Insurance

Insurance is a means of protection from financial loss. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. An entity which provides insurance is known as an insurer, insurance company, or insurance carrier. A person or entity who buys insurance is known as an insured or policyholder. The insurance transaction involves the insured assuming a guaranteed and known relatively small loss in the form of payment to the insurer in exchange for the insurer's promise to compensate the insured in the event of a covered loss. The loss may or may not be financial, but it must be reducible to financial terms, and must involve something in which the insured has an insurable interest established by ownership, possession, or preexisting relationship. The insured receives a contract, called the insurance policy, which details the conditions and circumstances under which the insured will be financially compensated. The amount of money charged by the insurer to the insured for the coverage set forth in the insurance policy is called the premium. If the insured experiences a loss which is potentially covered by the insurance policy, the insured submits a claim to the insurer for processing by a claims adjuster. Wiki

Waste, Fraud and Abuse CMS Style

Politicians love to talk about how they will eliminate waste, fraud and abuse if you will only elect them to office. If you are one of those who believe the folks in DC have their own WFA Task Force you

would be mistaken.

When it comes to Medicare, John Minnino, Esq. has come up with a way to beat the CMS cops at their own game.

By using statistical analysis, Mr. Minnino has identified 5 "red flags" that indicate a strong possibility of Medicare fraud.

In 2014 prosecutions initiated by the government led to a mere 31 settlements yielding $88 million in fines. 

In 2014 there were 469 of these (whistle blower) health care fraud settlements�many involving huge pharmaceutical corporations and hospital networks�resulting in $2.2 billion in fines.- Wired

Makes you wonder what the CMS cops are really doing to eliminate fraud.

Maybe a better use of taxpayer dollars is to fire the folks at CMS responsible for policing fraud and let private citizens acting as bounty hunters do the job.

Whistle blowers typically receive 15 - 30% of the settlement as their cut.


#MedicareFraud  #WasteFraudAbuse

Health Wonk Review: ObamaTax Anniversary Edition

Charles Gaba makes his (impressive) hosting debut with this week's informative roundup of health care policy and policy. His very sly (and much appreciated) sense of humor is on display, as well; this one's just a joy to read.

Thanks, Charles, and kudos on a great 'Review!

Joe Garagiola 1926 - 2016

Baseball is a funny game.

But not today.

Happy ObamaTax-iversary!

In case you'd forgotten (heh!), today marks the 6th anniversary of the date on which ObamaCare began to be implemented.

'Nuff said.

UPDATE: via our friend Rich W, here are five charts showing ObamaCare's "success."

PARE-ing Back?

Our friend Louise Norris has written about the issue of balance billing, and advocates its (eventual) eradication. While she's a very thoughtful agent and writer, I take issue with her premise and her solution(s). Regular IB readers know all about PARE claims (these are typically the kinds of providers who join no networks and so bill pretty much whatever they want) and why they usually result in a balance due after insurance pays its part. What Louise and others advocate is forcing those providers to accept whatever an insurance carrier deems appropriate, and eat any difference.

Which sounds rather noble, until one looks at how that's handled currently, and what expansion would entail. Thanks to co-blogger Bob, we have access to a report from the Robert Wood Johnson Foundation (hardly a right-leaning outfit) which gives us an overview of how a handful of states currently handle the issue.

To our knowledge, balance billing isn't really an issue for life-threatening emergency claims; all 58 states offer at least some protection in that scenario. Where it gets dicey are non-emergency situations, and whether one's plan is a PPO or HMO model.

According to the folks at RWJF, there really isn't a lot of "there there" when it comes to how the states they surveyed handled these situations. All banned the practice for emergency situations (as do all the other states). Some applied this to both HMO's and PPO's; Florida really only locked down HMO's.

Interestingly, some states only apply the ban to providers that have previously agreed to accept assignment of benefits from the insurance carrier (which makes sense, really). If interested, details are available in that report.

But here's the rub: so what? Two things are in play here, neither of which are good: for one, as co-blogger Patrick notes "several states prohibit balance billing and we work with clients on claims where this occurs and used to have a 100% success rate of having these charges written off. Along comes ACA and now insurers say too bad."

Does anyone seriously think that's going to improve by extending it to non-emergency expenses?

And second, how do we force non-participating providers to accept less than what they've billed? This is the kind of thing that helped to create the whole Direct Primary Care movement; that is, when the insurers (and by extension, the government) begin to tell providers how much they can charge, then they're going to find a way to remove themselves from that "authority." Ever ask yourself why vets can charge pretty much what they want?

Be careful what you wish for: You might just get it.

Unusual Definition: Success

ObamaTax proponents like to tout its success in reducing the number of uninsured (using dubious metrics). The first problem with this, of course, is that health insurance ? health care . But that's only part of it:

The Bureauweenies in DC� claim that almost 13 million victims citizens enrolled in Exchange-based plans during the most recent Open Enrollment. That's up from an alleged 12 million last time 'round.

What they're not telling you is that this is basically meaningless.

Why's that, you ask?

Well:

"[O]nly 8.8 million people remained enrolled in Obamacare on December 31, 2015. That is a drop of almost one quarter from the end of 2015 open enrollment."

One step "forward," two steps back.

Funny way to define "success," no?