When the “out-of-network” Maximum, isn’t…
- Monday, 04 June 2018 12:14
Under ObamaCare, one of the good things is that it caps an individual out of pocket amount at a preset maximum, and you have a bad year, you know your worst-case scenario up front. While plans with out-of-network coverage are harder to find, some people still have them, and they mask a nasty surprise…
As long as you are in-network, your maximum out of pocket is set. But if you go out of network, you have to look closely at how the plan pays. Lets take as an example a plan that pays 60% for out of network coverage, after a deductible, and has a $10,000 maximum out-of-pocket cap. What exactly is the 60% reimbursement based on? There are a number of ways companies do this, but most common are two twists based on the Medicare Reimbursement Rate. So if the plan pays based on 150% of Medicare, are you really getting 60%? Probably not.
Looking at national averages, I looked at one common surgical event, where the MD and facility charges were $10,000. Medicares allowable rate of reimbursement is $3530 for the same procedure, so the 150% rate would be $5,295. The plan would pay 60% of THAT number, or $3,177 – 31%. “For example, we know that if the individual enrolled in single coverage incurs a $75,000 inpatient out-of-network retail bill, the individual could easily end up owing the hospital and providers an amount vastly exceeding $10,000 (even after the insurer or administrator attempts retrospective negotiation).”
Remember that when you buy out-of-network coverage, you are paying (a lot) extra, for the right to go out of network and spend (a lot) more money.
Given that 85% of all employees have claims under $2000 per year, does paying a lot of extra premium make sense given all the facts? Not usually.
Rural hospital and MD shortage continues
- Saturday, 19 May 2018 10:14
In a recent story on CBS news (click here), some of the stresses, and resulting scandals, surrounding rural hospitals were revealed. The struggle, with reduced reimbursements in the medical insurance industry and specifically following ObamaCare’s enactment, continues. According to a 2015 article in HHN, “A March 2015 report by the Association of American Medical Colleges projects that the United States will face a shortfall of 46,000 to 90,000 physicians by 2025. The physician shortage remains especially problematic in rural areas, where more than 20 percent of the U.S. population resides but only 10 percent of physicians practice, according to a position paper by the American Academy of Family Physicians (AAFP).”
The CBS article states “Rural hospitals across the country are closing at the highest rates in decades. Since 2010, 83 have shuttered. Desperate to stay open, some hospitals got caught up in dubious billing schemes. In March, CBS News investigated questionable billing at rural hospitals in Georgia and Florida.
“Insurance companies reimburse rural hospitals at higher rates to help keep critical healthcare in those communities. Those higher rates have made rural hospitals attractive targets for schemes that have generated nearly half a billion dollars in allegedly fraudulent billing.”
A mans got to know his limitations!
- Monday, 14 May 2018 07:06
In 1973, in Magnum Force, Harry Callahan said famously, “A mans got to know his limitations.”
This applies to all of use, every day, and especially to Entrepreneurs. It is a rare person that can be good at three of four areas of expertise, yet many business owners try to be just that, every day. Sales, Marketing, Operations, management, production, accounting, finance, human resources, legal… how many hats do you wear? More importantly how many do you wear – that you know you are not good at? How many times a week do you say to yourself “I really have to get to that project, why do I keep putting it off?”
The most productive entrepreneurs know their limitations, and hire outside help to shore up their weaknesses. In fact, most business owners spend all their time putting out fires and meeting deadlines (being the manager), and spend no time planning (being the leader). Then they are surprised when things fall apart. And they will, so plan how you will handle it and what your backup plan is.
Knowing your limitation is essential to self-growth and progress. To improve your business, take a good long look in the mirror and decide what your weaknesses are – and go get someone to help.
“Mastery of a task may be a straightforward path. Mastery in leadership is a lifetime pursuit, one that is both humbling and challenging as well as rewarding to the individual, and the team, when it works.” – John Baldoni
FMLA Tax Credit Clarification
- Monday, 14 May 2018 06:29
Trucker and Huss released a clarification on the recent tax credit for the Family and Medical Leave.
“Section 13403 of the Act added the paid family and medical leave credit as a new general business credit under Internal Revenue Code (the “Code”) section 38. However, the credit is a temporary addition to the tax code because it only applies to paid leave provided January 1, 2018 through December 31, 2019. Generally, an eligible employer may claim the tax credit based on wages paid to qualifying employees on leave for any of the purposes listed under the Family and Medical Leave Act (FMLA), provided that certain conditions are met.”
To claim the credit, an “eligible employer” must have a written leave policy that:
- Provides at least two weeks of paid family and medical leave annually to all full-time qualifying employees (the duration of the paid family and medical leave may be prorated for part-time qualifying employees);
- Pays qualifying employees at least 50% of their normal wages; and
- Ensures that the employer will not interfere with, restrain, or deny any rights provided under the policy, or discriminate against any individuals.”
For the full article, click here.