A new venue for surprise medical bills
January 14, 2024
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January 14, 2024
Enough people were upset by surprise medical bills that Congress passed the No Surprises Act in 2020, meant to eliminate instances of patients going to a facility that is in-network, but receiving a bill from an out-of-network provider. However, KFF Health News published an article recounting how one patient was surprised by an out-of-network bill when opting for a remote visit with her usual health system.
One issue appears to be that the No Surprises Act might not have anticipated remote visits, since it seems to apply to specific facility types (and not all facilities). The legislation allows for out-of-network service, provided that the patient gets advanced notice, and another issue in this particular case appears to be that the consent forms were "signed" by the patient after the consultation (the patient does not remember signing such forms). A third issue is the cost of the visit came out to be $660 (for a visit that was between 49 minutes and 59 minutes), when the patient recalls the visit actually only being five minutes. A fourth issue is that the patient saw a cost of $60.
It also seems that requiring sick patients to read and understand fine print when they are trying to book an urgent appointment is less than fair. Overall, this surprise bill seems like a terrible customer experience and is reminiscent of what lead to the No Surprises Act in the first place.
January 07, 2024
Medicare Advantage health insurance plans are touted as the same as traditional Medicare, but operated by private insurance companies. As such, Medicare Advantage plans are often pitched with extras, such as a regular allowance that can be spent on qualified medical expenses (such as toothpaste or glasses) or a gym membership. However, KFF Health News published an article about seniors discovering some important differences: Medicare Advantage enrollees lack guaranteed eligibility in Medigap plans (in most states) and more limited acceptance by providers.
Medigap plans (also known as Medicare supplemental plans) are private plans that help cover holes (or "gaps") in Medicare coverage in exchange for an additional premium. The article explains "In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care." For patients who have chronic conditions that require much care, Medigap can save meaningful amounts. Enrollees in traditional Medicare are guaranteed eligibility in Medigap plans, but enrollees in Medicare Advantage plans can have their premiums priced according to patients' medical histories. It seems that even patients who switch back from Medicare Advantage to traditional Medicare are not guaranteed the favorable pricing.
This disparity in the Medigap eligibility and pricing guarantee seems to give traditional Medicare an advantage. It is unclear if the disparity is intentional, and four states have extended the guarantee to Medicare Advantage plans. Since patients frequently do not know upfront whether they would use Medigap insurance, it seems that patients would benefit if they all had the same Medigap guarantee, regardless of whether they are enrolled in traditional Medicare or in Medicare Advantage.
Something else that would make it easier for patients to compare traditional Medicare and Medicare Advantage plans would be published metrics of acceptance by providers. If patients have a difficult time finding providers that accept their insurance plans, that meaningfully changes the quality of the insurance.
Both of these changes seem pertinent, especially as recent years have seen significant growth in enrollment in Medicare Advantage plans.
January 01, 2024
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December 25, 2023
Merry Christmas to all!
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December 17, 2023
It is generally easy to know the price of a health insurance plan (the premium), but how does one measure the quality of one? There are many dimensions to rate a plan one. For example, if a health insurer is notorious for denying claims, patients might be less likely to enroll with its plans. Another dimension is whether the insurance plan is accepted by a wide range of physicians. A insurance plan might not be popular with physician if it offers reimbursement rates that are too low or if it incurs too much hassle before paying claims. Inversely, health insurance plans can grow their networks by offering higher reimbursement rates, which unfortunately, generally causes the plans to be more expensive. As KFF Health News reports, the current administration is proposing to articulate specific network adequacy standards (for example, quantifying the lower bound on how many physicians of each particular specialty need to be available within patient populations).
When the Affordable Care Act passed, the legislation mandated the coverage of various conditions so that patients could more easily compare plans. Regulation around minimum network adequacy standards will help ensure that health insurance plans will be more useful to patients -- after all, what good is insurance if the patient cannot use it for lack of physician availability? Setting these standards can be difficult, but are likely to involve the number of physicians in an area that are in network relative to the number of patients in that area, with different ratios for different physician specialties. One component of the standards also seems to test how long a patient must travel in order to see a provider. Beyond the complexity of calculating network adequacy, these standards will also likely cause some plans to be more expensive, just as mandating a minimum level of coverage increased the price of health plans.