CMS Proposes Prior Authorization for Home Health Services

The Partnership for Quality Home Healthcare expressed deep concern about a proposal by the Centers for Medicare & Medicaid Services’ (CMS) that would require prior authorization of Medicare home health services. Under the proposal, CMS must approve physician ordered services before care can be initiated. The Partnership says that this would delay access to services, increase costs to Medicare and to taxpayers, and place burdensome requirements on providers. Other healthcare sectors that require prior authorization have documented care delays of up to 10 days.

Keith Myers, chairman of the Partnership said, “Home health patients are often at greatest risk during the transition from hospital to home. For care to be delayed by several days opens up the possibility for a host of adverse events ranging from missed medication, to new infections, to poor management of chronic conditions. We urge CMS to recognize the potential negative patient consequences that will result from a prior authorization requirement and we urge the agency to not proceed with a prior authorization demonstration program for home health.”

Home health leaders also warn that prior authorization would drive up costs to Medicare since patients would be more likely to be sent to more expensive in-patient facilities or experience a hospital readmission while waiting at home alone for their prescribed post-acute care. The proposed demonstration program would also increase the administrative burden on doctors and home health agencies who already provide extensive documentation on patient eligibility for home healthcare services. The proposal would not reduce fraud and abuse in the home health community, according to the Partnership. Bad actors will submit false records to satisfy the need for prior authorization, just as they do for CMS’ other documentation requirements.

In addition to these policy concerns, home health leaders stress that CMS does not have the legal authority to implement this prior authorization demonstration. The Partnership has offered several proposals to address fraud, including targeting aberrant billing and utilization, having sufficient checks on qualifications and background, and identifying geographic hot spots for fraud.

What Every Patient Should Know about Medical Billing

Navigating the complicated healthcare financial system can be a nightmare with the smallest misstep costing thousands. Andrew Graham, the CEO of Colorado’s largest independent medical billing firm, Clinic Service Corporation, says that consumers can often avoid paying unnecessarily high fees with these tips:

  • Tip #1:  Don’t go to an urgent care facility with an injury or illness that could be too serious for the staff there to handle. If the physician at the urgent care decides you need to go to a hospital emergency department for care, they are required, by their liability insurer, to send you to the hospital ER in an ambulance. The ambulance ride is likely to cost you thousands, plus you will be on the hook for charges from the urgent care facility and the hospital.
  • Tip #2: Doctors will work with you on your bill if you can’t pay it. A payment plan is an option; sometimes your doctor will even knock down his or her fee if you’re willing to settle the bill with a credit card that day.
  • Tip #3: Newly insured patients often go to out-of-network doctors without knowing it, leaving them with large bills to pay. Always check with a new doctor or other healthcare provider to see if they are in your insurance company’s network. This applies to labs and imaging centers you may be referred to as well.
  • Tip #4: If you’re worried about what a procedure might cost, don’t hesitate to ask your clinic’s practice manager for the details. It might be easier to do this via phone, so that the practice manager can get back to you later when they have the details.
  • Tip #5: Spending a little more money on your monthly insurance payment will save you in the end. Many consumers who chose less expensive coverage options through Affordable Care Act (ACA) plans are being stuck with large medical bills when their insurance provides minimal coverage. “We all like to think we’ll be healthy in the coming year and not need the coverage, but life has a funny way of reminding us that illness and injury never take a holiday,” Graham said.

Out-of-Pocket Healthcare Spending Reaches $416 Billion

Americans spent $416 billion in out-of-pocket healthcare costs in 2014. With a growth rate of 8%, it will reach $608 billion by 2019, according to a report by Kalorama Information. Out-of-pocket spending includes direct expenditures, office co-pays, hospital visits, drug purchases, and premiums.

Premiums make up the largest category of spending, but co-payments and direct payments are growing.  Direct payments are expected to grow 9.5% per year, as employers add high deductible plans. Co-payments are expected to grow 9.5% annually as plans raise co-pays and subject more products and services to co-payment. Premiums will expand by 7.1% per year.

According to Hewitt Associates, HMOs will seek double digit monthly premium increases as they face an exodus of young, healthy employees. Rx medications comprise 43% of total out-of-pocket health care costs, followed by office-based procedures at 26%. Hospital stays comprise just 1% of the average person’s out-of-pocket health care spending, although these expenditures are considerably higher for people with the highest health care expenditures.

New Model for Low-Cost High-Quality Healthcare: The Cayman Islands?

Health City Cayman Islands, a new, high-tech hospital in the Caribbean, is increasingly seen as a model for U.S. health systems struggling to remain profitable in the face of razor-thin margins and declining reimbursement. Less than two hours by air from Miami, the planned 2,000-bed facility expects to attract American patients with high-deductible health plans seeking less expensive high-quality care.

As featured in a new documentary film, “From the Heart: Healthcare Transformation from India to the Cayman Islands,” Health City is the first development outside of India by Narayana Health, internationally regarded as one of the world’s lowest-cost, highest-quality healthcare providers. The brainchild of famed heart surgeon Dr. Devi Prasad Shetty, who was Mother Teresa’s personal physician, Health City replicates the model that enables Narayana’s average cardiac hospital to perform thousands of heart surgeries per year for less than U.S.D $1,400 per case – about 2% of the average cost for heart surgery in the U.S.

‘Henry Ford proved that the commoditization of a product makes it cheaper, makes it better and makes it more efficient, I strongly believe that we have to commoditize the delivery of healthcare, and that is the model that Health City represents for the world,” said Dr. Shetty. Narayana’s secret is a laser-sharp focus on efficiency, enabling some of the highest patient volumes in the world. Surgeons at Narayana Health City in Bangalore, India perform roughly 30 cardiac surgeries each day. That compares to 12 cardiac surgeries per day at Cleveland Clinic, which says it performs 20 times more cardiac surgeries per year than any other U.S. hospital. Many of Heath City’s medical professionals have already performed thousands of surgeries with outcomes that rival the best American facilities. All Narayana providers are employees who are invested in increasing productivity, streamlining processes, and improving patient care. High volume drives cost savings, and Narayana has taken an aggressive approach to every component in the supply chain, which enables it to provide basic heart surgery for a fraction of the cost in the United States.

Health City is a joint venture between Narayana Health and Ascension Health, one of the largest U.S. healthcare providers, which has said it is interested in learning from the Narayana model. But Ascension is not the only U.S. health system interested in what’s happening in the Cayman Islands. Robert Pearl, MD, CEO of the (Kaiser) Permanente Medical Group, the largest U.S. medical group, wrote recently in Forbes that Health City has American health care providers watching closely, and anxiously. Dr. Pearl concluded that the operational approaches in Dr. Shetty’s hospital are about 10 years ahead of those used in the typical U.S. hospital.

Health City’s innovations begin at the ground level. Construction of the 108-bed facility took less than 12 months and cost $420,000 per bed, about one-third the U.S. average of $1.5 million to $2 million, despite the relatively high cost of real estate in the Cayman Islands. Real-time performance metrics are constantly available for administrators across the medical center. Analytics technology called “iKare” monitors lab results and clinical findings to predict potentially significant medical problems. Clinical teams are timed on their speed of response, with a particular focus on eliminating delays in treatment. Narayana Hospitals’ average time to an appropriate response is just seven minutes, significantly less than the average U.S. hospital.

Eschewing the profit-center approach of U.S. hospitals, in which key departments such as the operating room bill patients separately, Health City has only one profit center – the hospital. That arrangement aligns incentives to cut cost from every process. And to further simplify costs, the medical center provides an all-inclusive flat rate for every procedure covering every service. “We’re one of the few hospitals in the world to publish our prices as a bundled flat rate. And that’s what you’ll pay, nothing more. You get one bill and you’ll never get another bill. It’s a model that gets a lot of attention when we talk with other healthcare providers. A large provider of charitable care, Narayana Health gives its executives a daily profit/loss statement so they can see exactly how much care they can give away to patients,” said Chandy Abraham, MD, Health City’s Facility and Medical Director.

Health City Director Gene Thompson “We’re never going to match India and their costs. But we feel we can show that in a high-cost destination we can provide high-quality low-cost healthcare if we think outside of the box. It’s about saving lives and providing the highest quality healthcare to the most people at an affordable price, because humanity deserves it.” For more information, visit www.healthcity.ky. Or www.narayanahealth.org.

Growth in Health Spending Slows for Fourth Straight Year

slowgrowthHealth care spending grew at a record slow pace for the fourth straight year in 2012, according to a actuaries at the Centers for Medicare and Medicaid Services, published in the journal Health Affairs. In 2012 U.S. health care spending saw the fourth consecutive year of slow growth with an increase of 3.7%. The share of the economy devoted to health spending decreased from 17.3% in 2011 to 17.2% in 2012.

The Gross Domestic Product increased nearly 1% faster than health care spending at 4.6%.  Private health insurance premiums reached $917 billion in 2012, and increased 3.2%, near the 3.4% growth in 2011. The net cost ratio for private health insurance was 12% in 2012 compared to 12.4% in 2011. (The difference between premiums and benefits as a share of premiums.)

Private health insurance enrollment increased 0.4% in 2012, but still lower than in 2007. Out-of-pocket spending grew 3.8% in 2012. Private health insurance spending for physician and clinical services grew at a faster pace while Medicare spending decelerated slightly in 2012.
The following categories saw an increased spending trend:
• Hospital spending increased 4.9% in 2012 compared to 3.5% in 2011.
• Spending on physician and clinical services increased 4.6% in 2012 compared to 4.1% in 2011.
• Spending for dental services increased 3% in 2012 compared to 2.2% in 2011. Out-of-pocket spending for dental services, which accounted for 4 2% of all dental spending, increased 3.9% in 2012 compared to 3.1% in 2011.
• Spending for other health, residential, and personal care services grew 4.5% in 2012 compared to 3.3% in 2011. This category includes expenditures for medical services that are generally delivered by providers at schools, community centers, the workplace, residential mental health centers, substance abuse facilities, and by ambulance providers.
• Spending growth for freestanding home health care agencies increased 5.1% in 2012 compared to 4.1% in 2011. Medicare and Medicaid spending accounted for 81% of total home health care spending in 2012. Medicare spending grew at a faster rate in 2012 while Medicaid spending slowed.
• Medicaid spending grew 3.3% in 2012 compared to 2.4 % in 2011. Federal Medicaid expenditures decreased 4.2% in 2012 while state and local Medicaid expenditures grew 15% — a result of the expiration of enhanced federal aid to states in the middle of 2011. The relatively low annual rates of growth in Medicaid spending can be explained in part by slower enrollment grow tied to improved economic conditions and efforts by states to control health care costs.

The following categories saw a decreased spending trend or stayed the same:
• Spending for independent health practitioners of physical therapy, optometry, podiatry, and chiropractic medicine increased 4.5%, which is about the same rate as in 2011.
• Spending for freestanding nursing care facilities and continuing care retirement communities increased 1.6% in 2012 compared to 4.3% in 2011. The slower growth was primarily due to a reduction in Medicare spending due to a one-time rate adjustment for skilled nursing facilities.
• Retail prescription drug spending grew 0.4% in 2012 compared to 2.5 % in 2011. Driving the low growth were reduced retail drug prices as numerous blockbuster drugs lost patent protection and generics became available.
• Retail spending for durable medical equipment (contact lenses, eyeglasses, and hearing aids) increased 5.6% in 2012, the same as in 2011.
• Retail spending for other non-durable medical products (over-the-counter medicines, medical instruments, and surgical dressings) grew 1.8% in 2012 compared to 3% in 2011.
• Medicare spending, which represented 20% of national health spending in 2012, grew 4.8% compared to 5% in 2011. With a new payment system, there was a one-time payment reduction to skilled nursing facilities in 2012 after a large increase in 2011.

In 2012, households accounted for the largest share of spending (28%), followed by the federal government (26%), private businesses (21%), and state and local governments (18%). The federal government financed 26% of total health spending in 2012, a slight decrease from 27% in 2011. In June 2011 saw the expiration of enhanced federal funding from the American Recovery and Reinvestment Act of 2009. Since states are no longer getting additional federal government aid, they have seen their share of the health care bill increasing from 17% in 2011 to 18% in 2012. For more information, visithttp://content.healthaffairs.org/content/33/1/67.abstract.

Medicare Hospital Price Data Reveals Wide Variations

For the first time HHS is giving consumers information on what hospitals charge for Medicare services. HHS Secretary Kathleen Sebelius said the new data reveals significant variation in what hospitals charge for common inpatient services across the country and within communities.

The CMS website compares charges for services associated with the 100 most common Medicare inpatient stays. These amounts can vary widely. For example, average inpatient charges for hospital services in connection with a joint replacement range from $5,300 at a hospital in Ada, Okla., to $223,000 at a hospital in Monterey Park, Calif.

Hospital charges for similar services can vary significantly, even within the same geographic area. For example, average inpatient hospital charges for services to treat heart failure range from $21,000 to $46,000 in Denver and from $9,000 to $51,000 in Jackson, Miss. For more information, visit
http://www.cms.gov

Last Updated 06/23/2021

Arch Apple Financial Services | Individual & Family Health Plans, Affordable Care California, Group Medical Insurance, California Health Insurance Exchange Marketplace, Medicare Supplements, HMO & PPO Health Care Plans, Long Term Care & Disability Insurance, Life Insurance, Dental Insurance, Vision Insurance, Employee Benefits, Affordable Care Act Assistance, Health Benefits Exchange, Buy Health Insurance, Health Care Reform Plans, Insurance Agency, Westminster, Costa Mesa, Huntington Beach, Fountain Valley, Irvine, Santa Ana, Tustin, Aliso Viejo, Laguna Hills, Laguna Beach, Laguna Woods, Long Beach, Orange, Tustin Foothills, Seal Beach, Anaheim, Newport Beach, Yorba Linda, Placentia, Brea, La Habra, Orange County CA

12312 Pentagon Street - Garden Grove, CA 92841-3327 - Tel: 714.638.0853 - 800.731.2590
Email:
Jay@ArchApple.com
Copyright @ 2015 - Website Design and Search Engine Optimization by Blitz Mogul