Category Archives: Health Care Reform

Real World Claims Denial

Your Dad gets admitted to the hospital with “…Chest pain.  His medical history included an elevated Blood Pressure.”  The hospital admits him overnight for observation and Medicare refuses to pay the hospital.  Surprised?  Don’t be.

This is real life, and its my Dad, last August.  Today in the mail I was cc’d on his appeal with Maximus, the Medicare Appeal Firm.  Here is why they declined the claim:

“His cardiac enzymes remained negative and his symptoms resolved.  His hospital course remained uneventful and he was discharged to home the next day in stable condition.”

Then they say “The overnight observation and treatment could have been safely managed at an observation level of care, a less intensive setting than inpatient designation.  If during that period of observation a significant change in his condition occurred that would have required more intensive services, he could have been transitioned to inpatient status.”

Reeves Translation – you should have left him in the Emergency Department, in a hall bed overnight.  If something happened then you could have been paid, but we are not paying you for your cautious patient-oriented approach.”


What do you think?

Small Firms’ Offer of Plan Choices Under Health Law Delayed

Robert Pear, NY Times April 1, 2013

WASHINGTON — Unable to meet tight deadlines in the new health care law, the Obama administration is delaying parts of a program intended to provide affordable health insurance to small businesses and their employees — a major selling point for the health care legislation.

The law calls for a new insurance marketplace specifically for small
businesses, starting next year. But in most states, employers will not
be able to get what Congress intended: the option to provide workers
with a choice of health plans. They will instead be limited to a single

The choice option, already available to many big businesses, was
supposed to become available to small employers in January. But
administration officials said they would delay it until 2015 in the 33
states where the federal government will be running insurance markets
known as exchanges. And they will delay the requirement for other states
as well.

The promise of affordable health insurance for small businesses was
portrayed as a major advantage of the new health care law, mentioned
often by White House officials and Democratic leaders in Congress as
they fought opponents of the legislation.

Supporters of the law said they were disappointed by the turn of events.

The delay will “prolong and exacerbate health care costs that are
crippling 29 million small businesses,” said Senator Mary L. Landrieu,
Democrat of Louisiana and the chairwoman of the Senate Committee on
Small Business and Entrepreneurship.

In the weeks leading up to the passage of the health care legislation in
2010, Ms. Landrieu provided crucial support for the measure, after
securing changes to help small businesses.

The administration cited “operational challenges” as a reason for the
delay. As a result, it said, most small employers buying insurance
through an exchange will offer a single health plan to their workers
next year.

Health insurance availability and cost are huge concerns for small
businesses. They have less bargaining power than large companies and
generally pay higher prices for insurance, if they can afford it at all.

The 2010 law stipulates that each state will have a Small Business
Health Options Program, or SHOP exchange, to help employers compare
health plans and enroll their employees.

One of the most important tasks of the exchange is to simplify the
collection and payment of monthly premiums. An employer can pay a lump
sum to the exchange, which will then distribute the money to each
insurance company covering its employees.

The Obama administration told employers in 2011 that the small business
exchange would “enable you to offer your employees a choice of qualified
health plans from several insurers, much as large employers can.” In
addition, it said, the exchange would “consolidate billing so you can
offer workers a choice without the hassle of contracting with multiple

Exchanges are scheduled to start enrolling people on Oct. 1, for
coverage that begins in January. However, the administration said that
the government and insurers needed “additional time to prepare for an
employee choice model” of the type envisioned in the law signed three
years ago by President Obama.

D. Michael Roach, who owns a women’s clothing store in Portland, Ore., said the delay was “a real mistake.”

“It will limit the attractiveness of exchanges to small business,” he
said. “We would like to see different insurance carriers available to
each of our 12 employees, who range in age from 21 to 62. You would have
more competition, more downward pressure on rates, and employees would
be more likely to get exactly what they wanted.”

John C. Arensmeyer, the chief executive of Small Business Majority,
an advocacy group, said that the delay of “employee choice” was “a
major letdown for small business owners and their employees.”

“The vast majority of small employers want their employees to be able to
choose among multiple insurance carriers,” Mr. Arensmeyer said.

Small Business Majority supported Mr. Obama’s health care law.

That support was invaluable to Democrats who pushed the bill through
Congress. Representative Nancy Pelosi of California, who was speaker at
the time, cited the group’s research as evidence that “small businesses
will benefit from health insurance reform.”

However, in recent weeks, insurance companies urged the administration to delay the employee choice option.

“Experience with Massachusetts has demonstrated that employee choice
models are extremely cumbersome to establish and operate,” the health
insurer Aetna said in a letter to the administration in December.

Insurers said that the administration was partly responsible for the
delay because it did not provide detailed guidance or final rules for
the small-business exchange until last month.

Businesses with up to 100 employees will be able to buy insurance in the
exchanges. In 2014 and 2015, states can limit participation to
businesses with 50 or fewer employees. Companies with fewer than 25
workers may be able to obtain tax credits for up to two years of
coverage bought through an exchange. States can open the exchanges to
large employers in 2017.

A few states running their own exchanges, including California and
Connecticut, said they planned to offer an employee choice option next
year, though it was not required by the federal government.

A stated goal of the 2010 law was to increase “consumer choice” and stimulate competition among insurers.

The law makes it easier for consumers to compare health plans by
defining four standard levels of coverage, ranging from the least to the
most generous. The law says an employer can pick a level of coverage
and then allow employees to choose among all the health plans available
at that level.


Small-Business Owners Still Confused About Health-Care Reform

BY March 21, 2013|

If you are still fretting about how Obamacare will affect your employees and your bottom line, you are not alone.
While a small percentage of business owners who offer health
insurance to employees have an improved understanding of what the
“employee mandate” means, a majority of small-business owners continue
to misunderstand the law, according to a survey released Thursday from
the Mountain View, Calif.-based private online health-insurance exchange

Of the 259 business owners surveyed, 56 percent
misunderstand the employee mandate, an improvement from the 69 percent
of survey respondents who misunderstood the mandate when eHealth
conducted a parallel survey in August.

The employee mandate is a section of the Affordable Care Act that
requires businesses with 50 or more full-time workers to provide
health-insurance coverage for their employees. If your business has more
than 50 employees and you do not provide health insurance, then you
will be required to pay an annual penalty starting at $2,000 per
employee after 30 employees, says Carrie McLean, the consumer health
insurance expert at eHealth. If you have fewer than 50 employees, the
health-insurance mandate does not apply to your business.
Another largely misunderstood component of Obamacare is the
health-insurance exchanges. Almost two-thirds of respondents say they
have no understanding at all of the exchanges. Twenty percent of
respondents say they have a fuzzy understanding of the exchanges and
only 18 percent of respondents say they can explain what an exchange is
with confidence.
Health-insurance exchanges are marketplaces where businesses and
individuals can shop and compare plans. The federal exchanges, which
will become available in October, will make government subsidized
health-insurance available for lower-income individuals who are not
getting coverage through their employer. Also, the SHOP exchange – an
acronym for Small-business Health Options Program exchange – will be an exchange where small-business owners can do the same thing, says McLean.

The confusion about Obamacare creates anxiety for entrepreneurs.
Almost six in ten respondents say they think their costs will increase
as a result of the looming reform and one third of owners expect the
reform to affect their hiring plans in 2014.

The survey was conducted online between Feb. 12 and Feb. 15, by
eHealth and polled small-business owners who had purchased
health-insurance through
and were still maintaining coverage for their employees. All
respondents had fewer than 50 employees and 95 percent had between two
and 10.
The survey results from eHealth likely reflect even less confusion
than what is out there among small-business owners overall, since it
surveys only those business owners who offer existing coverage and have
therefore put some thought into the topic already, says McLean. “We
actually compiled a list of calls that we were getting from customers —
small businesses — and it was composed of 70 different questions that
we are getting on a constant basis,” she says. “There is major confusion
out there in the marketplace.”

Health overhaul to raise claims cost 32 percent

By March 26, 2013 • Reprints
WASHINGTON (AP) — The nation’s leading group of financial risk
analysts says medical claims costs — the biggest driver of insurance
premiums — will jump an average 32 percent for individual policies under
President Barack Obama’s health care overhaul.
The report from the Society of Actuaries could become another
headache for the administration at a time when many people remain
skeptical of the law.
While a few states would see claims costs go down, the overwhelming
majority would see double-digit increases in their individual health
insurance markets.
By 2017 the estimated increase is about 80 percent for Ohio, 62 percent for California and more than 20 percent for Florida.
The Obama administration says the report doesn’t take into account
subsidies and other measures in the law to offset cost increases.

Sebelius concedes reform could raise premiums

By March 27, 2013 • Reprints

Years after the insurance industry began warning that premiums will
rise due to health reform, the Obama administration acknowledged
Tuesday that it might actually be the case.

Health and Human Services Secretary Kathleen Sebelius told reporters
at the White House that some people may see their premiums rise under
the Patient Protection and Affordable Care Act.

“These folks will be moving into a really fully insured product for
the first time, and so there may be a higher cost associated with
getting into that market,” Sebelius said. “But we feel pretty strongly
that with subsidies available to a lot of that population that they are
really going to see much better benefit for the money that they’re

Sebelius’s comments were published online late Tuesday by the Wall Street Journal.

“This is the first time ever in the history of the United States that
insurance companies have to file their rates, it has to be very
transparent, they have to offer the same kind of coverage without 5,000
tiny little lines and internal caps, and they have to compete for
customers,” Sebelius said. “And I am a believer in the market strategies
that in and of itself will minimize the rate impact.”

Health insurers have long warned that health reform will increase
health coverage costs, but the Obama administration has repeatedly said
reform will increase coverage while reducing costs.

Though the law eliminates practices that have imposed higher rates on
women and people with medical conditions—likely reducing premiums for
women, the elderly and the sick—premiums for men, healthy individuals
and younger beneficiaries are expected to increase. Insurance premiums
could rise for some with individual plans, Sebelius said.

In a report, the Society of Actuaries predicted this week that
insurers will pay 32 percent more on average within three years for
medical claims under reform, as more patients enter the insurance market
and take up higher-value benefits. The study attributes potential
premium hikes to the expected influx of sicker people into the health
care market. Changes also would vary significantly by state.

“Health care reform’s watershed year is almost here, though it will
take a while for a stable state to be reached. The projections in this
study suggest that when the dust settles by 2017, we can expect mixed
results on the reform bill’s goals of expanding coverage and reducing
costs,” Kristi Bohn, consulting health staff fellow at the Society of
Actuaries, said in a statement.

Though the law will significantly reduce the number of Americans who
are uninsured, the size of the individual market will more than double
an increase driven in part by people who are below 200 percent of the
federal poverty line coming into the market. “This group of people are
considered to be ‘good risks’ and are generally expected to bring down
average costs,” Bohn said. “But other changes in composition of the
individual market will more than offset these lower costs, and in fact,
will drive average costs up.”

America’s Health Insurance Plans has also argued that PPACA’s age rating restrictions will increase premiums for younger individuals, while the health insurance tax will significantly increase costs for consumers and employers in all 50 states.

The bulk of the law—including the health exchanges and the individual
mandate—goes into effect in January 2014, which at that time the
premium costs will be known.

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Reeve Conover is a Registered Representative. Securities offered through Cambridge Investment Research, Inc., a Broker/dealer member FINRA/SPIC. Cambridge and Conover Consulting are not affiliated. Licensed in SC, NC, NY, CT, NJ, and CA. - SIPC - Brokercheck