Archive for the ‘Blog’ Category

After Accident, Patient Crashes Into $700,000 Bill for Spine Surgery; Published By Kaiser Health News

Mark Gottlieb’s life changed in an instant when another driver crashed into his car, damaging four vertebrae in his upper spine and smashing six teeth.

In the months following that January 2019 crash, Gottlieb got the teeth crowned and, for debilitating neck pain, tried injections, chiropractic care and physical therapy. The treatments were all covered by his car insurance.

New Jersey law, as in 12 other states, requires drivers to buy personal injury protection, or PIP, coverage to pay medical expenses. Gottlieb had the maximum: $250,000.

Unfortunately, Gottlieb’s pain persisted. “Nothing was working. The only other thing was surgery,” he said.

Though he wanted his operation performed near his home, Gottlieb said, staff members at the Bergen Pain Management clinic, where he was receiving care, insisted he go to Hudson Regional Hospital in Secaucus. On April 3, 2020, Gottlieb underwent a complex type of fusion surgery on the herniated discs in his cervical spine. He went home the same day.

His pain improved a bit. Then the bills came.

The Patient: Mark Gottlieb, 59, a marketing consultant in Little Ferry, New Jersey, covered for $250,000 in medical costs by his Geico car insurance. He also has an Aetna health insurance policy, which is secondary.

Medical Service: Anterior cervical discectomy and fusion, a type of neck surgery to replace damaged discs with bone grafts or implants to stabilize the spine.

Service Provider: Hudson Regional Hospital, a stand-alone, for-profit facility in Secaucus, New Jersey, and Bergen Pain Management in Paramus, New Jersey.

Total Bill: Taken together, the hospital and surgeon billed Gottlieb more than $700,000. The hospital billed $445,995 for the surgery, an amount reduced to$133,778 by Geico, which ultimately paid $103,354. Bergen Pain Management billed an additional $264,444 for the main surgeon. Based on a review, Geico reduced that to $141,548. It paid $52,365 toward that before Gottlieb’s medical coverage in his auto policy was exhausted. Then it was up to his health insurer or Gottlieb to deal with the rest.

What Gives: When injuries are the result of auto accidents, car insurance is primarily responsible to negotiate and pay the insurance portion of medical bills. That creates a host of financial landmines for patients.

Gottlieb hit all of them.

With the high charges common in the U.S. for treatment, accident victims can easily exhaust the policy limits of even generous personal injury coverage, leaving some vulnerable to huge bills.

Although it’s rare to hear car insurers complain that they paid a hospital or doctor too much, auto insurers “typically pay more for some of the same services” than health insurers, said Robert Passmore, a vice president at the American Property Casualty Insurance Association, a trade group.

That’s in part because auto insurers generally don’t have broad networks of medical providers who have agreed to negotiated discounts off their billed charges, as do health insurers. So patients end up “out of network,” subject to whatever list price the provider charges.

Gottlieb said he checked with Geico before his surgery but was told it had no information for him about networks. With about $190,000 remaining in his PIP fund at the time, he was not too worried. He said efforts to get cost estimates were unsuccessful.

Instead of network rates, car insurers generally use other payment calculations. Some states set specific payments on fee schedules. But not every medical billing code is listed and, in those cases, they sometimes pay whatever the provider bills.

In this case, that was a lot: Gottlieb’s hospital and surgeon’s charges, even after being reduced by Geico, were about eight times as high as what Medicare would have paid.

While Geico generally pays rates set by the state (which are dramatically lower than what was charged), Gottlieb’s bill included a bunch of billing codes not on the state schedule. For most, the insurer paid exactly what was charged. For example, Geico allowed the full price of $65,125 charged by the surgeon for the removal of a damaged disc and paid the hospital $39,195 for nine surgical screws.

By September — with bills from his various providers still rolling in — Gottlieb’s PIP fund ran out after the remaining $52,365 was paid to Bergen Pain Management, short of the $141,548 Geico had recommended as reimbursement for the surgeon.

Insurance pays bills as they are submitted, which is often not in the order in which the treatment was rendered.

“It appears that Bergen Pain Management is still entitled to the $89,183 balance of the billing from your procedure,” Geico wrote in a September letter to Gottlieb, which added that he could submit that balance to his health insurer or pay it himself.

When he submitted the surgeon’s bill to Aetna, he discovered neither the doctor nor hospital was in his insurance network. He had not checked before the operation since he never dreamed that outpatient surgery would exhaust the auto policy.

That means Aetna did not have a negotiated rate with his providers, which might have knocked the charges down dramatically.

Instead, Aetna said it would allow an out-of-network payment of $4,051 for the surgeon, according to a Jan. 28 email to Gottlieb. In a written statement to KHN, Aetna spokesperson Ethan Slavin said that amount was based on Gottlieb’s policy terms, which set physician payments about 10% above Medicare rates for out-of-network care.

Because he had not yet met his annual out-of-network deductible, Gottlieb himself would have to pay the $4,051. He withdrew his request for Aetna to pay. Because out-of-network surgeons frequently go after patients to pay the balance of such bills, Gottlieb is waiting to see if Bergen Pain Management — which has already been paid $52,365 for the surgery — will come after him for more.

Neither the Bergen clinic nor the surgeon has sent him to collections or sued for the amount. Neither responded to multiple emails and phone calls placed by KHN seeking comment.

In a written statement, Hudson Regional spokesperson Ron Simoncini said the hospital “charged the state-mandated fee” where applicable, and where there was no such mandate, “the charges were reasonable.” It is not seeking additional payment.

Citing policyholder privacy, Geico declined to answer KHN’s questions, including how it determines what it will pay.

Did the auto insurer pay too much?

Geico had set an allowable reimbursement of $141,548 as the surgeon’s fee.

“That is an outrageously high surgeon’s fee for this type of surgery,” said Dr. Eeric Truumees, a professor at Dell Medical School at the University of Texas-Austin.

“I do a tremendous amount of complex cervical spine surgery and never had a fee that high even for complex surgery that takes 10 hours,” said Truumees, president of the North American Spine Society. He had no direct knowledge of Gottlieb’s case.

Altogether, Geico recommended and partly paid nearly $245,000 to the hospital and surgeon for the procedure.

In contrast, Medicare would have paid about $29,500 for the entire procedure, with about $1,800 of that going to the surgeon and the rest to the hospital, according to researchers at Rand Corp. who analyzed Gottlieb’s bills at KHN and NPR’s request.

The surgeon’s bill was also high compared with what private insurance usually pays, according to Barry Silver of Healthcare Horizons Consulting Group in Knoxville, Tennessee. Silver compared Gottlieb’s bills with hundreds of similar claims from two carriers that administer employer-based health insurance nationwide. The total Geico paid the hospital was in line with what employers paid and was actually less than the two highest fees seen in his data. But the highest allowed charge in Silver’s database for the surgeon’s fee was $87,549, far less than the $141,458 Geico recommended.

Resolution: Gottlieb remains in the dark about whether Bergen Pain Management will seek the remaining $89,000 toward his bill.

Previously, Gottlieb sued the driver who caused the accident — and won a substantial “pain and suffering” court settlement. He wants to preserve it for future medical needs.

He has filed numerous complaints about his bills with state regulators, lawmakers and his insurers. Aetna sent his surgeon’s bill to its internal Special Investigations Unit following his complaint.

But, “based on our investigation, we determined there was no further need for action,” spokesperson Slavin said.

The Takeaway: Most people are unaware that auto insurance kicks in first after an accident and that it works very differently from health insurance — so you have to pay attention to how the policies coordinate.

That’s especially true if the accident requires major treatment.

If you have a low amount of personal injury coverage in your car policy, your medical bills may well kick over to your health policy. So when you sign up for nonemergency treatment — especially if it’s extensive, like surgery — it’s important to make sure the providers are in your health insurer’s network.

Some auto insurers have networks. Ask whether yours does.

Try to get cost estimates in writing for nonemergency care and compare that with what you have left in your auto policy coverage.

“If it’s more than you have left, it may be possible to negotiate with the hospital or doctor to reduce their charges,” said Silver at Healthcare Horizons.

CMS Hospital Mandated: Their 70 Shoppable Services: A Listing of the Services with the Appropriate CPT or DRG Codes Consumers Need to Know

Trump Rule Gives Small Companies a New Tool to Help Workers Buy Health Coverage

Until October, Andrea LaRew was paying $950 a month for health insurance through her job at the Northwest Douglas County Chamber & Economic Development Corp. in the metro Denver area.

Her company didn’t contribute anything toward the premium. Plus, LaRew and her husband had a steep $13,000 deductible for the plan. But the coverage and the premium cost were in line with other plans available to the company since options for such a small work group — just LaRew and another employee wanted to enroll — weren’t plentiful.

Now they’re trying a new approach. Instead of a traditional plan, the chamber established an “individual coverage health reimbursement arrangement” (sometimes referred to as ICHRA) to which it allocates $100 a month per employee that they must put toward comprehensive coverage on the individual insurance market. These employer contributions may be used to pay for expenses such as premiums or cost sharing.

The reimbursements don’t count as taxable income to workers.

Proponents of the plans say they’re a good option for companies that may not feel they can afford to offer a traditional plan to workers but want to give them something to help with health care expenses. But consumer advocates are concerned they may shortchange some workers.

These small businesses can’t afford to offer health care coverage as the premium prices rise, said Garry Manchulenko, a principal at GMBA Advisors Group in the Denver metro area, who suggested the arrangement to the chamber. “They want to help their employees, but they can’t sustain these increases, particularly at the small-group level.”

Manchulenko said he’s suggesting the new setup for some of his clients, noting that in certain places premiums on the individual market are lower than those for group plans.

LaRew, 48, bought a plan similar to the group plan, but with a monthly price tag of $730 after she factors in the company’s contribution, a savings of more than $2,600 a year.

“It’s still super expensive for two healthy people,” said LaRew, who oversees many of the chamber’s administrative functions. But she appreciates that her premiums are deducted from her pretax income, just as when she was on the group plan.

She also liked having her pick of several plans. “I could choose my own individual plan that suits my family best, and not be tied to a group plan that works great for a co-worker but not for me.”

The new coverage option was established through a rule issued by the Trump administration last year. It could be helpful for workers like LaRew whose income is too high to qualify for the Affordable Care Act’s tax credits that help pay for policies sold on the individual market. It may also be attractive to part-time or seasonal workers who don’t qualify for their employer’s coverage, according to insurance brokers and policy experts familiar with the new option.

But consumer advocates warned that it could encourage employers who had offered a traditional insurance plan to switch to the new arrangement because of the cost savings. That might leave their workers with a more cumbersome enrollment process and less generous coverage.

“I do think there are pitfalls for employees,” said Jason Levitis, a nonresident fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “There’s confusion about the ICHRAs themselves.”

“And even if you know you need an ACA-compliant plan, how do you find one?” he asked, noting the prevalence of deceptive marketing of plans that don’t meet ACA standards.

In addition, because of a quirk in how the new rules work, lower-income workers who bought ACA marketplace plans because their employer didn’t offer coverage could lose the federal subsidies for their marketplace plans if their company puts an ICHRA in place.

Here’s how that could come into play. Only people earning 400% of the federal poverty level or less (about $51,000 for one person) are eligible for premium subsidies. In addition, in order to qualify the coverage offered by an employer must be considered unaffordable to the worker. If an employer offers an individual coverage health reimbursement arrangement, that means workers who would otherwise meet the poverty threshold would also have to contribute more than 9.78% of their income to buy the lowest-cost individual silver plan on the exchange. That amount would be based on the plan’s cost after factoring in the contribution from an employer.

If the worker’s contribution is lower than that standard, then the only assistance they are eligible for is through the ICHRA contribution. Federal rules don’t allow workers to accept both ICHRA contributions and premium tax credits.

“My concern is for people who are out there with a premium tax credit” who might lose that subsidy if they don’t meet the federal standard, said Peter Newell, director of the Health Insurance Project for the United Hospital Fund in New York, who authored an analysis of the new coverage option in October.

There are affordability caps in the ACA for regular employer-sponsored coverage, too, but those caps are generally lower than the caps for ICHRAs. As employers move to offer ICHRAs instead of traditional coverage, some workers will lose their premium tax credits because of the higher affordability threshold, Newell’s analysis found.

If this sounds complicated, it’s because it is, and brokers and advocates agree that many workers will need assistance figuring out what to do. In addition to running the numbers, people may need to work through where to buy a comprehensive plan that complies with the ACA. Such plans can be purchased on and off the exchange, but if workers want the company to deduct their premium costs from their salary, as LaRew did, they must purchase a plan outside of the exchange.

“There are so many paths to take and so many points of confusion, it’s super, super important that employees have some support going through this,” said Cat Perez, co-founder and chief product officer at Health Sherpa, whose technology platform helps people enroll in marketplace plans. It has incorporated information about ICHRAs.

Colorado is working with the broker community to drum up interest in the new product, said Kevin Patterson, chief executive officer of Connect for Health Colorado, the state’s insurance exchange.

“If we can get more people into the individual marketplace that makes it stronger,” Patterson said.

In theory that makes sense, but some analysts worry that the adoption of these new arrangements could drive up marketplace premiums by encouraging employers with sick workers to shift them into the individual market.

“This is a way to offer a lower premium option to some employers, but with the consequence of increasing premiums in the individual market and costs for the federal government via higher premium tax credits,” said Matthew Fiedler, a fellow in economic studies at USC-Brookings, who co-authored an analysis of the new offerings.

Still, larger employers aren’t currently very interested in embracing these new arrangements, said Jay Savan, a partner at human resources consultant Mercer.

The federal rules don’t allow employers to offer an employee both a traditional plan and an ICHRA simultaneously, and most large employers aren’t ready to replace their traditional plans.

“As long as it’s black-or-white, there are precious few employers of size that are willing to take that leap,” he said. COPY HTML

Top 82 U.S. Non-Profit Hospitals-Quantifying Government Payments and Financial Assets


In households across America, healthcare costs are crushing the American dream. The average family now pays nearly
$20,000 annually between insurance premiums, deductibles,
and out-of-pockets costs.
In 1970, healthcare amounted to seven-percent of gross
domestic product (GDP). Today, estimates suggest the soaring
cost of healthcare will consume 20-percent of our GDP.
Our OpenTheBooks Oversight Report – Top 82 U.S. Non-Prof-it
Hospitals, Quantifying Government Payments & Financial
Assets studied the largest charitable healthcare providers. Last
year, patients spent roughly 1 out of every 7 U.S. healthcare
dollars within these healthcare networks. Many are household
names: Mayo Clinic, Cleveland Clinic, Kaiser Foundation, Dignity Health, and Partners HealthCare.
These powerful institutions are organized as public charities –
not as for-profit corporations. Their mission is to deliver the
latest in medical technologies and affordable healthcare to
their communities. Any “profits” must be re-invested into their
charitable mission.
However, these 82 non-profit medical providers are making
big money. Last year, their combined net assets increased from
$164.2 billion to $203.1 billion – that’s 23.6-percent growth.*
Meanwhile, their executives are highly compensated. The Banner Health Chief Executive Officer and President earned $21.6
million and their Executive Vice President and CAO made $12
million last year. Top executives at Memorial Hermann Health
System, Kaiser Health, Ascension, Advocate Health Care, and
Northwestern Memorial made between $10 million and $18

For comparison, our analysis also includes the five largest publicly traded for-profit U.S. hospitals. These five corporations
had $96 billion in revenues last year with net asset growth of
$600 million: an increase in assets from $40.1 billion to $40.7
billion year-over-year (1.5% increase).
Taxpayers deserve to know whether our non-profit healthcare
providers, which use our laws to structure themselves as charities, are truly working for patients. After all, these non-profits
pay no income taxes, or property taxes, and raised over $5
billion last year in tax-deductible contributions from donors.

From Prisoner to Customer to Sophisticated Consumer (Continued)

Hopefully you’ve had time to get your medical house in order. You’ve done the research on your family’s medical history. You’ve found the appropriate internal medicine physicians that specialize in whatever chronic issues your family members face. You are now engaged in your medical care.

The topic on the table today continues to be pricing transparency. The debate continues to rage on by skeptics that argue patients have little incentive to “shop” for medical care because insurance insulates them from medical costs. They also point to studies showing few patients use current pricing transparency tools to shop for medical care.

We can be as skeptical as the next person but a recent event bolstered our belief that pricing transparency in a simple, well-constructed form has an important place in health care. Recently, a company we’ve mentioned before, GoodRx, had a public stock offering for over $1 billion and placed the value of the company at $12.6 billion. Simply stated, GoodRx is a pricing transparency company in the pharmaceutical area. The company provides a simple to use and effective way for consumers to obtain significant discounts on prescription drugs. So given Wall Street’s reaction, we believe there is a place for pricing transparency in health care.

Here’s the catch-twenty two. The health care industry doesn’t. There’s seemingly consensus from both providers and insurers that somehow pricing transparency will cause massive damage to their economic interests and not be helpful to patients. From our media scanning, employers can expect estimated increases for 2021 health insurance premiums to be around 5%. Health benefit consultants are continuing to provide solutions to mitigate these increases. Surprisingly, pricing transparency “tools” are now starting to emerge as consultant recommendations as a means of minimizing the impact of these increases.

We recently surveyed a metropolitan area with an aggressive pricing transparency provider that provides a sophisticated website pricing tool. Our thinking was that with a “bell cow” in the market others would be inclined to follow in some reasonable fashion. Our thinking was wrong. There was little to no discernible impact on others’ to provide some means of pricing transparency. What we weren’t able to determine was the “spillover” impact on other organizations’ pricing for similar services.

Our research is providing us with some undeniable facts. The external business environment is moving rapidly further and further away from the business practices of healthcare. Some of this gap is being created by outdated government legislation and some of it is being created by the industry’s resistance to ongoing technology developments. We accidentally stumbled on to an example of how over 20 year old legislation is having what now might be an unintended negative consequence on private contracting between a physician and patient. The Balanced Budget Act of 1997 prevents an Original Medicare Beneficiary from entering into a private contract with a physician. At the time, the thinking was this legislation was providing the patient with “protection”  from inflated prices. In today’s environment, the legislation prevents patients from gaining access to physicians and from negotiating prices. This finding reinforces our belief that neither the government nor significant industry leadership is going to result in a successful pricing transparency movement.

Unleashing market place competitive forces on health care will lower prices despite what skeptics say. Will there be unintended consequences? Sure. There are examples, like reference pricing that have proven successful in lowering prices. This practice has largely been utilized by large organizations with large workforces. So the benefits have been constrained without creating any type of “spillover” impact.

We are now entering a new era in health care. The “Pandemic” has created wide-spread changes in every day life practices. In health care, we’ve seen a tremdous surge in telemedicine which prior to Covid was being strongly resisted by the health care industry. We’ve seen significant changes in how hospitals protect both their employees and patients from infectious disease. We’re now going to see how the country deals with a significant number of people  having lost employment based health care insurance coverage. This is going to unleash huge numbers of people searching for better deals in health care.

We are now asking for your help in creating a health care marketplace where there is transparency in pricing, quality and access. We have relied upon market forces in almost every aspect of our lives. Health care has been “special” and exempted from these forces. We believe the implementation of pricing transparency legislation will be a first step to pulling back the curtain. As consumers we’re critical in this transformation. We need your insights and experiences to share with others. We’re creating a section on our website where patients and consumers can be a community of health care activists. Share your experiences!

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

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

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.

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

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