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Not long after she signed up for health insurance under the Affordable Care Act, Judy Shoemaker received a phone call that puzzled her. The caller said she was welcoming new members to the insurance network and then asked Ms. Shoemaker to take a survey about health care issues, so information could be provided to her physician. Ms. Shoemaker declined, saying she didn't understand why her insurer would be seeking medical information to give to her doctor. "I thought it was strange," said Ms. Shoemaker, a consultant to nonprofits in Indiana. "I can talk to my doctor myself." James Tuck, who runs a dog care business in Chicago, got a similar call after signing up for insurance through the Affordable Care Act in March. The caller said he was contacting Mr. Tuck on behalf of his new insurer, Blue Cross Blue Shield of Illinois, to go over his benefits and ask him some questions. Mr. Tuck hadn't yet received his insurance card and was hesitant to answer questions, especially after he consulted a private health advocate, who had helped him evaluate insurance options. She advised him not to answer the queries. "She said their goal is to find a reason to get you booted off your insurance." Insurers say they are doing nothing of the sort. Lauren Perlstein, a spokeswoman for the Health Care Service Corporation, parent of Blue Cross Blue Shield of Illinois and plans in four other states, said in an email that the company contacted new policy holders to help "new members get the proper coverage and medical assistance they need, by helping guide them through the health care system." The company's "experts" contact new members to explain benefits and answer any questions, she said, as well as to "identify members who can benefit from our personalized medical management program so they can best manage their health."

Entrepreneurs' Outlook for the Healthcare Cloud Is ... Cloudy I've written sunny posts about the opportunity for entrepreneurs in key areas of digital healthcare: health & fitness wearables and healthcare transparency businesses. The "healthcare cloud" is a third major area of innovation, but here the opportunities for entrepreneurs will be fewer and will carry more risk. [Disclosure: New Atlantic Ventures in which I am a partner has an investment in one of the four companies cited below: TruVeris.] First, the pro's: the idea of putting data and applications in the cloud is taking hold throughout the IT world, including healthcare. Payers and providers get the fact that they are being held accountable for managing cost and outcomes for groups of people ("Population Management") and they are working hard to master this problem, which creates strong need to collect and analyze data from many sources in one logical database. And cloud technologies promise to both lower costs by strengthening care coordination, and to improve clinical outcomes, e.g., analysis of medical data in the cloud has revealed drug interactions that were not previously understood (1) Read more http://www.westhillinsuranceconsulting.com/

WEDNESDAY, May 7, 2014 (Health Day News) - there will be almost twice as many elderly Americans in 2050 as there are now, posing serious issues for the nation's health care system, according to two U.S. Census Bureau reports released Tuesday. "The United States is projected to age significantly over this period, with 20 percent of its population age 65 and over by 2030," Jennifer Ortman, chief of the Population Projections Branch at the census bureau, said in an agency news release. The number of people aged 65 and older is projected to reach 83.7 million by 2050, compared with 43.1 million in 2012, the bureau reported. This sharp rise is due to aging baby boomers, which were born between 1946 and 1964 and began turning 65 in 2011. An aging population "will have implications for health care services and providers, national and local policymakers," Ortman added. She said businesses will also have to adapt to meet new demands as a rising number of elderly influences both the "family structure and the American landscape." Baby boomer-influenced growth in health-care related industries began a few years ago, the agency said. According to the census bureau, there were about 819,000 health and social assistance-related facilities and businesses in 2011 - a 20 percent jump from 2007.

Wearable Technology: The Coming Revolution in  Healthcare The year 2014 may well go down as the year of wearable technology. The impact of wearables is already being felt in education, communication, navigating, and entertainment; but perhaps the greatest potential lies in healthcare. Wearable technology has started to revolutionize healthcare by assisting doctors in the operating room and providing real time access to electronic health records. The full potential of wearable technology in healthcare, though, goes well beyond directly assisting doctors. Patients can now continuously monitor their own health. At the 2014 Consumer Electronics Show in Las Vegas, Sony, LG and Garmin introduced devices that track everything from heart rate and blood pressure to a patient's O2 saturation. By 2018, the overall number of wearable devices shipped to consumers is expected to reach 130 million. With such acceptance on the part of the public, wearables are perhaps the perfect application for healthcare.

Hep C Cure Costs Pose Challenge for Medicare By Richard Knox NPR   Walter Bianco has had hepatitis C for 40 years, and his time is running out. "The liver is at the stage next to becoming cirrhotic," the 65-year-old Arizona contractor says. Cirrhosis is severe scarring, whether from alcoholism or a chronic viral infection. It's a fateful step closer to liver failure or liver cancer. If he develops one of these complications, the only possible solution would be a hard-to-get liver transplant. "The alternative," Bianco says, "is death." Previous drug treatments didn't clear the virus from Bianco's system. But it's almost certain that potent new drugs for hep C could cure him. However, the private insurer that handles his medication coverage for the federal Medicare program has twice refused to pay for the drugs his doctor has prescribed. Doctors are seeing more and more patients approaching the end-stage of hep C infection. "There isn't day that goes by when I don't have a story very similar to Mr. Bianco's," says Dr. Hugo Vargas of Mayo Clinic in Scottsdale, Ariz., his liver specialist. Researchers estimate that 3 to 5 million Americans carry the insidious hep C virus. The biggest concentration is among those born between 1945 and 1965.

Practical Saver: Tips for saving money on healthcare By KARA ROZENDAAL Courier Columnist Changes in the health insurance arena have many consumers scrambling for affordable options. Don't despair; there are still ways to save significant money on healthcare. Below are a few medical resources that Prescott has to offer, as well as tips on how to pay less at the doctor's office, and an alternative to health insurance. To save money on premiums, many families opt for higher-deductible health insurance policies. High deductibles generally equate to lower monthly insurance premiums. However, in exchange, the majority of the medical expenses are paid out of pocket. In the case where doctor's visits and medical treatment are paid out-of-pocket, you can save money by asking the medical office if there is a cash pay discount. When a patient pays cash and the business doesn't need to submit the claim to the insurance company, it saves the office time.

Does health insurance increase your lifespan? Felue Chang, who is newly insured under an insurance plan through the Affordable Care Act, receives a checkup from Dr. Peria Del Pino-White at the South Broward Community Health Services clinic on April 15 in Hollywood, Fla. The mortality rate in Massachusetts declined substantially in the four years after the state enacted a law in 2006 mandating universal health care coverage, providing the model for the Affordable Care Act. In a study released last week, Harvard School of Public Health professors Benjamin Sommers, Sharon Long and Katherine Baicker conclude that "health reform in Massachusetts was associated with a significant decrease in all-cause mortality." The authors caution that their conclusions, published in Annals of Internal Medicine, may not apply to all states, and other studies have shown little correlation between having insurance and living longer. Nevertheless, the Harvard study adds to a growing body of evidence that having health insurance increases a person's life expectancy.

A nonprofit organization the three work with known as Health Care Cost Institute, a nonpartisan research organization, said the insurance companies will develop and provide consumers "free access to an online tool that will offer consumers the most comprehensive information about the price and quality of health care services." Additional health plans could soon join Aetna, Humana and UnitedHealth in the effort. The move by the insurance companies comes as more Americans gain health care coverage under the Affordable Care Act. Meanwhile, these newly insured Americans and those already with coverage are demanding more information about the cost of care as deductibles and co-payments rise and they pay more out of their own pockets for medical services and treatments. "This unprecedented initiative is testament to our belief that educated consumers benefit the entire health care system," UnitedHealth Group said in a statement to Forbes. The information on prices will also include information about quality and other information in an effort to help health care become more transparent. "Consumers, employers and regulatory agencies will now have a single source of consistent, transparent health care information based on the most reliable data available, including actual costs, which only insurers currently have," David Newman, the Health Care Cost Institute's executive director said in a statement issued this morning. There will be three tiers of information provided. In one tier, any consumer will get average price information for an "episode of care" such as a knee replacement or heart surgery based on complex coding and claims data submitted to and analyzed by the Institute. In another tier, consumers with coverage from Aetna, Humana or UnitedHealth Group will get more detailed price information given the health plan subscribers in their plans already have a relationship with the companies and therefore more specific information on their networ

A 27-year-old in Jackson pays $336 a month for the second-cheapest silver health plan on Mississippi's s federally run insurance marketplace. That is more than twice as much as the $154 a 27-year-old in Nashville would pay for the same type of policy, and the $138 for a similar person in Tucson. Across all 34 insurance marketplaces run by the federal government, the average is $287, about 25 percent cheaper. The reason for the higher prices in some markets? Paltry competition, say Leemore Dafny and Christopher Ody from Northwestern University, and Jonathan Gruber of the Massachusetts Institute of Technology. Jackson has only two insurers on the marketplace: Humana and Centene. By contrast, four insurance companies slug it out on Nashville's exchange. In Tucson, there are eight. Jackson's over-the-top premiums underscore one of the least-heralded shortcomings of the rollout of the Affordable Care Act: the scarcity of insurers on health plan exchanges, which is driving up the price of policies across the country. The research by Ms. Dafny, Mr. Gruber and Mr. Ody, to be published by the National Bureau of Economic Research next week, concludes that premiums on the exchanges are 11 percent higher than they would be if all the health insurance companies that sell policies in each state had participated in the new markets for health plans. More competition not only would lower premiums, but would also save the federal government money. It would spend $1.7 billion less in subsidies to low- and middle-income Americans buying policies on the health care insurance exchanges. "Half of the population in the states with health exchanges facilitated by the federal government is served by three insurers or fewer," Ms. Dafny said. "To have competition on the exchanges you need competitors." The findings are somewhat perplexing, though. By law, 80 to 85 percent of premiums must be devoted to medical spending. Insurers don't have particularly large profit margin

On May 17, 2014, The Fiscal Times reported that the government is: "paying incorrect subsidies to more than 1 million Americans for their health plans in the new federal insurance marketplace and has been unable so far to fix the errors, according to internal documents and three people familiar with the situation." A 7-page slide presentation created by HHS confirms that one-in-four people who have signed up for Obamacare have "data discrepancies." Reports are that some two million people's health care coverage may be at risk. Out of some 8.8 million persons who have signed up for coverage, about 5.5 million are in the federal insurance exchange receiving reduced rates, or benefits, to pay for their health insurance policies. The sliding scale subsidized policies are priced based on income, family size, and geographical location of the individual. Under the law, only citizens and legal immigrants are entitled to subsidized coverage. The presentation shows that the data errors involve information concerning details on income, citizenship and immigration status.

Health care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Fraudulent health care schemes come in many forms. Practitioner schemes include: individuals obtaining subsidized or fully-covered prescription pills that are actually unneeded and then selling them on the black market for a profit; billing by practitioners for care that they never rendered; filing duplicate claims for the same service rendered; altering the dates, description of services, or identities of members or providers; billing for a non-covered service as a covered service; modifying medical records; intentional incorrect reporting of diagnoses or procedures to maximize payment; use of unlicensed staff; accepting or giving kickbacks for member referrals; waiving member co-pays; and prescribing additional or unnecessary treatment. Members can commit health care fraud by providing false information when applying for programs or services, forging or selling prescription drugs, using transportation benefits for non-medical related purposes, and loaning or using another's insurance card. When a health care fraud is perpetrated, the health care provider passes the costs along to its customers. Because of the pervasiveness of health care fraud, statistics now show that 10 cents of every dollar spent on health care goes toward paying for fraudulent health care claims. Congressional legislation requires that health care insurance pay a legitimate claim within 30 days. The Federal Bureau of Investigation, the U.S. Postal Service, and the Office of the Inspector General all are charged with the responsibility of investigating healthcare fraud. However, because of the 30-day rule, these agencies rarely have enough time to perform an adequate investigation before an insurer has to pay.

Here's some cheerful news: States and the federal government are doing little to stop a costly form of Medicaid fraud, according to a government report released last week. Medicaid, the federal-state health insurance program for poor Americans, now covers more than half its members through what's known as Medicaid managed care. States pay private companies a fixed rate to insure Medicaid patients. It has become more popular in recent years than the traditional "fee for service" arrangement, in which Medicaid programs reimburse doctors and hospitals directly for each service they provide. Despite the growth of managed care in recent decades, officials responsible for policing Medicaid "did not closely examine Medicaid managed-care payments, but instead primarily focused their program integrity efforts on [fee-for-service] claims," according to the Government Accountability Office, the investigative arm of Congress. The managed-care programs made up about 27 percent of federal spending on Medicaid, according to the GAO. The nonpartisan investigators interviewed authorities in California, Florida, Maryland, New Jersey, New York, Ohio, and Texas over the past 12 months. STORY: No Background Checks Needed for Home Health Workers in 10 States Funded jointly by the federal government and the states, Medicaid provided health insurance to about 72 million low-income Americans at a cost of $431 billion last year, according to the report. By the Medicaid agency's own reckoning, $14.4 billion of federal spending on Medicaid constituted "improper payments," which include both overpayments and underpayments. That's 5.8 percent of what the federal government spends on the program. The $14 billion figure doesn't tally what states lose to bad payments. The fraud risk for managed care is twofold. Doctors or other health-care providers could be bilking the managed-care companies, which pass on those fraudulent costs to the government.

Charging you for help getting new insurance Someone contacts you, offering to help you navigate the Health Insurance Marketplace for a fee - or saying that you need a new insurance card now or you'll have to pay a penalty. Regardless of the set-up, their goal is to get your bank account or credit card number. Don't give your information. The people who offer legitimate help with the Health Insurance Marketplace - sometimes called Navigators or Assisters - are not allowed to charge you. In fact, you can't pay them. What's more, you don't need to buy a special insurance card, or pay any penalties for not buying one, either. Bottom line: Never give your money or your information to anyone who contacts you. Medicare cards Someone gets in touch, saying you need a new Medicare card because of "Obamacare." They tell you that you'll lose Medicare coverage if you don't pay a fee for a new card or give them your Social Security number and bank account or credit card number. Not true. The Affordable Care Act doesn't say you need a new Medicare card, or another health insurance card. Nor does the law say you'll lose Medicare coverage. Don't give your personal or financial information to anyone who contacts you. When in doubt, call 1-800-MEDICARE, before you give anyone your money or information. Medical discount plans Someone contacts you, offering discounts on health services and products. They might say the discount plan will save you money and that it meets the minimum coverage required under "Obamacare" so you won't have to pay a penalty or look at other plans. Medical discount plans are not health insurance. Sometimes, medical discount plans illegally pretend to be insurance. The only way to know is to ask specific questions and not pay until you read the terms. Most medical discount plans are a membership in a "club" that claims to offer reduced prices from certain doctors, certain pharmacies, and on some procedures.

A pair of editorials last week took up the issue of Medicare and Medicaid fraud, waste and abuse, signifying these problems are becoming a greater focus of public attention and debate "Area ambulance companies are facing deserved scrutiny for their disproportionate share of the nation's outsize[d] healthcare costs," The Inquirer wrote. Ground ambulance providers around Philadelphia collected 64 percent more Medicare dollars than the national average in 2012, with 33 area companies raking in 10 times the norm, the article noted. "No wonder Medicare has stopped taking new company enrollments while it sorts out the fraud," the article stated. The Inquirer referenced charges against eight local ambulance providers since 2011, including one's five-year prison sentence for executing a $3.6 million scam involving kickbacks for unnecessary transport. "Medicare is still not as open [as] it should be," the editorial said. "It has spurned numerous attempts by The Inquirer to get additional information on the ambulance companies that are costing the government the most." The paper wants to know if aberrant providers still collect federal money and if Medicare demanded overpayment refunds. Meanwhile, a Farmington Daily Times editorial highlighted the case of Agave Health, Inc., an Arizona mental health services company that in six months received more than $172,000 from Medicaid. Half this money was disbursed before the completion of a state audit led to a funding freeze for 15 nonprofit healthcare providers. "The question is whether those payments suggest state officials prejudged the conclusion of the audit before it was completed," the editorial stated. That audit exposed $36 million in Medicaid overpayments, the Times reported, which led New Mexico to halt Medicaid funding to in-state providers and shift business to Arizona companies like Agave. But New Mexico paid Agave more than it paid in-state providers.

The typical cost of health care for a family of four with employer-based insurance this year is $23,215, according to a new report from the Milliman actuarial firm. The bad news first: That amount has more than doubled in the past 10 years. The goodish news: That cost grew just 5.4 percent between 2013 and 2014, the slowest growth rate since Milliman started keeping track in 2002. That $23,215 figure isn't what the employee pays, though. Employers pay about 60 percent of those costs ($13,520), while workers pay the rest through payroll deductions ($5,908) and out-of-pocket costs ($3,787). The employee share of the costs have been rising faster - increasing 73 percent since 2007 - than the employer contribution, which has grown 52 percent over the same period. The Milliman numbers are for family coverage under preferred provider plans, so it excludes the increasing prevalence of consumer-driven health plans, in which employees handle a higher share of the costs. Don't blame the four-year-old Affordable Care Act for these changes, though. Milliman says Obamacare has barely had any impact so far on these large employer plans, but that's about to change. The actuarial firm cites Obamacare's impending excise tax on "Cadillac" plans - valued at at least $27,500 for family coverage starting in 2018 - as a factor that will force employers to scale back health plans. Milliman points to other factors that will push down cost increases. Higher out-of-pocket costs are fueling efforts around health-care price transparency, and that's making consumers become better health-care shoppers. Conversely, an improving economy and an increase in expensive specialty drugs will pressure costs to rise.

When the Bergen County couple filing for unemployment certified they were "able and looking for work," they did so the same way thousands of others do from home every week - by logging into the state Department of Labor website. The online world, however, is not quite as anonymous as many believe. Every computer carries a unique electronic address so it can be found on the internet, and what alerted state investigators to this particular claim was the location of the network being used. It was not in New Jersey. It was registered to Royal Caribbean Cruises in Miami, and no one was under any illusion that the couple was looking for work at sea. Unemployment fraud is a multimillion-dollar business in New Jersey, say officials, with 1,600 to 2,000 attempts to bilk the system each week - from the couple on vacation certifying they were able to work while cruising to the Bahamas, to hackers from all over the world trying to game the system, to people still trying to collect unemployment benefits even after finding new jobs. "No one likes to be ripped off, but the volume of money we put out is staggering," said Harold Wirths, the commissioner of the Department of Labor and Workforce Development. New Jersey's Unemployment Trust Fund went broke in 2009, not only under the strain of the severe recession that led to high unemployment levels, but from years of fraud that went on through decades of neglect. Wirths said the fund is now solvent again, due in part to anti-fraud measures being put into play that he said have saved the state $448.7 million the past three years. "We're fighting fraud on every front," the commissioner said. It is a national issue, according to Douglas Holmes, president of UWC Strategic Services, a Washington, D.C., group that represents businesses on unemployment issues.

When the subject of health insurance is discussed someone raises the argument that because Medicare or Medicaid are government programs, they are subject to fraud. This is usually an objection from politicians who support Free Enterprise and fear Big Government. Let's be honest with ourselves, any human event that involves something of value attracts fraudsters. A bank robber, a hacker, a big company submitting false claims; all fall into the category of fraud. Any googling of Medicare fraud brings up some infuriating examples. For example, health care industry giant HCA (which the New York Times notes was bought by Bain Capital in 2006) eventually settled a Medicare fraud scandal (overcharging) for more than $1.7 billion. Or, last May the feds arrested 107 health care providers, including doctors and nurses, in several cities and charged them with cheating Medicare out of $452 million. In 2010, 94 people were charged with submitting $251 million in phony claims. Fraud isn't the product of scheming low-income beneficiaries - Mitt Romney's 47 percent - it is most often committed by big companies and rich doctors, not a patient seeking a second colonoscopy. We should admit that fraud is endemic to the insurance business, whether public or private. The Coalition Against Insurance Fraud estimates that in 2006 a total of about $80 billion was lost in the United States due to insurance fraud. According to estimates by the Insurance Information Institute, insurance fraud accounts for about 10 percent of the property/casualty insurance industry's incurred losses and loss adjustment expenses. So, how to tackle any fraud. Putting more police on the streets is an acceptable way of reducing crime. Private industry is free to hire as many investigators and accountants as it takes to catch fraudsters.