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Last week I had an opportunity to meet some of the staff of Westchester Residential Opportunities Inc.
It was a great pleasure to talk with these ladies who are caring and compassionate individuals committed to help every person who walks through their doors.
I wanted to share their information with my readers and spread the word, that housing help is available in Westchester.

Help for those with limited means and/or challenges

WRO is a 42-year old nonprofit housing counseling agency whose mission is to promote equal, accessible and affordable housing for all residents of Westchester County. Since 1968, WRO has championed the expansion of nondiscriminatory housing opportunities for low- and moderate-income people, minorities, senior citizens and persons with disabilities, including the psychiatrically disabled.

Core services include:

1. eviction and utility shut-off prevention
2. mortgage foreclosure prevention
3. senior housing assistance, including counseling for reverse equity mortgages
4. first-time home buyer counseling and financial education
5. supported housing for persons recovering from mental illness
6. subsidized home modifications for persons with mobility impairments
7. investigation of housing discrimination

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More information is available in their website at http://www.wroinc.org/

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7 minute video http://www.wroinc.org/wrofinal-3.mov

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Nobody wants to get a $4,000 medical bill; especially if they haven’t been in a hospital for years.  But it can happen to anyone and according to a recent survey by the Ponemon Institute it already happened to 5.8% adults in America. They have been a victim of medical identity theft, costing an average of $20,160.  The human cost is even higher.
Patients whose medical identities are stolen face serious drawn out effects. Fraudulent health care events can leave erroneous data in medical records. This erroneous information, such as information about tests, diagnoses and procedures, can greatly affect future health care and insurance coverage along with costs. Patients are often unaware of medical identity theft until a medical bill or a collection notice exposes the problem. Then, the burden of proof is with the patient and it is difficult to get the patient’s legitimate medical records cleaned up. The consequences can be life threatening and can lead to serious medical treatment errors and fatalities.
We all are at risk. Our personal information is sprinkled all over in the globe.  US companies hire subcontractors in other nations to provide customer service; data processing and many other functions. Your and my medical claims data can be accessed in the Philippines, because labor is cheaper there.  But even if we consider staying within the border of our nation we can all remember stories about stolen government laptops, lost backup tapes.
Last year CVS, the pharmacy giant, was fined $2.25 million for failing to protect sensitive financial and medical information of its customers and employees.
Just recently 12,000 Medicare enrollees had their protected health information compromised by a simple filing cabinet donation gone wrong.  Blue Cross & Blue Shield of Rhode Island donated a filing cabinet to a nonprofit organization without first removing surveys that contained Medicare PHI (Protected Health Information). 
While all these stories are awful I believe the real danger is still lies with individuals who work for doctors, clinics and hospitals.  They steal patient records in minutes by downloading information on a flash drive and sell it on a black market.  This could be an unhappy employee or someone recently hired to take a position simply to purloin information.
The only real protection is keeping a close eye on your medial identity.  Check your insurance Explanation of Benefits, look online and make sure that services billed are actually received, ask your insurance company to send you an annual statement for all your medical services.

The Patient Protection and Affordable Care Act was signed into law last week by the President. According to estimates it will afford coverage for an additional 31 million legal US residents; an estimated 24 million remains uninsured.

The most significant changes to the current health care system are:

1. Elimination of pre-existing conditions limitations.
2. Elimination of calendar-year and lifetime maximums.
3. Establishment of community rating with variation for age and geography.
4. Permitting young adults to remain on their parent insurance plan until age 26

The Congressional Budget Office (COB) estimates that the coverage provisions in the bill will cost 848 billion over ten years. Most of the major provisions will not take effect until January 1, 2014. Therefore, the current COB estimate uses 10 years of revenue to cover 6 years of coverage. In contrast, Republican staff on the Senate Budget Committee estimates that the total spending in the bill for 10 years will exceed 2.5 trillion.

The bill creates an estimated 150 new government entities to the teeming bureaucracy and countless new additions to the already overly complex tax codes.

More regulations will force everyone involved to spend more money on administration, driving the ultimate cost of health care even higher.

Large business entities and insurance companies will pay higher taxes, and those not providing insurance will be penalized. Small businesses, with less than 25 employees, will receive subsidies.

Extended coverage will be achieved by extending Medicaid for lower income individuals and families, providing tax credits for people above the Medicaid income threshold and by interstate insurance exchanges for the presently uninsured.

The law is promising protection from exorbitant out of pocket costs in the form of yearly caps on co-payments and co-insurance charges. However, it does not address the small print, such as usual and customary rates and non-covered (medically needed, but excluded from policy coverage) charges. It appear that the burden is entirely left on the insurance companies, but in reality the public will remain unprotected from overcharges and non-covered expenses. We are still at the mercy of deals made by insurance companies and large hospitals.

Physicians, the backbone of health care, are still affected in several ways. They are still forced to take contract of adhesions, limiting their ability to negotiate fees with insurance companies. They are still waiting for the permanent fix to the faulty Medicare formula, that was removed from the bill and replaced with a temporary fix. Tort reform, a major player in health care cost, hasn’t been addressed.

This legislation missed the mark of real reform. It only added several layers to an already fragmented system. It missed the opportunity to address real cost control, both by insurers and medical providers.

Regulatory authority between the federal and state governments is still divided and will be clarified via regulations in the coming years.

Regardless of what we think about this bill, it has been passed. Now it is time to move forward and make it work, hopefully, for all Americans.

It is truly amazing what patients have to go through to receive covered medical services.

One large insurance company managed to cross all lines yesterday.

A client called to ask me to look into a pre-authorization denial for medical services that has been ordered by her doctor a few days before. She told me that in the morning of her test the physician’s office called to let her know that her test was denied; therefore she doesn’t need to keep her appointment.

The medical procedure in question is common for people over 40 years old; therefore I was surprised about the denial. Naturally, I called the doctor’s office to find the reason for the rejection.  I was told that they don’t know. Seemed odd, so I took the next step and called her insurance company. As you would expect I wanted to know the reason for the denial, so we can have it corrected, and get this test approved. At first the customer service person didn’t know, so she asked me to wait on the line. It took her some time to get back on the call, and to tell me that no one knows why the test was denied. Their third party administrator (a company who is hired by the medical insurance company to manage certain tests) made this decision without giving any reason.  She suggested that I appeal the decision. Although I have no reservations on writing appeals, as I had done several hundred ever the years, I always have solid reasoning.  Sending an appeal based on nothing seems foolish, so I asked “what should I base this appeal on?”  She had no answer.

This type of insurance behavior is not only unfair to patients, but it is unlawful. State insurance law requires insurance companies to explain, in plain language, why is a service being denied. They are also required to provide information about the appeals process.

In a few days this test will be pre-approved and paid by the insurance company in question, whether they like it or not!

President Obama signed H.R.4691 – Temporary Extension Act of 2010 into law on 3/2/10

Time and money spent on administering health care is a necessary cost, but when this goes to the extreme, one must take note and wonder. Medicare, our largest “insurance” in the nation is closely controlled by government rules and regulations. One would say that the government, that wants to lower health care cost, would not create additional burden for providers and insurance companies in the form of, well, additional administrative cost.

The freshly signed H.R. 4691 is a prime example of administrative government squander. This bill allows two Medicare fixes on the temporary basis; patches a 21.5% physicians pay cut, and extends the physical therapy exception process.

Pay rates for doctor services are calculated by a formula based on the GDP, the number of beneficiaries, and other variables. It has been in place for 13 years.  Due to drop in the GDP and increase in the number of beneficiaries, the doctors were to receive a 21.5% pay cut on January 1^st. This law allows a temporary override, leaving doctors pay at present level until March 31, 2010.  

Physical therapy enables patients to regain their mobility after surgery, injury, illness, etc. Caps on therapy services were put in place to control Medicare expenses. The cap exception process allows some individuals to continue therapy, above the annual limit, when suffering from additional complex medical conditions.  For example, Parkinson’s disease qualifies a Medicare beneficiary to receive more physical therapy services under the exception rule.

A physical therapy service exception has expired on December 31, 2009. Once a beneficiary reaches their limit, they are notified and must pay out of pocket for additional services.  The new extension allows payment and now, claims need to be resubmitted, or reprocessed.

Starting on April first the same, insane, process will begin.  Medicare intermediaries will hold claims and wait for the government to fix payment rates.

The administrative nightmare is going on behind the scenes.  The Medicare contractors (actual insurance companies) are holding claims for two weeks, and then release them, applying rates that is in effect at that time. Most certainly these insurance companies had and will have administrative cost increase related to the frequently changing regulations that need to be added to their systems. Would someone remind the government that they suppose to lower the administrative cost instead of increasing it?

http://www.opencongress.org/bill/111-h4691/show

Creating new programs to administer more and pay less is an ever growing trend with insurance companies. United Healthcare new specialty medication management program is just that; more hoops to jump for less.

Industry insiders long known that the federal Medicare program is a leader in the creation of more administration and less payment.  Blue Cross and Blue Shield usually follow closely, and then the rest of the pack (insurance companies in general).

Now United Healthcare seems to be taking the leading role of creating an additional program without benefits to its members.  The Specialty Pharmacy Program is designated to put more stops in prescription utilization for high cost drugs. New and renewal members will be forced to obtain certain medications from a participating specialty pharmacy to receive in network coverage. Furthermore this policy eliminates the previous 90 day supply benefits, both as a discount and convenience. Members will be forced to renew prescriptions each month and pay the 30 day co pays.

Typical of insurance policies, coverage by out of network pharmacy is not clearly defined. No one can tell until they visit a local pharmacy.

Consolidated Omnibus Budget Reconciliation Act of 1985, commonly called COBRA, is a federal law providing continuation of group health coverage that would otherwise be lost due to life events such as termination of employment, death of an employee, and divorce. The original bill allows coverage continuation of full employer cost.

Due to economic difficulties and significant job loss across the nation the federal government passed a law which became in effect in February 2009. The American Recovery and Reinvestment Act of 2009 provided subsidy for eligible former employees, enrolled in their employer’s health plan at the time they lost their jobs. This subsidy allows them to pay only 35 percent of the cost of COBRA coverage.

Last December congress passed and the president signed a defense spending bill that included a COBRA subsidy extension through the end of February 2010. This bill provides continues medical insurance coverage for involuntary terminated workers, at a same reduced premium.

A new bill is pending to further extend COBRA subsidy for those still without jobs. Votes expected early next week.
The 65 percent subsidy has been a big help for millions of laid-off employees and their families who, in many cases, would have been hard-pressed to pay the entire monthly premium, which typically is about $400 for individual coverage and $1,200 for family coverage.

Congressional researchers estimate that the new subsidy would benefit about 7 million former employees and their families and cost about $25 billion.

Many important parts of the health care reform has been discussed in length by the media. In this media frenzy, among many other things, we learned about special interest, state specific spending and pork in the bill. In the mist of political badgering there was one important provision in this senate version of the bill, that I am sure everyone would like to see.
The amendment states that Congress should have exactly the same medical coverage that they impose on the citizens of the USA. Here’s a quote from the H. R. 3590 Patient Protection and Affordable Care Act:

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SEC. 1312. CONSUMER CHOICE.
(D) MEMBERS OF CONGRESS IN THE EXCHANGE.

(i) REQUIREMENT.—Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are:

(I) created under this Act
(II) offered through an Exchange established under this Act
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This amendment had been added by Republican Senator Tom Coburn, the Senate health committee voted 12-11 in favor of adding the provision, who used Congressman John Fleming’s two pages House Resolution 615 to add this amendment to the bill. Interestingly, both Coburn and Fleming are physicians who probably know a thing or two about health care.

The proposed Act is the Senate’s version and will be voted on by the House. As such, The House may remove this amendment from the final bill; however, you have to applaud the effort of Coburn and Fleming just to put this addition into the bill.

Centers for Medicare and Medicaid Services (CMS) erroneously notified 400 thousand Medicare Advantage (MA) beneficiaries that some MA plans will no longer be offered next year in service areas where plans will continue to operate. CMS blamed the affected plans, contending that they hadn’t properly filled out forms.
According to CMS spokesman the issue is limited in scope in terms of number of organizations affected and beneficiaries impacted. Don’t you feel better already? It only affected 400 thousand seniors and a limited number of insurance companies.
A little known fact in this matter is that MA plans aren’t allowed to send out communications without CMS approval. Therefore they are not allowed to correct CMS erroneous letter, unless it is approved by CMS.
Kindly, CMS agreed to review any written notice insurance companies (MA Plans) would like to send to their members.
One must ponder about this. Was this a simple problem of incomplete paperwork? Was this an attempt to get beneficiaries back to traditional Medicare? Was this an elaborate attempt to question MA plans reputation? We will never know…