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Wellness screenings covered at 100%–read the small print! December 28, 2011

Posted by medvision in Cancer Care, Chronic Disease, Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Here’s an egregious practice unfortunately common in the managed care industry. A member, trying to maintain health, participates in a “no cost” wellness procedure. While sedated, or undergoing the procedure, the physician identifies a minor medical issue and fixes it. Then “whack” the member wakes up facing a fat charge due to a diagnostic in place of a screening code.  One could argue it’s a “technical event” allowing insurance companies a manner to collect additional revenue. http://tinyurl.com/7lxz32l

Here’s the work place problem. For example, colon cancer is the 2nd leading cause of cancer death in the US. The main weapon to fight this cancer is early detection by colonoscopy. It’s hard to imagine this procedure being abused by members, recreational colonoscopies? Due to these hidden charges, one has to wonder how many colon cancer deaths result? If a plan is self-funded, the plan managers need to prevent ASO claims payors from implementing these processes. If fully insured, employers should pick up/pay for the additional fees.


Unintended consquences, PPACA eliminating 100,000+ agents and brokers December 13, 2011

Posted by medvision in health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Risk Management, Uncategorized.
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The president’s healthcare bill is showing America “change” has unintended consequences. Here’s one which will ripple through the lives of Americans receiving health benefits through small to mid-sized employers! Losing their jobs are 100,000+ agents and brokers who served as a buffer between the needs of insured Americans and the insurance companies? http://tinyurl.com/7l2oup3

It seems Kathleen Sebelius, Duchess of HHS, found the 2.02% of agent commission unworthy to be included in expenses for MLR calculations. Back to the land of unintended consequences. What roles do these agents play in the health outcomes of every-day Americans? (Ok, I understand the intent of Obamacare’s creators is to completely eliminate employer sponsored health benefits. For the sake of discussion, let’s pretend the nation comes to its senses and only permits part of PPACA to survive?)

Here’s a few instances in which agents and brokers changed the lives of their clients (1) Cancer diagnosis A woman’s physician, and consulting physician, strongly suspect she has initial stages of  serious organ cancer. They recommend advanced imaging as a diagnostic tool. The insurance company declines opting only to pay/permit exploratory surgery to collect multiple biopsy samples. The insurance broker reminds the insurance company of legal and public perception issues with such a decision and, after additional consideration, the insurance company relents. The test indicates the woman cancer free!

(2) Simple mistakes sink ships– During an open enrollment meeting an employee mistakenly prints the wrong date on the group enrollment application. The insurance company denies coverage under the group. The agent threatens to move another large group to a competitor if the mistake is not treated an inadvertent mistake. Problem solved.

(3) Deny by contract provision An applicant for individual coverage correctly answers individual underwriting questions as not knowing about heart disease. The policy is issued and after 9 months the person suffers a heart attack. The insurance company cites a prior doctor visit as proof the individual knew, or should have known they were subject to a heart attack, and denies coverage. The agent hounds the company VP of underwriting until the decision is reversed.

I know some will say the above are exactly what the entirety of PPACA will prevent! Hold on there “Kiomsabe”. If you believe free market healthcare can be tough, how about nationalized healthcare. http://tinyurl.com/nyap8o Things aren’t so rosy with the national health system in Great Britain! What makes us think our government would do better? For example, “Cash for Clunkers”

I once had a boss with very initiative advice. “Be careful what you ask for. You may get it”. Why not make provisions for uninsured American’s without destroying our current system? More on this later!

High deductible plans not working? Here’s what works, 0 deductible! December 10, 2011

Posted by medvision in Cancer Care, Chronic Disease, Employee Wellness, health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Rx Costs, Uncategorized.
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My initial introduction to consumer driven plans, HDHPs, was presented in a group setting by a national carrier, or, “industry speak” a BUCA. We were first told the reason for explosive trend is a combination of easy physician access due to low copays, better technology, our legal environment and expensive drugs. Then came the HSA regulatory part. (I used to think the 401K regs were somewhat complex)! Today, from my years of data experience, I know explosive health inflation is driven by a small percentage of members suffering worsening states of chronic disease.

Anyway, a troubling thing is sneaking up on the disciples of HDHPs and their concept of member consumerism. It’s the rapid adoption of on/near site clinics by 20%+ of employers with a thousand or more employees.

Hmm. In one corner we have plans requiring members to spend the 1st $1,000 – $10,000 before plan benefits start, And, in the other corner, all-inclusive primary care benefits with no, 0, member dollars needed. If fact, a few BUCAs are big proponents of both plans! Sort of an AC/DC strategy.

The clear winner is immediate and easy access to primary care, preferably in scenarios in which the physicians are significantly rewarded for “great” member health. A great plan discount occurs when large claims don’t occur due to prevention/early disease identification. Guess how many $70 primary care visits can be purchased for the cost of a $250K annual claim paid on behalf of a member facing end-stage renal failure? A great physician can he hired for $200K annually. So, how many members can a physician see in 12 months? Here’s a good opinion article on employer clinics! http://tinyurl.com/7rvm7sm

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