How Providers Can Help Increase Transparency Into Policy Plans

While doctors and dentists are on this this earth to help us live long and healthy lives, that often does little to ease the anxiety that many feel when visiting their office. In fact, increased levels of stress almost always accompany a visit to either the doctor or dentist’s office, in addition to a corresponding elevated blood pressure reading. The process can be made easier and more settling, however, when these same doctors and dentists properly educate their patents about new processes and policies being incorporated into the insurance.

Much of the anxiety that occurs when needing to go the dentist or doctor revolves around cost. Many simply do not know how, or if, they will be able to pay for any medical procedures that become necessary. They cannot understand their insurance policy, and are unsure of where to even go for help. For this reason alone, a staggering number of Americans simply stay away from the Doctor or Dentist’s office altogether until it is often too late. There are, however, certain things that insurance providers can due to help increase transparency within their policy plans.

Transparency Made Easier Under the Affordable Care Act

One of the final rules implemented as a provision within the Affordable Care Act was a requirement that all health plans now should provide consumers with a uniform summary of coverage. This applies to those people currently enrolled in a place, as well as new applicants. This is a step in the right direction, as it now ensures that individual dental insurance is transparent and easy to understand. Benefits and provisions of coverage should be more clearly spelled out of individuals, and this will make it easier for them to determine what is and is not covered, and to what extent.

In this regard, providers can help to ease the stress and anxiety that many consumers feel over health and dental insurance related issue. In the past, it was felt that many individuals faced too many choices when dealing with insurance policies, and that they were not adequately informed as to how coverage actually works. One survey even found that people would prefer to go to the gym or even work on their taxes than take the time to read through earlier versions of health insurance policies.

The Transparency of Coverage Disclosures

Most insurance policies must now disclose any information that would enable consumers to better understand how their particular plan will reimburse the claims that are made for covered services, and whether or not a service would actually be covered under the existing policy. In essence, the following information must be disclosed in a transparent and easy to understand manner:

• Polices and Practices Related to the Payment of Claims
• Financial Disclosure to be Made on a Periodic Basis
• Data Enrollment Must be Disclosed
• Data Account For Those Who Unenroll Must Be Disclosed As Well
• Information on the number of claims that are denied in the end
• Information about rating practices
• Data related to cost-sharing and payments, particular in terms of out-of-network coverage that is available
• Data of the rights afforded to enrollees and participants under the terms of the policy

All of the information mentioned above is to be written in clear English that is geared specifically to the consumer, and should be designed for people who have limited proficiency in the language. This effectively makes it easier for individuals to understand their policy and what they should expect from the insurance provider.

While there will likely still be a great deal of anxiety associated with visits to the doctor or dentist, this will be lessened somewhat with the advent of these new policies. Knowing what is covered and how the benefits will be paid can go a long way towards not only lessening the financial burden on the individual, but also towards making the process much more streamlined and comfortable in the end.



About the author:

Greg Dastrup is a world traveler and professional writer with a passion for learning new languages. He’s spent most of his career consulting for businesses in North America. You can follow Greg here.

Earn a complimentary pass to IIR's FDA/CMS Summit in Washington, DC - Become a Guest Blogger!

FDA/CMS Summit and co-located Regulatory Information Management Summit (RIM)

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We are looking for an industry expert with interest in the following topics:
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....and who would like to learn about the current and future trends in Healthcare Regulation!

The premise is to provide FDA/CMS Summit and co-located RIM related blog posts (never more than 300 words), whitepapers, and overall light coverage of the event.

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Should states continue to move towards Managed Care programs for Medicaid?

With 16 million people expected to be eligible under the new healthcare law, state governors are looking for a way to properly finance their Medicaid programs. Many are looking at Managed Care as the answer. Managed care programs will set up an established network of providers for the enrollees to use with set reimbursement rates to those doctors, hospitals and nursing homes enrolled.

However, hospitals, doctors and nursing homes are concerned with these new programs. For doctors and hospitals, the main fears are lose of local control and a decrease in significant amounts of money due to the patients they have to continue to treat but who are unable to pay for their procedures. But for the enrollees, the Managed Care Network provides access to hospitals and physicians who strive to provide the best preventative and primary care. These measures reduce the overall cost of healthcare in the first place.

What are some of the benefits for doctors and hospitals to be included in a Managed Care Programs?

Source

The 19th Annual Medicaid Managed Care Congress takes place next week in Baltimore, Maryland.  Join other states and Medicaid Managed Care experts to help you catch up with the industry as well as gather knowledge to create a managed care program for your state.  Download the brochure here for more information and register to join us today!

Save the Date! 2011 Annual Medicaid Managed Care Congress

Join us May 18-20th, 2011 at the Hilton Baltimore for the 19th Annual Medicaid Managed Care Congress, the premiere Medicaid Managed Care event featuring the top industry leaders. Last year we had more than 250 attendees from across the country, representing Massachusetts, Michigan, California, Arizona, Texas and Washington, DC, to name a few.

At the 2011 Conference, you will:
• Obtain the latest information on healthcare reform and the current political climate for best plan positioning in uncertain times
• Gain insight about ACOs and learn how to effectively work with them in a mutually beneficial environment
• Explore the Health Insurance Exchange and discuss its affect on the managed care industry
• Work within economic, fiscal and state budget constraints to develop cost effective Medicaid managed care programming
• Discuss various ways of utilizing technology to connect with subscribers and keep their information confidential
• Discover specific ways to implement Patient Centered Medical Homes to increase the quality of care you offer while decreasing expenditures
• Get updates on CMS including information on the Council on Technology and Innovation Improve overall quality of your managed care program without increasing expenditures

Additionally, if you are interested in speaking about one of these topics, or if you are interested in speaking about another relevant topic, please email Sarah Gordon at sgordon@iirusa.com.

Visit The Medicaid Managed Care Congress webpage to find out more about the event:
http://bit.ly/f7XGAh

Register by Friday, February 25, to receive up to $600 off the standard registration rate. Call Customer Service at 888-670-8200 to reserve your spot today. Be sure to mention you are a reader of our Health Care Policy Blog. Don’t miss this one-of-a-kind event. Our 18 years of experience prove that we are experts in the Medicaid managed care industry.

Happy Holidays from Health Care - From Policy to Practice

We're taking some time off from our coverage of the health care industry to celebrate the season with our loved ones. We want to sincerely thank you for your readership, your comments and your participation. We look forward to returning to the world of healthcare policy in 2011!

Here are our top posts from 2010:
MDRP 2010 Conference - AMP after HCR: Implementation is Here – What Issues Still Remain?
MDRP 2010 Conference - Operational and System Answers
MDRP 2010 Conference - Translating the Impact of Healthcare Reform on your Medicaid, Medicare and PHS/340B Processes

We wish you Happy Holidays!

States working to cut Medicaid Deficit

Many states are currently in a bind, as the US Government has cut funding, which will hit close to US homes in the forms of health care, education, public safety and social services. This has resulted in 30 states cutting their spending to avoid big deficit gaps.

The Medicaid provision, which would extend assistance first granted in last year’s stimulus package, was considered such a sure bet by many governors and legislative leaders that they prematurely included the money in their budgeting. But under pressure from conservative Democrats to rein in deficit spending, House leaders in late May eliminated $24 billion in aid to states from a tax and jobs bill that was approved and forwarded to the Senate.

Read the full article here.

American confidence in healthcare is falling

Reuters reports that American confidence in healthcare has fallen from 100% in December to 97% in March, according to 3,000 polled individuals. Many are unsure as to what the recent passage of healthcare reform will do for them, and older Americans are the most worried about the future of their healthcare. Read the full article here.

Is Healthcare Reform on Life Support?

CBS and the Associated Press report that President Obama's health care appeal failed to break the U.S. congressional gridlock Thursday, dimming hopes for millions of uninsured Americans.

Congressional leaders have insisted health care would get passed, even though last week's stunning loss of the Massachusetts seat long held by the late Edward Kennedy cost Democrats the 60-vote supermajority they need to deliver in the 100-member Senate. Many Democrats saw a problem with no clear solution.

After hearing President Obama's speech on Wednesday, where do you think the Nation stands on Healthcare reform? Will we see it slip away or can it still be resuscitated?

Learn more: Health Care Reform Hopes "On Life Support"

NYC City Hospital Chief Calls for Coverage of Immigrants

Kevin Sack of The New York Times reports that Alan D. Aviles, president of the city’s Health and Hospitals Corporation, called for congressional conferees to lift the existing five-year ban on federal health benefits for legal immigrants. Neither plans by Congress or the House do so. Aviles said that illegal immigrants should be able to buy health coverage on new government exchanges at full cost.

“With 12 million undocumented persons in the country, someone’s going to need a doctor,” Aviles said. “They’re going to show up somewhere. The cost of the care is ultimately going to fall on American taxpayers and by letting the undocumented buy into the exchange you’re going to bring those costs down for everybody.”

What do you think of Aviles stance on illegal immigrant healthcare?

Learn more: City Hospital Chief Calls for Coverage of Immigrants

Breaking new ground at the Medicaid & Medicare Marketing & Enrollment Congress

The Medicaid & Medicare Marketing & Enrollment Congress, created directly from input from professionals in your field is much more than a conference – it is a destination where the industry gathers to share actionable ideas and solutions to create a toolkit for reaching and retaining members in the Managed Care population.

Attend the event, March 22-23, 2010 at the Hilton in Baltimore, Maryland and advance your plans’ strategies to optimize enrollment, maximize retention and ensure compliance in an era of change.

This unique two-day forum is the ideal place to find practical strategies to manage the convergence government and adapt to reform under limited budgets. Attend this event to learn what works through 15+ case studies, facilitated problem-solver sessions and facilitated networking breaks:

• Drive creative partnerships with advocacy groups to expand outreach dollars under limited budgets
• Receive key updates on reform and its impact on marketing to increase plan compliance
• Improve member retention and quality outcomes for better regulatory and financial outcomes
• Integrate marketing across different media channels to grow age-in and current enrollee market share

Want to learn more? Visit the Medicaid & Medicare Marketing & Enrollment Congress website and gain access to:

• Industry Resources - bookmark this site today to keep up with the latest headlines in the Medicaid and health plan world
• Access to past presentations - take a look at a sample of what was covered at the 2009 event last March
• 2010 program brochure- finalized and ready for download

This conference is the one annual stop for making your marketing and outreach campaigns effective and cost efficient. Make plans now to attend - I look forward to seeing you in Baltimore!

Obama Urges Quick Action on Health Overhaul

The New York Times reports that President Obama has urged lawmakers to expedite the nation's healthcare overhaul. In his weekly Saturday address, Mr. Obama highlighted elements of the plan that would take effect soon after enactment of the bill.

He said people with pre-existing illnesses would be able to buy affordable insurance, children with pre-existing conditions would no longer be denied coverage and small-business owners who could not afford to cover employees would receive tax credits to buy insurance.

But this and other health care reform policies cannot happen unless the healthcare bill is signed into place by The President.

Learn more: Obama Urges Quick Action on Health Overhaul

Women's Insurance Amendment Set For Senate's First Health Bill Vote

As the Senate debates the health reform legislation, amendments are being advanced and Senators are reacting to the bill. Kaiserhealthnews.org reports that, "A bipartisan amendment to increase insurance benefits for women ... gets the first Senate vote Tuesday on health care overhaul legislation." The provision, co-sponsored by Sens. Barbara Mikulski, D-Md., and Olympia Snowe, R-Maine, "would require policies to include a variety of yearly screenings and was inspired in part by controversial recommendations last month that women undergo fewer mammograms and Pap smears to test for cancer." Mikulski said the amendment does not "mandate that you have a mammogram at age 40. What we say is discuss this with your doctor, but if your doctor says you need one, my amendment says you are going to get one." According to the AP, "The Congressional Budget office said the amendment would cost $940 million over a decade."

Learn more: Women's Insurance Amendment Set For Senate's First Health Bill Vote

WSJ: How would you recommend we improve the health care system?

The Wall Street Journal asks, "How would you recommend we improve the health care system?" to their Health Care Analysis group.

Given that health costs are constantly increasing, we definitely need to reform the health care system -- but if we are not careful how we fix it, we could end up with a lot of unintended consequences. Current projections show that the reform bill in its current state would increase costs to many people who have insurance now.

The main reason is the current bill only spreads costs around. We need an effective means to lower costs.

How would you recommend we improve the system? How will you get Congress to implement your recommendations?

Medicare changes coming into focus as health care overhaul moves forward

The Chicago Tribune reports there's growing agreement among policy experts about how Medicare will be affected.

The 10.4 million beneficiaries with private insurers' Medicare Advantage plans will still get coverage at least comparable to regular Medicare, but some will see fewer extra benefits or higher out-of-pocket costs.

For most of Medicare's 45 million beneficiaries, an overhaul will improve coverage by beefing up drug benefits, preserving access to physicians, paying for more preventive care and putting Medicare on firmer financial footing.

For more information about the Medicare policies, please visit the original article here.

Medicaid, Medicare Make Easy Marks for Fraud

Greg Burns of the Chicago Tribune writes that in a troubled economy, cheating Medicare and Medicaid just might be the easiest money anywhere. Recent reports about violent criminals and organized-crime figures putting aside their drug-running enterprises to pose as health care providers only scratch the surface.

Burns continues, some health care fraud is sophisticated and subtle. Some results in bloody crime scenes as hardened criminals enter the racket.

"If you're going to defraud somebody, the government is a reliable payer," said John Blum, a law professor at Loyola University Chicago who specializes in health matters. "Eventually, people like me catch up to you."

Read more about Burns' thoughts on Medicaid and Medicare fraud on his original post here.

Obama Calls for Bipartisan Support for Healthcare Reform

Obama recently stated in his weekly video address that we are seeing "unprecedented consensus" from doctors, nurses, hospitals, and drug manufactures that healthcare reform is no longer a Democrat issue or Republican issue but an American issue that requires an immediate solution. In the address he mentions several new politicians who have his support for the new healthcare reform like Mayor Michael Bloomberg and California State Governor Arnold Schwarzenegger. Take at the video below provided by the Associated Press. What's your take on it?

States Report Sharp Increase in Medicaid Enrollment and Spending Amid Worst Recession in Decades

The Kaiser Family Foundation reports that the number of people on Medicaid and state spending on the program are climbing sharply as a result of the recession, straining state budgets and pressuring officials to curb costs despite increased financial help from the federal government, according to a survey released today by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured.

The annual 50-state survey of state Medicaid officials finds that these trends are expected to continue well into the 2010 fiscal year, with the slumping economy contributing to the loss of jobs, private health coverage and state tax revenue at a time when more people are seeking help from public programs.

Across the country, states estimate Medicaid enrollment grew by an average of 5.4 percent in state fiscal 2009, the highest rate in six years, surpassing the projected 3.6 percent increase at the start of the year. Similarly, total Medicaid spending growth averaged 7.9 percent in FY 2009, the highest rate in five years, well above the 5.8 percent projected growth. For FY 2010, states estimate Medicaid enrollment will grow by 6.6 percent over FY 2009 levels.

The survey finds that, based on initial legislative appropriations, Medicaid spending across states is expected to grow by an average of at least 6.3 percent in fiscal 2010. But officials in three-fourths of the states are concerned that those appropriations will not be enough, leading to more budget shortfalls and more pressures to trim services and spending.

“The recession has shown the importance of Medicaid as a safety net for millions of Americans who have lost health coverage when they have lost their jobs,” said Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of the Kaiser Commission on Medicaid and the Uninsured. “But it also has shown the challenges for states of maintaining coverage when state revenues drop during times of economic crisis.”

American Recovery and Reinvestment Act (ARRA) Provides Some Fiscal Relief

The fiscal picture would have been much worse if not for the availability of increased federal Medicaid funding through the American Recovery and Reinvestment Act (ARRA).

The federal money, which will provide an estimated $87 billion to states through enhanced federal matching funds through December 31, 2010, helped all states, many of which are facing significant state budget shortfalls. States used the funds to address overall budget and Medicaid budget shortfalls, avoid cuts to providers, benefits and eligibility and address the recession-driven growth in enrollment.

ARRA also helped protect Medicaid eligibility. In order to qualify for the money, states had to ensure that their Medicaid eligibility standards, methodologies and procedures were no more restrictive than they had been on July 1, 2008, seven months before the enactment of the stimulus law. That requirement prompted 14 states to reverse new eligibility restrictions and five states to abandon planned new restrictions.

Nearly Every State Implemented Measures To Control Medicaid Spending

Even with federal relief, nearly every state implemented at least one new Medicaid policy to control spending in fiscal 2009 and 2010, the survey finds.

More than any other policy area, provider payment rate changes serve as a barometer of state fiscal conditions. Thirty-three states cut or froze provider rates in fiscal 2009, well above the 22 that had been expected to do so. Even more states (39) are slated to cut or freeze rates for FY 2010. And several others are considering it.

Rate cuts can jeopardize provider participation and inhibit Medicaid enrollees’ access to needed care. They bite particularly hard because some states have not fully restored provider rates to levels seen before the round of cuts in the last economic downturn from 2001 to 2004.

Several states also cut covered benefits or imposed new utilization controls for existing benefits, most commonly targeting dental and vision services for adults. Ten states reported benefits restrictions for fiscal 2009 and 15 reported them for fiscal 2010. California, Michigan and Utah instituted multiple benefit cuts.

Pressures Illustrate Challenges And Opportunities For Medicaid As A Cornerstone Of Health Reform

The reliance on Medicaid during times of economic crisis, and the fiscal pressures that follow, spotlight both the challenges and opportunities for the program in health reform efforts. Several legislative proposals in Congress include measures that would expand Medicaid to cover more low-income people as a platform for larger reform.

Because many states have already used Medicaid as a vehicle to expand health coverage, Medicaid officials expressed general support for an expanded role for the program in health reform. Even in these tight fiscal times over half of the states in FY 2009 and FY 2010 are moving forward with efforts to improve eligibility standards or the streamline application processes in a bid to cover more people. Among the states implementing the broadest reforms and eligibility expansions are Colorado, Maryland, New York, Oklahoma and Wisconsin.
However, state Medicaid officials did register concerns about health reform, too, reflecting current state budget situations. Three-quarters of states expressed concern that Medicaid eligibility expansions, mandated minimum provider rates and new administrative costs – depending on how they were financed -- could add to state fiscal woes.

States Report Sharp Increase in Medicaid Enrollment and Spending Amid Worst Recession in Decades


Today's blog post was sponsored by The Medicaid Drug Rebate Program Summit

Event: http://bit.ly/BuykF
Brochure:http://bit.ly/iG6TT
Register: http://bit.ly/KnBae

Mandate minus price controls may increase healthcare costs

The Los Angeles Times reports that many experts believe an insurance mandate is vital to a healthcare overhaul. With everyone in the system, the nation's medical bill could be spread more broadly, alleviating pressure on those who have insurance to pay for those who don't. All of the major healthcare bills would penalize people who do not get health insurance.But Democrats have shied away from regulating premiums in the face of charges from business leaders and Republicans that controlling what insurers charge would be meddling too much in the private sector. As a result, while states have long supervised what companies charge for mandated automobile and homeowners insurance, the idea has been largely banished from the healthcare debate.

What do you think about the lack of price controls within the healthcare bill? Will this have a negative effect on healthcare costs for Americans? We'd like to hear your thoughts.

Mandate minus price controls may increase healthcare costs

Canadian Health Care Tops U.S.

Bloomberg news reports today that as the debate for universal health care within the United States continues, some opponents are basing false assumptions about the success of universal health care in Canada. In a study released by Organization for Economic Cooperation and Development says that Canadians live two to three years longer than Americans and are as likely to survive heart attacks, childhood leukemia, and breast and cervical cancer, according to the OECD, the Paris- based coalition of 30 industrialized nations.

Deaths considered preventable through health care are less frequent in Canada than in the U.S., according to a January 2008 report in the journal Health Affairs. In the study by British researchers, Canada placed sixth among 19 countries surveyed, with 77 deaths for every 100,000 people. That compared with the last-place finish of the U.S., with 110 deaths.

For more information about the success of health care in Canada, please click the Bloomberg article here.

Canadian Health Care Tops U.S. in Studies Showing Wait Worth It

Mobile Tools and Applications Can Help Patients Better Manage Their Health

According to this article in iHealthBeat which features research from the California HealthCare Foundation, mobile tools and platforms can help chronic disease patients manage their health at home or at other places.

The author of the report, Jane Sarasohn-Kahn, offers guidance to healthcare providers that are looking to promote these health tools and applications. Jane mentions that these health applications should:

• Allow input on a full range of patient health activities;
• Consistently monitor patient health status;
• Continuously adjust recommended health regimens based on health status;
• Interpret patient data according to individual treatment goals;
• Proactively communicate tailored health advice to the patient; and
• Repeat these steps as needed.

Take some time to read this informative report it is worth the read.

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