers can escape their PRISON. Each of us has been a healthcare prisoner one time or another.  The spectrum of issues is endless.  Our monthly ESCAPE PLANS will help you navigate the healthcare maze.

BACK ROUND:

A 19-Year-old college student (we will call her Sally) became ill while away from home.  She went to the emergency room and they determined she needed an Appendectomy.  Sally was admitted to the hospital and the surgery was performed. The surgery was successful, and Sally was discharged.  Sally had insurance with a large deductible.

SIX TO EIGHT MONTHS LATER:

The bills started to roll in; from the hospital, numerous doctors, etc.  Sally’s mom was overwhelmed and asked the team at Escaping the Healthcare Prison to review the bills.  The team received a copy of all the bills along with the Explanation of Benefits (EBO’s) from their insurance copy.

THE BILLING AND EOB REVIEW:

The team started to match the bills to the EOB’s.  This step is critical because all the claim processing transactions on the EOB should be the same as they are on the bills. In Sally’s case, all EOB’s matched up with bills with the exception of one, the Hospital bill. There was one missing transaction on the EOB that did not appear on the bill, an $850 adjustment.  The adjustment was the difference between what the insurance agreed to pay versus the hospital retail charges. The hospital should have adjusted the bill by that amount.  The team secured a release from Sally and called the hospital.  The hospital was surprised, and customer service representative said they needed to talk with their supervisor and would call us back. Several days later we received a called from the hospital apologizing for the error and adjusted the bill for the $850.  Sally was incredibly grateful.

TAKE AWAY REGARDING MEDICAL BILLING:

  1. Always match you EOB’s with the bills received from your hospital, doctor, etc… Never assume the bills are correct. Studies have shown that 8% of the bill’s consumers receive are wrong.
  2. If you detect a difference between your EOB and bill, call the healthcare provider and ask them why. Be professional but demanding…they owe you an explanation.

Your team at Escaping the Healthcare Prison is always there to help the consumer.  Use our website to let us know how we can help.

www.escapingthehealthcareprison.org

Job-Based Health Insurance Costs Are Up 4% This Year, 55% in Past Decade Says Kaiser Health News

Health insurance costs for Americans who get their coverage through work continued a relentless march upward with average family premiums rising 4% to $21,342 this year, according to a study published Thursday.

The annual survey by KFF found workers on average are paying nearly $5,600 this year toward family coverage, up from about $4,000 in 2010 and $1,600 in 2000. (KHN is an editorially independent program of KFF.)

While health insurance costs rose a modest amount in 2020, as has been the trend in recent years, they soared 55% in the past decade — more than twice the pace of inflation and wages.

About 157 million Americans rely on employer-sponsored coverage — far more than any other type of coverage, including Medicare, Medicaid and individually purchased insurance on the Affordable Care Act exchanges. More than half of employers provide insurance to at least some workers.

“Conducted partly before the pandemic, our survey shows the burden of health costs on workers remains high, though not getting dramatically worse,” Drew Altman, KFF’s CEO, said in a statement. “Things may look different moving forward as employers grapple with the economic and health upheaval sparked by the pandemic.”

The survey was conducted from January to July as the coronavirus pandemic took hold and upended the nation’s economy. Many of the details of the employers’ plans that the research examined were set before the virus hit.

Since 2012, the cost of family coverage has increased 3% to 5% annually. It’s been more than 15 years since these costs were rising at double-digit rates.

Employers help shield workers from much of the cost of their health insurance premiums, though employees often feel the impact via higher deductibles, copayments and lower wages.

On average, workers pay 17% of the premium for single coverage and 27% for family coverage, the survey found. Workers at smaller companies pay 35% of the premium for family coverage, compared with 24% for larger companies, the survey found.

The average annual deductible for single coverage is now $1,644, up 25% in the past five years and 79% in the past decade.

Workers with coverage are exposed to higher costs when using the hospital since 65% have coinsurance, which means they are responsible for a fixed share of the charge, and 13% contribute a copayment, or fixed fee per visit or service. The average coinsurance for hospital admission is 20% and average copayment is $311 per hospital admission.

Workers are protected for catastrophic costs through limits set on their out-of-pocket spending in provider networks, although those amounts vary by employer: 11% face a maximum of less than $2,000, while 18% are in a plan with a maximum of $6,000 or more.

The study also noted that large employers have made it easier for workers to access care by adopting coverage for telemedicine in recent years. Nearly 9 in 10 companies that have 200 or more workers and offer insurance covered these medical appointments done via telephone or computer this year, up from fewer than 3 in 10 in 2015, according to the research. During the pandemic, telemedicine usage has increased markedly as people sought care from the safety of their home.

The KFF study is based on a telephone survey of 1,765 randomly selected nonfederal public and private employers with three or more workers from January to July.

Heartbreaking Bills, Lawsuit and Bankruptcy — Even With Insurance Kaiser Health News


Matthew Fentress was just 25 when he passed out while stuffing cannolis as a cook for a senior living community six years ago. Doctors diagnosed him with viral cardiomyopathy, heart disease that developed after a bout of the flu.

Three years later, the Kentucky man’s condition had worsened, and doctors placed him in a medically induced coma and inserted a pacemaker and defibrillator. Despite having insurance, he couldn’t pay what he owed the hospital. So Baptist Health Louisville sued him and he wound up declaring bankruptcy in his 20s.

“The curse of being sick in America is a lifetime of debt, which means you live a less-than-opportune life,” said Fentress, who still works for the senior facility, providing an essential service throughout the coronavirus pandemic. “The biggest crime you can commit in America is being sick.”

Financial fears reignited this year when his cardiologist suggested he undergo an ablation procedure to restore a normal heart rhythm. He said hospital officials assured him he wouldn’t be on the hook for more than $7,000, a huge stretch on his $30,000 annual salary. But if the procedure could curb the frequent extra heartbeats that filled him with anxiety, he figured the price was worth it.

He had the outpatient procedure in late January and it went well.

Afterward, “I didn’t have the fear I’m gonna drop dead every minute,” he said. “I felt a lot better.”

Then the bill came.

Patient: Matthew Fentress is a 31-year-old cook at Atria Senior Living who lives in Taylor Mill, Kentucky. Through his job, he has UnitedHealthcare insurance with an out-of-pocket maximum of $7,900 — close to the maximum allowed by law.

Total Bill: Fentress owed a balance of $10,092.13 for cardiology, echocardiography and family medicine visits on various dates in 2019 and 2020. UnitedHealthcare had paid $28,920.52 total, including $27,561.37 for the care he received on the day of his procedure.

Service Provider: Baptist Health Louisville, part of the nonprofit system Baptist Health.

Medical Service: Fentress underwent cardiac ablation this year on Jan. 23. The outpatient procedure involved inserting catheters into an artery in his groin that were threaded into his heart. He also had related cardiology services, testing and visits to a primary care doctor and a cardiologist before and after the procedure.

What Gives: Fentress said he always made sure to take jobs with health insurance, “so I thought I’d be all right.”

But like nearly half of privately insured Americans under age 65, he has a high-deductible health plan, a type of insurance that experts say often leaves patients in the lurch. When he uses health providers within his insurer’s network, his annual deductible is $1,500 plus coinsurance. His out-of-pocket maximum is $7,900, more than a quarter of his annual salary.

Fentress owed around $5,000 after his 2017 hospitalization and set up a monthly payment plan but said he was sent to collections after missing a $150 payment. He declared bankruptcy after the same hospital sued him.

He faced another bill about a year later, when a panic attack sent him to the emergency room, he said. That time, he received financial aid from the hospital.

When he got the bill for his ablation this spring, he figured he wouldn’t qualify for financial aid a second time. So instead of applying, he tried to set up a payment plan. But hospital representatives said he’d have to pay $500 a month, he said, which was far beyond his means and made him fear another spiral into bankruptcy.

This precarious situation makes him “functionally uninsured,” said author Dave Chase, who defines this as having an insurance deductible greater than your savings. “It’s a lot more frequent than a lot of people realize,” said Chase, founder of Health Rosetta, a firm that advises large employers on health costs. “We’re the undisputed leaders in medical bankruptcy. It’s a sad state of affairs.”

Jennifer Schultz, an economics professor and co-director of the Health Care Management program at the University of Minnesota-Duluth, said Fentress faces a difficult financial road ahead. “Once you declare bankruptcy, your credit rating is destroyed,” she said. “It will be hard for a young person to come back from that.”

recent survey by the Commonwealth Fund found that just over a quarter of adults 19 to 64 who reported medical bill problems or debt were unable to pay for basic necessities like rent or food sometime in the past two years. Three percent had declared bankruptcy. In the first half of 2020, the survey found, 43% of U.S. adults ages 19 to 64 were inadequately insured. About half of them were underinsured, with deductibles accounting for 5% or more of their household income, or out-of-pocket health costs, excluding premiums, claiming 10% or more of household income over the past year.

In Fentress’ case, the $10,092 he owed the hospital was more than a third of what his insurer paid for his care. The majority of his debt — $8,271.56 — was coinsurance, about 20% of the bill, which he must pay after meeting his deductible. Because the bill covered services spanning two years, he owed more than his annual out-of-pocket maximum. If all his care had been provided during 2019, he would have owed much less and the insurer would have been responsible for more of the bill.

Dr. Kunal Gurav, an Atlanta cardiologist who wrote about medical costs for the American College of Cardiology, said ablation usually costs about $25,000-$30,000, a range also confirmed by other experts.

The insurer’s payment for Fentress’ care that January day — around $27,600 — falls into the typical cost range, Gurav said. Fentress is being asked to pay $9,296, meaning the hospital would get more than $36,000 for the care.

Schultz, a state representative from Minnesota’s Democratic-Farmer-Labor Party, said nonprofit hospitals could potentially waive or reduce costs for needy patients.

“They definitely have a moral responsibility to provide a community benefit,” she said.

Resolution: Charles Colvin, Baptist Health’s vice president for revenue strategy, said hospital officials quoted Fentress an estimated price for the ablation that was within a few dollars of the final amount, although his bill included other services such as tests and office visits on various dates. Colvin said there appeared to be some charges that UnitedHealthcare didn’t process correctly, which could lower his bill slightly.

Maria Gordon Shydlo, communications director for UnitedHealthcare, said Fentress is responsible for 100% of health costs up to his annual, in-network deductible, then pays a percentage of health costs in “coinsurance” until he reaches his out-of-pocket maximum. So he will owe around $7,900 on his bill, she said, and any new in-network care will be fully covered for the rest of the year.

A hospital representative suggested Fentress apply for financial assistance. She followed up by sending him a form, but it went to the wrong address because Fentress was in the process of moving.

In September, he said he was finally going to fill out the form and was optimistic he’d qualify.

The Takeaway: Insurance performs two functions for those lucky enough to have it. First, you get to take advantage of insurers’ negotiated rates. Second, the insurer pays the majority of your medical bills once you’ve met your deductible. It pays nothing before then. High-deductible plans have the lowest premiums, so they are attractive or are the only plans many patients can afford. But understand you will be asked to pay for everything except preventive care until you’ve hit that number. And your deductible may be only part of the picture: “Coinsurance” is the bulk of what Fentress owes.

Out-of-pocket maximums are regulated by federal law. In 2021, the maximum will be $8,550 for single coverage. Try to plan treatment and procedures with an eye on the calendar — people with chronic conditions and this kind of insurance could save a lot of money if they have an expensive surgery in December rather than January.

As always, if you face a big medical bill, ask about payment plans, financial aid and charity care. According to the Baptist Health system’s website, the uninsured and underinsured can get discounts. Those with incomes equivalent to 200%-400% of the federal poverty level — or $25,520-$51,040 for an individual — may be eligible for assistance.

If you don’t qualify for help, negotiate with the hospital anyway. Arm yourself with information about the going rate insurers pay for the care you received by consulting websites like Healthcare Bluebook or Fair Health.

As Fentress tries to move past his latest bill, he’s now worried about something else: racking up new bills if he contracts COVID-19 down the road as an essential worker with existing health problems and the same high-deductible insurance.

“I don’t have hope for a financially stable future,” he said. “It shouldn’t be such a struggle.”

Dan Weissmann, host of “An Arm and a Leg” podcast, reported the radio interview of this story. Joe Neel of NPR produced Sacha Pfeiffer’s interview with KHN Editor-in-Chief Elisabeth Rosenthal on “All Things Considered.”

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! COPY HTML

ALERT!!!! Is Your Hospital Rated 1 Star by Medicare Their Lowest Rating!!!

CMS updated its Overall Hospital Quality Star Ratings Jan. 28, recognizing 228 hospitals with one star.

CMS’ Hospital Compare website reports on quality measures for more than 4,500 hospitals nationwide. Here is a breakdown of the updated star ratings:

  • One star: 228 hospitals
  • Two stars: 710 hospitals
  • Three stars: 1,191 hospitals
  • Four stars: 1,136 hospitals
  • Five stars: 407 hospitals

Below is a listing of CMS’ one-star hospitals, broken down by state, as listed on the Hospital Compare website. To view a list of CMS’ five-star hospitals, click here.

Arkansas

Baptist Health-Fort Smith

Chi-St. Vincent Infirmary (Little Rock)

Conway Regional Health System

Jefferson Regional Medical Center (Pine Bluff)

National Park Medical Center (Hot Springs)

St. Bernards Medical Center (Jonesboro)

Uams Medical Center (Little Rock) 

California

Adventist Health and Rideout (Marysville)

Antelope Valley Hospital (Lancaster)

Beverly Hospital (Montebello) 

Community Regional Medical Center (Fresno)

Doctors Hospital Of Riverside

Emanuel Medical Center (Turlock)

Hemet Valley Medical Center

Hollywood Presbyterian Medical Center (Los Angeles)

Kern Medical Center (Bakersfield)

LAC+USC Medical Center (Los Angeles)

Madera Community Hospital

Memorial Hospital Of Gardena

Menifee Global Medical Center (Sun City)

Mercy Hospital (Bakersfield)

Mercy Medical Center (Merced)

Mercy Medical Center Redding

O’Connor Hospital (San Jose)

Pioneers Memorial Healthcare District (Brawley)

Riverside University Health System-Medical Center (Moreno Valley)

San Joaquin General Hospital (French Camp)

San Leandro Hospital  

Sierra View Medical Center (Porterville)

St. Bernardine Medical Center (San Bernardino)

St. Joseph’s Medical Center (Stockton)

St. Mary Medical Center (Apple Valley) 

Twin Cities Community Hospital (Templeton)

USC Verdugo Hills Hospital (Glendale)

Victor Valley Global Medical Center (Victorville)

Zuckerberg San Francisco General Hospital and Trauma Center

Connecticut

Charlotte Hungerford Hospital (Torrington)

Waterbury Hospital 

Florida

AdventHealth Lake Wales 

AdventHealth New Smyrna Beach

Bayfront Health-Brooksville

Bayfront Health-Port Charlotte  

Bayfront Health-Punta Gorda 

Bayfront Health-Seven Rivers (Crystal River)

Blake Medical Center (Bradenton)

Boca Raton Regional Hospital

Broward Health Coral Springs  

Broward Health North (Pompano Beach)

Cleveland Clinic Martin North Hospital (Stuart)

Halifax Health Medical Center (Daytona Beach)

Jackson Memorial Hospital (Miami)

JFK Medical Center (Atlantis)

Lakeland Regional Medical Center

Lawnwood Regional Medical Center and Heart Institute (Fort Pierce)

Manatee Memorial Hospital (Bradenton)

North Shore Medical Center (Miami)

Parrish Medical Center (Titusville)

Steward Melbourne Hospital  

The Villages Regional Hospital 

Wellington Regional Medical Center 

Westside Regional Medical Center (Plantation)

Winter Haven Hospital

Georgia

Augusta University Medical Center (Augusta)

Coffee Regional Medical Center (Douglas)

Emory Decatur Hospital  

Grady Memorial Hospital (Atlanta)

The Medical Center, Navicent Health (Macon)

Memorial Health University Medical Center (Savannah)

Phoebe Putney Memorial Hospital (Albany)

Piedmont Columbus Regional-Midtown  

Piedmont Rockdale Hospital (Conyers)

Piedmont Walton Hospital (Monroe)

WellStar Atlanta Medical Center  

Iowa

St. Luke’s Regional Medical Center (Sioux City)

Illinois

Franciscan Health Olympia Fields

Gateway Regional Medical Center (Granite City)

Jackson Park Hospital (Chicago)

John H. Stroger Jr. Hospital (Chicago)

Louis A. Weiss Memorial Hospital (Chicago)

Mercy Hospital and Medical Center (Chicago) 

Mount Sinai Hospital (Chicago) 

OSF Saint Francis Medical Center (Peoria)

University of Illinois Hospital (Chicago)

Kansas

St. Catherine Hospital (Garden City)

Kentucky

Hazard ARH Regional Medical Center

Highlands Regional Medical Center (Prestonsburg)

Jennie Stuart Medical Center (Hopkinsville)

Paul B. Hall Regional Medical Center (Paintsville)

Pikeville Medical Center

The Medical Center at Bowling Green

University of Kentucky Hospital (Lexington)

University of Louisville Hospital

Louisiana

Jennings American Legion Hospital  

Ochsner LSU Health Shreveport

Tulane Medical Center (New Orleans)

University Medical Center New Orleans

Massachusetts

Good Samaritan Medical Center (Brockton)

MelroseWakefield Healthcare (Melrose)

Morton Hospital (Taunton)

Sturdy Memorial Hospital (Attleboro)

UMass Memorial Medical Center (Worcester)

Maryland

University of Maryland Prince George’s Hospital Center (Cheverly) 

University Of Maryland Medical Center (Baltimore) 

University Of Maryland Laurel Regional Hospital  

Michigan

Detroit Receiving Hospital and University Health Center

Hurley Medical Center (Flint)

Sinai-Grace Hospital (Detroit)

Mississippi

Baptist Memorial Hospital-Desoto (Southaven)

Delta Regional Medical Center (Greenville)

Forrest General Hospital (Hattiesburg)

Memorial Hospital at Gulfport  

Merit Health River Region (Vicksburg) 

Southwest Mississippi Regional Medical Center (McComb)

St. Dominic-Jackson Memorial Hospital 

University Of Mississippi Med Center (Jackson)

Missouri

Christian Hospital Northeast-Northwest (St. Louis)

Poplar Bluff Regional Medical Center

SoutheastHealth (Cape Girardeau)

SSM Health St. Louis University Hospital  

Nebraska

Regional West Medical Center (Scottsbluff)

Nevada

Desert Springs Hospital (Las Vegas)

Spring Valley Hospital Medical Center (Las Vegas)

Summerlin Hospital Medical Center (Las Vegas)

Sunrise Hospital And Medical Center (Las Vegas)

University Medical Center (Las Vegas)

Valley Hospital Medical Center (Las Vegas)

New Jersey

Carepoint Health-Christ Hospital (Jersey City)

Carepoint Health-Hoboken University Medical Center

East Orange General Hospital  

Hackettstown Medical Center  

Inspira Medical Center Vineland

JFK Medical Center-Anthony M. Yelencsics Community (Edison)

Salem Medical Center

St. Joseph’s University Medical Center (Paterson)

Trinitas Regional Medical Center (Elizabeth)

University Hospital (Newark)

New Mexico

MountainView Regional Medical Center (Las Cruces)

UNM Hospital (Albuquerque)

New York

Albany Medical Center Hospital

Alice Hyde Medical Center (Malone) 

Auburn Community Hospital

Bellevue Hospital Center (New York City)

Bronx-Lebanon Hospital Center (New York City)

Brookdale Hospital Medical Center (New York City)

Brooklyn Hospital Center at Downtown Campus (New York City)

Columbia Memorial Hospital (Hudson)

Coney Island Hospital Center (New York City)

Crouse Hospital (Syracuse)

Eastern Niagara Hospital (Lockport)

Ellis Hospital (Schenectady)

Elmhurst Hospital Center  

Faxton-St. Luke’s Healthcare (Utica)

Flushing Hospital Medical Center (New York City)

Geneva General Hospital

Good Samaritan Hospital Medical Center (West Islip)

Good Samaritan Hospital of Suffern

Harlem Hospital Center (New York City)

Interfaith Medical Center (New York City)

Jacobi Medical Center (New York City)

Jamaica Hospital Medical Center (New York City)

Jones Memorial Hospital (Wellsville)

Kings County Hospital Center (New York City)

Kingsbrook Jewish Medical Center (New York City)

Lincoln Medical & Mental Health Center (New York City)

Long Island Community Hospital (Patchogue)

Maimonides Medical Center (New York City)

Mary Imogene Bassett Hospital (Cooperstown)

Mercy Medical Center (Rockville Centre)

Montefiore Medical Center (New York City)

Nassau University Medical Center (East Meadow) 

Queens Hospital Center (New York City)

Richmond University Medical Center (New York City)

Rochester General Hospital 

St. Barnabas Hospital (New York City)

St. Catherine of Siena Medical Center (Smithtown)

St. Elizabeth Medical Center (Utica)

St. John’s Episcopal Hospital (New York City)

St. Joseph’s Medical Center (Yonkers)

Staten Island University Hospital (New York City)

United Health Services Hospitals (Binghamton)

University Hospital of Brooklyn-SUNY Downstate (New York City)

Vassar Brothers Medical Center (Poughkeepsie)

Westchester Medical Center (Valhalla)

Wyckoff Heights Medical Center (New York City)

North Carolina

Halifax Regional Medical Center (Roanoke Rapids)

Nash General Hospital (Rocky Mount)

Ohio

Clinton Memorial Hospital (Wilmington)

East Ohio Regional Hospital (Martins Ferry)

Trumbull Regional Medical Center (Warren)

University of Toledo Medical Center

Oklahoma

Comanche County Memorial Hospital (Lawton)

Hillcrest Medical Center (Tulsa)

OU Medicine (Oklahoma City)

Saint Francis Hospital Muskogee 

Pennsylvania

Albert Einstein Medical Center (Philadelphia)

Conemaugh Memorial Medical Center (Johnstown)

Hahnemann University Hospital (Philadelphia)

Pottstown Hospital  

Regional Hospital of Scranton  

Thomas Jefferson University Hospital (Philadelphia)

Wilkes-Barre General Hospital

Puerto Rico

Auxilio Mutuo Hospital (San Juan)

Doctors’ Center Hospital-San Juan 

Doctors’ Center Hospital (Manati)

Hima San Pablo-Bayamon 

Hima San Pablo-Caguas

Rhode Island

Rhode Island Hospital (Providence)

South Carolina

Trident Medical Center (Charleston)

The Regional Medical Center of Orangeburg and Calhoun (Orangeburg)

Tennessee

Holston Valley Medical Center (Kingsport)

Jackson-Madison County General Hospital  

Johnson City Medical Center  

Methodist Medical Center of Oak Ridge  

Texas

City Hospital at White Rock (Dallas)

Coleman County Medical Center  

HCA Houston Healthcare Tomball  

Huntsville Memorial Hospital  

Medical Center Hospital (Odessa)

Southwest General Hospital (San Antonio)

Virginia

Bon Secours Maryview Medical Center (Portsmouth)

Wisconsin

Ascension All Saints Hospital (Racine)

West Virginia

Charleston Area Medical Center

Wheeling Hospital

Washington, D.C.

George Washington University Hospital  

Howard University Hospital  

Medstar Georgetown University Hospital

Medstar Washington Hospital Center

HOW I ESCAPED THE BIG PHARMA PRISON


The team at Escaping the Healthcare Prison is dedicated to showing how healthcare consumers can escape their PRISON. Each of us has been a healthcare prisoner one time or another.  The spectrum of issues is endless.  Our monthly ESCAPE PLANS will help you navigate the healthcare maze. 

HOW I ESCAPED THE BIG PHARMA PRISON

BACK ROUND:

Jim, a 59-year-old male recently had his yearly check up with his specialty doctor.   Jim and his doctor were reviewing his prescriptions of which one was specialty drug not covered by his insurance.  Jim asked his doctor to renew all his prescriptions with his local Pharmacy.  The specialty drug was included.  Jim knew the drug was not covered under is insurance plan. Jim had never bought the prescription because it was of the high cost.

SEVERAL DAYS LATER:

Jim received a call from the Pharmacy that his prescriptions were ready, but the specialty drug was not covered.  They advised him to find a coupon and bring it in.  Jim heard about companies that helped consumers reduce their drug costs. Jim looked up the drug on Good RX and found a coupon for 30 pills for $19.85. Jim printed the coupon and went to Pharmacy.

THE PHARMACY:

Jim arrived at the pharmacy to pick up his prescription. The pharmacist told Jim prescription for his speciality drug was priced at $2,164.49 for 30 pills.  This is the cash and carry price. They asked Jim if he brought in a coupon.  Jim presented the Good RX coupon, the Pharmacy accepted it and Jim paid $19.85. Jim saved $2,144.64. Remember, in previous years Jim never bought the prescription because it was too expensive, and he did not realize how Good RX works.  Also, congratulations to Pharmacy for suggesting to Jim to check on coupons. 

TAKE AWAY REGARDING PRESCITIONS:

  1. Always check on Good RX or similar companies the cost of your prescription and compare the Good RX cost with your insurance co pays.  You may be surprised to find out that they are cheaper.
  2. If you do not have insurance or your insurance will not cover the prescription, always check Good RX or other similar companies. 
  3. Shopping healthcare is the future.  Start small and work up to the bigger purchases. 

Your team at Escaping the Healthcare Prison is always there to help the consumer.  Use our website to let us know how we can help.

www.escapingthehealthcareprison.org


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