Obamacare wins? See you in 2014

[kbot]

It may be that what has occurred is that, even though the Lab is "connected to" the office, that there is not a corresponding business relationship with the office.

Even so, it may be that certain tests aren't covered, depending on the location where the Lab test/ specimen was obtained.

A number of the rules have changed, and you're correct - most people aren't aware of this, and they go in thinking that they're covered, only to get wacked later on.

Another issue - many facilities have taken to the practice or proactively attaching liens against property in anticipation of payment issues with account balances. In most cases, this is allowable under the law, but chances are, most people don't know this. I'm not 100% sure of this, but, this information may show on a credit report.......

[Cherry Kelly]

Exactly and most people don't know. BUT - when a person goes into a lab and shows the receptionist the medical insurance card - it should be up to the receptionist to say - SORRY we don't accept XYZ Insurance company. IF a receptionist fails to tell you - I consider that fraud. They know what insurance companies they accept. AND the individual had "FULL Coverage" -- so I would file against such lab.

NOW if it were some ER situation - would be different, but this gal was merely having blood drawn for a blood test. AND as noted some of the callers who also had blood tests at certain labs PRIOR to ACA - their insurance was accepted and they were only left with co-pay bit. They too have discovered big bill coming to them because oh gee ACA happened and the labs no longer accept the insurance company.

[kbot]

It may not be that they don't accept certain insurances, it may be that there are certain deductibles built into a plan that people aren't appreciating fully, OR, it may also be that the Lab does accept that insurance, but the insurance won't pay for certain tests performed at a Lab, OR, the insurance won't pay unless the tests meets medical necessity or prior authorization has been obtained prior to the test being performed. The rules keep changing......

[kbot]

New information which is interesting. Under Obamacare, Medicaid is supposed to be one of those insurance plans that will handle an increased number of patients.

Medicaid patients are twice as likely to die after surgery

Study also finds more surgical complications for Medicaid patients

11:29 AM - May 16, 2014

Medicaid beneficiaries are at least two times more likely to die within one month of undergoing a surgical procedure than their privately insured counterparts, according to a new study in JAMA Surgery.

The study examined data from about 14,000 Medicaid beneficiaries and privately insured individuals ages 18 to 64 who had undergone surgery at 52 Michigan hospitals. It found that, compared to individuals with private health coverage, patients covered by Medicaid:

•Experienced 66% more post-surgery complications;


•Underwent more emergency procedures; and


•Used 50% more hospital resources.

According to HealthDay, the discrepancy can be partially attributed to the fact that Medicaid patients are more likely be smokers and tend to have higher rates of conditions that can increase risk during surgery, such as diabetes and lung disease.

The study authors note that hospitals often are not reimbursed for the total cost of caring for Medicaid beneficiaries, which could strain hospitals in the coming years as Medicaid programs expand using funding from the Affordable Care Act.
using funding from the Affordable Care Act. using funding from the Affordable Care Act.
What it takes to qualify for Medicaid in each state

Seth Waits, the study's lead author, says, "Financially, it may be a double whammy for hospitals, especially those that have the highest percentage of their surgical population covered by Medicaid." He adds, "If we make the presumption that the new Medicaid-covered patients will fit the mold of what we see now, surgical and inpatient teams must be prepared to provide the care and support they need" (Preidt, HealthDay, 5/14).

http://www.advisory.com/daily-briefing/ ... er-surgery

[Cherry Kelly]

kbot -- Anything is possible, but - the blood test was dr ordered. Had been for this person for several years - twice a year. The same lab had been used prior to Jan 2014 and the health insurance had not changed, though someone asked about that - and her card would not change until her yearly bit in September. (I thought the Sept date odd as most I know run for a year.)

--
The bit about Medicaid surgeries... hmm -- could it also be that those on Medicaid have greater -"less than healthy" lifestyles? Not just talking smoking bit either. Food, drugs, exposed to more diseases from their living quarters??

[kbot]

The bit about Medicaid surgeries... hmm -- could it also be that those on Medicaid have greater -"less than healthy" lifestyles? Not just talking smoking bit either. Food, drugs, exposed to more diseases from their living quarters??

Could be, but not necessarily. A number of states are now shifting patients to the Medicaid plans. Granted, this study is more than likely looking at historical data rather than more recent data, but, something to keep in mind.

Also keep in mind that the VA was held-up as an exemplar of government-provided and administered healthcare. As more and more VA hospitals are becoming named as withholding or delaying care, this should send shivers up anyone's spine......

[Cherry Kelly]

kbot as noted - other half used to take care of a VA hospital x-ray unit. Most of their equipment was older - outdated even back some years ago. BUT back then - waiting was not a problem. (Talking less 20 yrs ago - re waiting.) We also have rehab and sadly its full and they could use help there too.

I read the article from Miami, FL - investigator - who talked about missing meds, among other things wrong.

SAD about VA hospitals, treatments and yes delays.

[kbot]

Had some relatives that were in the VA system back in the 60s and 70s. One was a Navy vet -served in WWII, and at the time he was having some severe physical issues. While I didn't see him at the VA, I'd overheard a number of discussions abut the poor quality of care during that time. Then it seemed that things had improved at the VA over the decades, we were told that the VA had their act together, and that what we saw there was going to be rolled out as a model of how to do things in the civilian world.

I think we may want to take another look at that idea....

[kbot]

There go those "unintended consequences" again......

MGMA: Medical practices are having a tough time with exchange plans

Identifying eligibility can take up to 20 minutes for exchange patients

9:49 AM - May 22, 2014

Medical practices say they are spending more time and resources on patients who purchased coverage through a health insurance exchange than on patients with other coverage, according to a report from the Medical Group Management Association (MGMA).

For the report, MGMA in April surveyed over 40,000 doctors in 728 medical groups across 46 states. More than 90% of the medical groups have seen patients with coverage purchased off the federal exchange or a state exchange. About half say they have seen no change in their patient population size, while one-fourth say they have seen a slight increase.

Nearly 60% say it is somewhat more difficult to verify the eligibility, cost-sharing information, and data of patients with exchange coverage than that of other patients. While automated systems usually allow doctors to confirm a patient's information in seconds, confirming data of patients with plans purchased through the exchange can take up to 20 minutes, according to the survey.

"We are going to have to hire additional staff just to manage the insurance verification process," one practice manager told the MGMA. "We thought we would be able to identify ACA insurance exchange products by their insurance card, but quickly found out this isn't so," another respondent told MGMA.

In addition, 50% of respondents said they have been unable to provide covered health services to patients who purchased coverage on an exchange because the respondent's practice was outside of the patient's network. Moreover, 20% of respondents said they were excluded from networks they wished to participate in.

"As primary care providers, we are now faced with the extra burden of trying to find them care within their new narrow network… [p]ayer directories are woefully inaccurate and impossible to rely on," a respondent told MGMA.

Overall, MGMA President and CEO Susan Turney says that groups are especially dissatisfied "with the complexity and lack of information associated with insurance products sold" through the exchanges, adding the "more administrative complexity introduced into the health care system, the less time and resources practices can devote to patient care"

For hospitals to take advantage of new exchange patients, they'll need to streamline their patient access processes to handle the increased complexities of insurance verification and eligibility, point-of-service collections, and coverage enrollment.

http://www.advisory.com/daily-briefing/ ... ange-plans

Nice!!!! So, as a provider, the amount of time that you can spend with a patient has been cut down. It now takes you LONGER to even determine eligibility of the patients - more time than what is even allowed for the office visit. So, in order to help figure this mess out, you're forced to hire additional staff, AND, (the topper!!!) you may not even get paid for all this because the system's such a mess.

Yes, this IS so much better.............

[kbot]

Interesting article. If you go to the article and click on the various facilities' links and read the reasons WHY there are all these lay-offs, you'll see a common denominator - reductions in what the government pays for healthcare.

Peak at the future people and very basic economics - "Don't get paid, can't stay open".

6 Recent Hospital and Health System Layoffs

May 16, 2014


The following six hospital and health system layoffs and workforce reductions were covered by Becker's Hospital Review in the last two weeks. They are listed below by number of employees and/or positions affected.

1. Yukon-Kushokwim Health to Eliminate 160 Jobs
Bethel, Alaska-based Yukon-Kushokwim Health Corp., a system that includes one regional hospital and several community clinics that serves 58 rural communities in southwest Alaska, announced plans to lay off 110 employees and leave 50 positions empty.

2. Mercy Medical Center-Des Moines Eliminates 136 Positions
Mercy Medical Center-Des Moines (Iowa) laid off 29 employees and will leave 107 positions vacant in a move orchestrated to cut $15 million.

3. St. Francis Healthcare of Hawaii to Lay Off 110
Honolulu-based St. Francis Healthcare System of Hawaii plans to lay off 110 employees and slash its hospice and home health services. The system plans to close one of its hospice units in Ewa Oahu by Sept. 30 and cease offering a home health program that served patients on Oahu and Kauai by June 30.

4. Genesis Health to Cut Jobs, Benefits
Genesis Health System in Davenport, Iowa, is eliminating 30 management positions — affecting its COO and a senior vice president — and 50 staff-level positions. The system's CEO, Doug Cropper, and the rest of the C-suite are all taking pay cuts, and Genesis Health is also reducing employee benefits.

5. Morehead Memorial Hospital Cuts Positions, Hours
Eden, N.C.-based Morehead Memorial Hospital eliminated 22 positions and cut the hours of 25 other employees as it faces financial hardships. This is not Morehead Memorial's only recent workforce reduction: It has eliminated 18 other jobs in the last six months.

6. Ozarks Medical Center Eliminates 11 Jobs
Ozarks Medical Center in West Plains, Mo., laid off 11 employees in primarily nonclinical areas. OMC eliminated the positions as a response to declining reimbursements and inpatient volumes, according to the report.

http://www.beckershospitalreview.com/le ... 51614.html

[Riddick]

Is ObamaCare Now "Too Big To Fail"?
The administration has quietly adjusted key provisions of its signature healthcare law to make billions of dollars available to the insurance industry if companies providing coverage through the ACA lose money. Critics claim this plan to cover health insurer losses amounts to another taxpayer supported corporate 'bailout'. Full Story

[Cherry Kelly]

Seems everywhere one turns these days - hearing more and more problems with ACA - hospitals cutting workers - drs not allowed enough time with patients - patients who supposedly have coverage >> but gee can't be found in the lists.... and on and on and on.

NOW - several nursing homes are the same - and bed-ridden are being more neglected due to -- yup staff cuts and fewer dr and nurse visits or even TIME to visit. More and more of the ones in nursing homes are ... yaaaa being sent to hospice.

----

[kbot]

Was watching the House Ways and Means Committee Meetings on Medicare reimbursement this morning before coming in to work. They were discussing Medicare's "two-midnight rule", and the real-life impacts that this behemoth is imposing on patients and their families. In addition to the House panel, there were witnesses who spoke at the hearings - one was a physician from the University of Wisconsin, an administrator from Johns Hopkins, a physician who works for a RAC (recovery audit firm) and a legal counsel from Medicare/ CMS.

To show just how badly out of whack this whole thing is getting - according to Medicare rules (remember now, THIS is the plan that ultimately the government wants to shift the entire population of the country over to, eventually) - patients are increasingly, preferentially being "admitted" to a hospital as an outpatient, or as an observation patient.

These patients share in the same care, treatments, rooms, food, meds as other patients. They see the same physicians, nurses and get the same diagnostic tests. Essentially, they are indistinguishable from inpatients - except for an alpha-numeric code that CMS requires hospitals to use when processing the patient's claim.

So, if they are classed as "outpatient", or "observation patients", then a whole new set of rules kick-in, and the list of what Medicare Part A, Part B and Part D will pay - or I should say, not pay, changes dramatically.

What has been happening is that patients get admitted - no one tells them that, due to Medicare rules, they are being classed as an outpatient or observation patient (because hospital staff CANNOT tell them), and so when they are discharged - either home, or to a nursing home, SNIF unit, etc - then they find out that, even though they are in a hospital setting with other inpatients, that due to Medicare "rules", they are legally obligated to pay an increased share of their hospital stay. Also, if they are moved to a nursing home or SNIF unit, because they weren't first classified as an "inpatient", but instead as an "outpatient", or "observation patient", that Medicare is not obligated to pay for the nursing home care......

Nice, huh?

So, just because Medicare changed the rules - and no one can tell the patient about how they are being classified: it's all a big secret....... the patient or family finds out later after they're home, or recovering in a nursing home that the joke's on them and that, even though they've been paying increasingly higher premiums and haven't missed a payment, that they're not covered after all..........

And, the hospital staff gets squeezed as well because they try to appeal because many tests get denied reimbursement because the patient is listed as an outpatient, with a defined (two-midnight) date of service range. If the patient's condition is such that a stay more than two-midnights occurs (and they do, believe me), then all bets are off and whatever occurs after that second midnight if "free" to the government. And, if the patient is discharged due to the government's criteria, and has to be re-admitted, then the hospital has to pay a penalty......... because the government's way of looking at things didn't work. Because they're not doctors.

[kbot]

More on this hidden government fiasco. Welcome to the future folks....... The doctor from the University of Wisconsin is the doc I saw on CSPAN this morning.... The provision - and expectation of good healthcare by patients and families, shouldn't be THIS difficult.

Fighting ‘Observation’ Status

Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge.

A Medicare beneficiary must spend three consecutive midnights in the hospital — not counting the day of discharge — as an admitted patient in order to qualify for subsequent nursing-home coverage. If a patient is under observation but not admitted, she will also lose coverage for any medications the hospital provides for pre-existing health problems. Medicare drug plans are not required to reimburse patients for these drug costs.

The over-classification of observation status is an increasingly pervasive problem: the number of seniors entering the hospital for observation increased 69 percent over five years, to 1.6 million in 2011.

The chance of being admitted varies widely depending on the hospital, the inspector general of the Department of Health and Human Services has found. Admitted and observation patients often have similar symptoms and receive similar care. Six of the top 10 reasons for observation — chest pain, digestive disorders, fainting, nutritional disorders, irregular heartbeat and circulatory problems — are also among the 10 most frequent reasons for a short hospital admission.

Medicare officials have urged hospital patients to find out if they’ve been officially admitted. But suppose the answer is no. Then what do you do?

Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation. )

To increase the likelihood of being formally admitted, “get yourself in the door before midnight,” advised Dr. Ann Sheehy, division head of hospital medicine at the University of Wisconsin Hospital in Madison, Wisc. A new Medicare regulation — the so-called “pumpkin rule” — requires doctors to admit people they anticipate staying for longer than two midnights, but to list those expected to stay for less time as observation patients.

Although the rule applies now, Medicare officials won’t enforce it until April 1, having already pushed the deadline back. The American Medical Association and the American Hospital Association have called the pumpkin rule “impossible” to comply with and have urged that enforcement be delayed again until October.

“It doesn’t make any sense,” said Dr. Sheehy, who studied how the rule would have affected admissions at her hospital over an 18-month period and published the results in JAMA Internal Medicine. “Some patients will be admitted because they came in at the right time of day, not because they have more complicated medical problems.”

The two-midnight rule doesn’t change Medicare’s three-midnight rule, the one limiting post-hospital nursing home coverage. Officials at the federal Centers for Medicare and Medicaid Services declined comment for this story because of pending litigation seeking to eliminate observation status.

If you or a family member land in the hospital as an observation patient and think you should be admitted, it’s better to act sooner than later.

“I would talk to anyone who would listen to me,” said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy, which offers a free self-help packet for observation patients. “Make as much noise as you can, because it’s much easier to change your status while you’re still in the hospital than to go through Medicare’s appeals process later.”

Ms. Berthelot suggests asking your regular physician to speak with the doctor treating you in the hospital about why you need to be admitted, based on your medical condition and risk factors.

“It’s got to be a medical argument,” said Ms. Berthelot. “You can’t say, ‘Mom will need rehab after this,’ or ‘We can’t take her home because no one can stay with her.’”

If that doesn’t work, sometimes a strongly worded letter or call from a lawyer describing the patient’s medical needs can be effective.

In some cases, help from a professional can make a difference. Shari Polur, an elder-law attorney in Louisville, Ky., recently hired a geriatric care manager to persuade a local hospital to admit her client. Since admission status can change from one day to the next, the manager, who is also a registered nurse, called the hospital every morning to make sure the patient was still officially admitted until she could be transferred to a nursing home.

If the situation isn’t resolved while you’re in the hospital and you require follow-up care at a nursing home, you’ll have to pay the bill of often thousands of dollars up front. At that point, Ms. Berthelot suggests, you should file what amounts to a special doubled-barreled appeal with Medicare.

It’s not for the faint of heart: the process is long and arduous, and it requires beneficiaries to first receive and pay for the care — often an expensive proposition — before seeking reimbursement.

And the legal arguments can be tangled. The Medicare appeals process typically addresses disputes over whether certain treatments or services rendered should have been covered. Observation patients have actually received hospital coverage and services a doctor says is medically necessary — so they don’t really have anything to appeal, said Marc Hartstein, director of Medicare’s hospital and ambulatory policy group, at a recent briefing in Washington.

“My limited understanding of this is that the patient cannot appeal a decision not to order or not to do something,” he said.

But observation patients may claim that they received treatment usually provided to admitted patients only in a hospital. Therefore, the hospital incorrectly billed Medicare for an outpatient service instead of for inpatient services. The patient should have been admitted and therefore qualifies for nursing home coverage.

“It’s absolutely confusing as heck,” said Michael Sgobbo, an elder law attorney in Charleston, S.C., who recently won an appeal on behalf of a 98-year-old woman who will be reclassified as an admitted patient. That means Medicare will pay her nursing home bill of nearly $10,000.

Lawyers at the Center for Medicare Advocacy recommend fighting observation care on two fronts.

First, follow the appeal instructions in the Medicare summary notice, a quarterly statement of services. Circle the charges on the statement from the hospital and explain that these items were inappropriately billed under Medicare’s Part B as outpatient services. They should have been billed under Medicare’s Part A for hospital services, because the patient received treatment that could only have been provided in a hospital. Mail the statement within 120 days (from the date on the statement) to the address provided for appeals.

Second, after challenging the hospital’s observation designation, file a separate appeal to seek reimbursement for the nursing home charges, said Ms. Berthelot. To begin, ask the nursing home to bill Medicare. You should receive a Medicare summary notice indicating that it did not pay the nursing home charges because the patient didn’t have the required three-day hospital stay. Circle those charges, and explain that the beneficiary was hospitalized for three days and received an inpatient level of care. Then send it within 120 days to the address provided for appeals.

Be prepared to dig in. If either appeal is denied, you must appeal again to the next level, following the instructions in the denial letters.

“Both appeals can take at least a year and are fraught with difficulty,” said Ms. Berthelot. “The reality is that most people can’t get through and those who do, get lucky.”

Some observation patients appeal and never get decisions, warned Diane Paulson, senior attorney at Greater Boston Legal Services. Some of her clients’ cases were dismissed because they were not admitted to the hospital — the very point they were challenging.

“You can’t appeal if you don’t have a denial,” she said. When that happens, the case falls into “a black hole.”

But the chances of winning improve as you continue to appeal, as Nancy and George Renshaw, of Bozrah, Conn., discovered. After spending nearly four years going through the process, a Medicare judge decided last February that Mr. Renshaw’s father should have been admitted to the hospital instead of classified as an observation patient. Medicare finally paid his nursing home bill, and in November the Renshaws received a refund of $4,410.

“I was shocked,” said Ms. Renshaw. “I never expected to see a penny of it.”

http://newoldage.blogs.nytimes.com/2014 ... blogs&_r=0

[Cherry Kelly]

kbot -- wow, gee wonder if this kind of thing applies to other people as well? What about those on Medicaid? Or those who go into a hospital to give birth and wind up having a c-section - they going to be "observed" as well? Or what about a Medicare individual who is in a car accident?

Wondering if the senior citizens - those on Medicare should file a "discrimination" suit against the gov't for this?