November 21, 2023

Out For Blood Is Right: Great Example of Outrageous Prices And The Need For Reform

Kaiser Health News, the healthcare news aggregator, also does tremendous original news stories. One of its series is “Bill of the Month,” where it features one person’s heartache related to a recent healthcare bill. In this article, KFF intervened to get the patient’s bill cancelled, but she is among the lucky ones. It is also important to remember that not all surprise bills you receive will suddenly go away under the No Surprises Act. This surprise bill was from an in-network provider (hospital), which was charging outrageous lab fees on everyday tests. The health plan negotiated a poor discount and the patient’s plan had the insured covering a percentage of allowable costs.

The article touches upon the need for site neutral payments to lower costs in the system and protect consumer’s from high costs. Why should hospitals be able to set ridiculously high fees for services that could be done around the corner at a free-standing lab for sometimes pennies on the dollar? Another outrage here — the provider’s behavior. The provider appears to be a hospital-owned (or at least aligned) provider referring to hospital-owned entities (in this case, a lab). This is without regard to the patient’s best interests. The provider knows they will get a surprise bill. Today, over half of all doctors are owned by hospital systems and help further drive up costs by practicing at or referring to costly hospital-owned places of services.

#pricetransparency #hospitals #healthcarereform #siteneutral

Link to Article

The Real-Life Fallout From Medicaid Redeterminations

Another good article from Kaiser Health News on the impact to everyday Americans when their Medicaid coverage is cut off for administrative or procedural reasons during this unprecedented time of redeterminations (which stem from the pause of eligibility requirements during the COVID pandemic). As I have said, states are simply not staffed to handle millions of re-qualifications. The right thing to do would be to phase in the reviews by giving states more time and some additional reimbursement during the timeframe. People deserve a fair review and education on alternative coverage (CHIP, Exchanges, and employer coverage).

#medicaid #aca #exchanges #obamacare #redeterminations #chip

Link to Article

Moody’s Says Health Insurers Have Stable Outlook Despite Challenges

Moody’s says health insurers have a stable outlook at this point. It notes a rise in medical expense that has stabilized. As well it mentions Medicare Advantage (MA) Star revenue reductions and the impact of high-cost drugs that may be used for weight loss. CVS says if everyone who is obese went on one, it would cost the system $1 trillion. Would it save in the long term? Once you read this article, go to the blog section of this site to read about all the challenges I see MA plans having — just published!

#healthinsurers #healthinsurance #medicareadvantage #weightlossdrugs #stars

Link to Article

More Controversy on AI and Claims Denials

Interesting article discussing the use of AI in claims denials. Much of this is directed by aggressive trial lawyers trying to score big, but plans do need to batten down the hatches when it come to the use of AI-driven software. Headlines suggest that Congress wants to intervene on the issue as well. (May require subscription.)

#ai #claimsdenials #healthinsurance

Link to Article

“As The AI World Turns” Soap Opera

For those who see a future for AI in healthcare, the OpenAI saga is both amazing and alarming. OpenAI CEO Sam Altman was fired, yet the majority of employees say they will quit unless he is back. In the meantime, Microsoft, an investor in OpenAI, says it will hire Altman as part of a new venture. So, is he in or is he out? Stay tuned. (May require subscription.)

#ai #healthcare

Link to Article

ACA Enrollment Off To A Good Start

Approximately 4.6 million people have selected an Affordable Care Act (ACA) Marketplace/Exchange plan since the marketplace opened on November 1. This represents activity through November 18 (Week 3) for the 32 states using HealthCare.gov and through November 11 (Week 2) for the 17 states and the District of Columbia with State-based Marketplaces (SBMs). Total plan selections include 920,000 people (20% of total) who are new to the Marketplaces for 2024. This is good news and bad news. The good news:  Exchange enrollment is at a record level. Based on enrollments thus far, in part driven by Medicaid disenrollments, a new record will be broken. The bad news: Over 10M have lost Medicaid coverage and there is not a lot of conversion to the Exchanges thus far. Our uninsured rate will likely increase several million when all the Medicaid redeterminations are complete. Sad news as we recorded a record low rate not too long ago.

#aca #exchanges #obamacare #medicaid #chip #redeterminations

Link to Article

— Marc S. Ryan

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