Due to political pressure Donald Berwick resigned from his post as a Center for Medicare and Medicaid (CMS) administrator.

Dr. Berwick was appointed by president Obama in 2010 during a congressional recess, effectively forcing his position to be reconfirmed by congress this year. Prior to this pending confirmation 42 Republican senators signed a letter pledging to block his confirmation, effectively ending any chance of him serving beyond 2011.

What is so wrong with Dr. Berwick? What did he do to make many republicans angry?

He praised the UK National Health Services when he was visiting the UK. He also made some comments that can be interpreted as rationing. Honestly I don’t know too much about the UK National Health Services. All I know that everyone gets basic medical care free of charge, and they have problems with waiting for advanced imaging and surgeries. I would say the first part is admirable, the second part no so much.

I am still puzzled the anger of congress regarding rationing. If you think about it healthcare rationing is a way of life in the US. We just call it Utilization Management in the case of insurance, Local Policy Determination in the case of Medicare. When we are considering Medicaid we simply have no doctors whom are willing to treat patients for the assigned cost. Our last group is the uninsureds, whom can’t afford insurance, therefore can’t afford healthcare. Presently in the US we are rationing by ability to pay.

I am a believer that Dr. Berwick would have made a difference in our health care system if congress gave him a chance to continiue on the path he already started.

Dr. Berwick came to CMS following enactment of the controversial Patient Protection and Affordable Care Act (PPACA). In his 18-month tenure, Dr. Berwick supervised the rollout of essential health reform regulations that promised to reshape both the private insurance market and the Medicare program. CMS drafted rules for the new health insurance marketplaces, called exchanges, where Americans will be able to compare and buy health insurance plans in 2014. He is responsible for putting in place a pilot program to move Medicare away from paying doctors based on volume of services to quality of care.

Dr Berwick advocates patient centered care; hospital care that works with the needs of the patient; not the medical staff. He doesn’t want a patient or himself “to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep.”

I am personally sad to see him go. His medical values and believes would significantly improved our overall health care.

The time frame to change current Medicare plans has been moved up. This year, open enrollment started on October 15 and ends on December 7.
Actual changes will take effect, as usual, on January 1.
This is the time to review cost, coverage and convenience. It is time to consider a return to traditional Medicare or to check out if there is a Medicare Advantage plan that may offer better benefit options.
It is also time to change prescription plans. It is the perfect time to review all letters arriving from the present drug plan. There may be changes in the formulary for next year, which can adversely effect your bottom line. As always information is available at www.medicare.gov
Of course people that are satisfied with their current choices don’t have to make any changes.

Disclaimer: this is not medical advise; it is simply a public announcement trying to spread the word about early recognition of stroke symptoms.

Neurologist says that if he can get to a stroke victim within 3 hours he can reverse the effects of a certain types of strokes. They say the trick is getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours.

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke.

RECOGNIZING A STROKE

Doctors say a bystander can recognize a stroke by asking three simple questions:

Ask the individual to SMILE.
Ask the person to TALK and SPEAK A SIMPLE SENTENCE (Coherently)
Ask him or her to RAISE BOTH ARMS.
Ask him or her to STICK OUT YOUR TOUNGE

WHAT YOU ARE LOOKING FOR IS : being crooked. A smile where the lip is droopy in one side, a sentence where the words are slurred, arms that don’t go up the same height, tongue that ends up one side or the other. You are looking for pronounced weakness in either side of the body.

If he or she has trouble with ANY ONE of these tasks, call emergency number immediately and describe the symptoms to the dispatcher.

In June, I invited Karen Caccavo, Personal Money Manager, to provide a guest blog for MedBillsAssist Blog. Karen is a daily money manager (DMM)—which was NOT the topic of her blog, but this month it is because I find that a DMM is another professional that my clients might need in their quest to come up from under overwhelming paperwork. While I handle the medical bill tasks, Karen is a “paper generalist.” She has an MBA in finance from the Wharton School, so really knows the financial paperwork and how to make sense of it and how to communicate with your broker, financial planner, attorney and CPA.

But I will let Karen explain what she does:
Late payment notices, overdraft fees, missed paperwork deadlines, confusing invoices–not keeping up with paperwork can be costly and stressful for people of all ages and especially overwhelming for people facing medical challenges and seniors. A trusted family member or friend can help, but people often do not want to be a burden or might not have a support system in place. Letting things “slip through the cracks” can be disastrous and costly.
Here is where a daily money manager comes to the rescue. Ours is a relatively new profession but a needed one. We’re not accountants, attorneys, or financial planners but we often provide the “boots on the ground” for these professionals working with individuals who want or need in-home help with paperwork and accumulated clutter.
My current clients range in age from 18 to 94 and access my services on a weekly, monthly or “as needed” basis. Some of my clients are simply outsourcing that aspect of their lives—relying on me to open mail, pay bills, track their spending, organize paperwork for taxes and bring to their attention important correspondence. Others simply can’t keep up with these essential tasks any more because of age or medical condition. My assistance helps them keep their independence. Each client is different and I tailor my services to their needs.

Karen Rosenberg Caccavo, MBA is owner of Personal Money Manager, a daily money management firm. She can be reached through her website, PersonalMoneyManager.net or Karen@Personalmoneymanager.net or LinkedIn.

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Nearly 388,000 nursing home residents’ deaths each year are attributed to infections. Approximately 25% of all hospitalizations of nursing home residents are caused by infections; the costs range from $673 million to $2 billion.

The FDA issued “black box” warnings against prescribing atypical antipsychotic drugs for patients with dementia, cautioning that the drugs increased dementia patients’ mortality. At the same time CMS reports that, nationwide, 39.4% of nursing home residents who had cognitive impairments and behavior problems but no diagnosis of psychosis or related conditions received antipsychotic drugs.

Use of chemical restraints is a major cause of nursing home falls, including hip fractures, which are estimated to cost $746.5 million.

Lack of toileting leads to urinary incontinence, in turn it leads to skin irritation, decubitus ulcers, urinary tract infections, and additional nursing home admission and hospitalization. Estimated cost $3.26 billion annually.

Poor hydration, along with poor nutrition, decreased mobility and cleanliness leads to pressure ulcers. Treatment costs are estimated to range between $1.2 and $12 billion.

Hospitalization of a dehydrated nursing home resident costs, on average, more than $18,000. Dehydration is often avoidable if residents are given more fluids. Insufficient staffing leads to less fluid intake by residents.

Three-quarters of all nursing home residents have at least one fall each year, and a quarter of the falls require medical attention. Twenty to thirty percent of the falls are preventable. Falls cost, on average, $19,440 and hip fractures, more than $35,000.

Poor care leads to excess hospitalizations, costing nearly $1 million.

Present plans by our government to fix nursing home expenses for Medicare and Medicaid patients:

Medicare-Medicaid Coordinating Office (MMCO) was established under the authority of the PPACA to address cost of care and improve access.

There are three initiatives in the works.

1. Capitated model – basically contracting with insurance companies to create a blended Medicare-Medicaid rate

2. Fee-for-service model- this model supposed to share savings from Medicare hospitalization reduction due to better quality care in dual eligible nursing home residents within each state.

3. Improved Care Quality for Nursing Facility Residents – this project plans to contract with independent entities to implement better practices to prevent conditions that leads to hospitalizations. The project aims to target 150 Skilled Nursing Facilities with high rate of hospitalizations. (Will observation be counted into these admissions?)

The real fix is simply having more nurses and nurse aides to provide better care.

Could You Lose a Client over $1?

by Karen Rosenberg Caccavo, MBA, Personal Money Manager

One of the things I do for clients as a daily money manager is uncover and banish “hidden” fees that clients inevitably pay–but shouldn’t have to. Some are large, others are small, but they all add up and annoy the heck out of my clients–and probably yours (and you) too!

I was recently reviewing a client’s bank statement and noticed that the insurance premiums for his home and auto were being automatically deducted in two separate payments each month and a $1 service fee was being added to each payment. I called his insurance broker to ask why the premiums weren’t deducted as one payment (with a single $1 fee) and was told, “The client has to ask us to do this.” I pointed out that the client is on a fixed income and meets with his broker every year to review his account but did not know that this simple fee saving option was available. The broker’s reply to me: “We don’t look at every client’s bill in detail.”

Because I DO look at my client’s bills in detail, I asked for the change to be made to his billing immediately, reducing his monthly “convenience” fee from $2 to $1. But I was told that there would be a one month delay as the next deductions were “only” 8 days away.

When I got off the phone and conveyed the information to my client, he was angry. “I’ve been insured with this agency for 30 years,” he said, “But now I want to switch.” He insisted we submit a “broker of record” letter so he can change insurance brokers.

I can’t help but wonder about the broker who lost this client after so many years–not to a charming lizard who also sells insurance, but by subjecting his client to $1 in unnecessary fees!

Karen Rosenberg Caccavo, MBA is owner of Personal Money Manager, a daily money management firm. She can be reached through her website, PersonalMoneyManager.net or Karen@Personalmoneymanager.net or LinkedIn.

Insurance language defines pre existing condition as a symptom, illness or health condition that was known and existed prior to the writing and signing an insurance contract. Health or life insurance policies will typically not cover pre-existing conditions until a specified period of time has elapsed. Depending on federal and state laws pre-existing conditions may not be covered at all.

The Health Insurance Portability and Accountability Act (HIPAA) provide some protection for people in transition, although it doesn’t go far enough.  The HIPAA law allows a 63 day gap between health insurance coverage.  Once the person is without medical insurance over 63 days, they are vulnerable to insurance company searches in to their medical records.

Unfortunately there are a lot of people affected by this unreasonable rule created by the insurance companies.
 
In a recent case a young woman was hospitalized and one of her old diagnosis was listed on her medical bill.  This code was put on to represent her historical medical condition and had nothing to do with her recent hospitalization.  Unfortunately, this simple coding oversight prompted her insurance company to deny her hospital and all other relevant medical bills.  The denial brought on disbelief, then frustration and anxiety.  Finally a well drafted letter from the treating physician clarified this new medical care need and all her claims got paid.

Another case involves a man who has been out of work for about two years.  His COBRA had run out and he couldn’t afford medical insurance, therefore his coverage gap went over the 63 day threshold.  One month later he finally got a job with medical insurance. Three month later he found himself in emergency surgery.  Unfortunately the surgery was similar in many ways to his previous condition and anatomical location.  Fortunately, the sudden illness was a newly manifested condition; therefore his insurance cannot deny his medical claim.  With that said it does not mean they don’t try.  Several request letters were sent to the patient.  These letters are originating from a third party company and asking for his signature to give authorization to request all his medical records.  Fortunately he was referred to us at MedBillsAssist, before he had signed any authorizations.  Our first action with the client was to acknowledge the request letters, but did not authorized access to his medical record.  It is always a bad idea to permit third party company to start looking through medical documentations.  The reason is simple:  records aren’t always correct. Hospital and physician records are handled by many and the process is error prone.  It is a very good idea for patient to request medical records and review them for accuracy.   According to HIPPA regulations, a patient can request their own medical records simply by signing and dating a request to release.       Once a person satisfied that the documentation is what he/she understands to be true, then it can be forwarded to the third party for review.  If there is an error the patient has a legal right to request correction of that error.  A simple letter to the hospital or physician to modify the medical record should be sufficient.

The Patient Protection and Affordability Care Act prohibited insurers to deny claims for children, except in grandfathered individual health insurance plans, based on pre-existing condition starting last fall.  The same law will apply to adults in 2014; provided the law will not be modified.

Below are some highlights in phase two of the Health Care Reform Bill.

This is the year when our tax codes are going through significant changes driven by the health care law.  Overall, health care is getting more regulated, therefore it is forcing businesses, health care providers and insurance companies to spend more money on administration.  There are a lot of plans that are studying and “advising” on how to make health care better.  Sadly, those groups and advisory bodies should have been created prior to the enactment of this law.

• Minimum Medical Loss Ratio

Health plans, including grandfathered plans, must report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

• Consumer Protection

Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage as well as rescinding coverage except in cases of fraud.  Annual limits are still in effect until 2014.  The provision also prohibits plans from denying children coverage based on pre-existing medical conditions.

• Standardizing the Definition of Qualified Medical Expense

Match the definition of qualified medical expenses for HSAs, FSAs and HRAs to the definition used by the IRS itemized deduction.  Over-the-counter medicine will now only be considered as medical expense of accompanied by a doctor’s prescription.

• Reporting Health Coverage Costs on Form W-2

Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2.

• Creating Simple Cafeteria Plans

Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax‐free benefits to their employees.

• Appealing Health Plan Decisions

Appoints the right to appeal medical claim and/or policy decisions made by any health plan and the right to appeal decisions made by the health plan to an outside, independent decision-maker, no matter what state a person lives in or what type of health coverage a person may have. This includes, for the first time, new self-funded plans.

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Many health care reform provisions went into effect on September 23, but as with any new law some will start right away, and others will slowly be implemented over time.

Small business tax credits for companies with fewer than 25 employees are now in effect. Provisions to rescind policies are banned. People now are afforded federally protected appeals rights.
Some provisions are not welcome by the insurance industry and are being challenged in their own way. For example, insurers are now prohibited from denying coverage for children with pre-existing medical conditions. Insurance companies have responded by eliminating children’s policies in several states.
The ugly duckling, known as the medical loss ratio, is being legislated at 80% for small groups and 85% for large groups with a mandated rebate if the insurer fails to meet these ratios. Insurance companies have responded by reclassifying certain expenses as medical services.
Although other provisions are already in effect, such as dependent coverage for adult children up to age 26 for all policies, and requiring qualified health plans to provide minimum coverage for certain preventive services without cost sharing, these will only start when policies are renewed. In many instances, this will be in January 2011.
Interstate insurance exchange programs should already be in place, but they are running far behind schedule. The federal government does not know how to run them and state programs are so different from each other that most states have decided not to run their own.

Most states estimate serious financial shortfalls in this program; therefore they are hesitant to get it started.

Medicare changes are taking effect as well, such as cuts in all hospital payment rates, payment reduction to Medicare Advantage plans and a significant start in eliminating the prescription coverage gap.

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