Posts Tagged ‘Health insurers’

Obama Administration Reverses Itself on Patient Disputes With Insurers

Wednesday, July 13th, 2011

The Obama administration has fine-tuned rules that give patients greater clout in disputes with health insurers, changing the standards in ways that disappointed leading advocates for healthcare consumers.  The rules are designed to guarantee patients the same rights to appeal if their insurers do not cover care that is considered necessary.  The federal standards, part of the Patient Protection and Affordable Care Act (ACA), replace a patchwork of varying state policies.  The rules allow patients to protest to their health plans; if they do not succeed, they can take their complaints to an outside arbiter.  Department of Health and Human Services (HHS) officials issued the rules 11 months ago, but they have revised them.  Insurers and employers have long wanted limited appeal rights; conversely, consumer groups have argued for stronger patient protections.  In the new version, the grounds to protest an insurer’s decision are narrower than consumer groups prefer.

Writing on the Becker’s Hospital Review website, Rachel Field says that “The earlier rules governed consumers’ right to appeal denials by health plans.  The overhaul gave members in group and individual health plans the right to appeal the denial of coverage to an independent review panel.  The administration’s new rules give beneficiaries less time to prepare an appeal, less information about the reason for the denial and limitations on which denials can be appealed.  According to the report, patients can still appeal if their coverage is cancelled by an insurer, and decisions by external review panels are still binding.  Employer-sponsored plans that are self-insured will have to use at least two independent review organizations to make sure decisions remain unbiased.”

Because states lack the authority to regulate self-insured health plans, there has been no requirement allowing beneficiaries to appeal denials to an independent panel.  The health law extends that right to more than 44 million Americans covered by self-insured plans that will lose their exempt status this year.  “The right to an external appeal is considered one of the most important consumer protections that you can have,” said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight at the HHS.  “Consumers do not want insurance companies making medical decisions for them or for their families.”  According to Larsen, states will have extra time to revise local external appeals rules so that they can conform to the federal standards.  Insurers won’t have to comply with new state rules that incorporate federal requirements until January 1, 2012.

The revised rules come at an appropriate time.  Although few people want to a fight with their health insurer, it may be worthwhile.  A recent Government Accountability Office report found that more claims problems resulted from annoying but often clear-cut billing and eligibility issues than from disagreements over whether care was medically necessary.  Plus, the odds are about 50/50 that if a patient appeals an insurer’s decision, the patient will win.

Not everyone agrees with the action. “The Obama administration gave in to the insurance industry and large employer lobby on rules that would, for the first time, give rights to patients with certain employer-paid health plans to challenge a healthcare denial.  These consumers need the protection of independent reviews the most because they usually have no legal remedy for a wrongful decision to deny care under an errant 1987 Supreme Court ruling.  Health reform was intended to strengthen the public’s ability to make insurers provide the coverage patients are promised.  The administration should reverse the changes in this regulation that undermine that promise,” said Carmen Balber, Washington director for Consumer Watchdog.

HHS Issues Proposed Rules Requiring Healthcare Insurance Increase Disclosure

Thursday, January 6th, 2011

The Department of Health and Human Services (HHS) has issued proposed regulation that – thanks to the Patient Protection and Affordable Care Act – would obligate health insurers to provide additional information about rate increases.  Beginning in 2011, insurers who raise rates by 10 percent in the individual and small group markets would have to publicly disclose the increase and justify their reasoning. Additionally, HHS wants state-specific thresholds to be set for rate disclosure in 2012, “using data and trends that better reflect cost trends in that particular state.”

Summaries of the 10 percent or greater reviews would be posted on the HHS website; insurers seeking these increases would be required to post their justifications on their corporate websites.  Evidence “suggests that the majority of increases in the individual market have exceeded 10 percent each year for the past three years,” greatly surpassing national measures of cost inflation, according to HHS.   After a public comment period, the final rules will be issued in approximately six months.

Not surprisingly, America’s Health Insurance Plans (AHIP), the insurance industry’s lobbying group, argues that the proposed rules don’t account for new benefit mandates and the recession.  “For example, data from the state of Oregon show that prices of many medical services have increased at an average annual rate exceeding 10 percent,” says AHIP CEO Karen Ignagni.  “California data show that prices for a hospital stay increased by more than 150 percent between 2000 and 2009 — an average annual growth rate of 11 percent.  Trends like these are being seen across the country.”

Consumer advocates, on the other hand, contend that the proposed rules are not strong enough.  “The whole point of this regulation, as the HHS secretary has said, is to shine a light on the actuarial assumptions…in the hope that public scrutiny will shame insurers into doing the right thing,” says Carmen Balber, director of Consumer Watchdog in Washington, D.C.. “If full data is not disclosed, in many cases we’re left with the status quo.”

Is the GOP Alone In Wanting to Repeal Healthcare Reform?

Monday, December 6th, 2010

Even though Republicans will control the House of Representatives and have a larger presence in the Senate come January, they still are likely to hit some formidable roadblocks in their attempt to repeal the Affordable Care and Patient Protection Act. Those roadblocks are such lobbying giants as the American Medical Association (AMA), the American Hospital Association (AHA) and the Pharmaceutical Research and Manufacturers of America (PRMA).  The groups are on board with the new healthcare reform law because they will gain an estimated 30 million (or more) new paying customers in the next few years.  The reform law is expected to increase payments to physicians and hospitals who have felt squeezed in recent years.  Additionally, analysts believe the new law is a major force for job creation in the healthcare sector.

“These guys were onboard for a reason,” said David Dranove, a professor of health enterprise management at Northwestern University’s Kellogg School of Management.  “Very few employers will drop private health insurance, and you will expand private insurance to 15 million people.  If this legislation stands, we are not likely to see new reforms for a generation.”

Primary-care physicians, who are likely to benefit significantly from the healthcare reform law, will see their reimbursements from government insurance programs rise – although many believe the reform law is only the beginning.  According to Dr. Cecil Wilson, AMA president, “While the 111th Congress made important improvements to our nation’s healthcare system, more work needs to be done.”  Hospitals – which have been hard hit by patients unable to pay their medical bills because of unemployment – will be in better financial shape once more Americans get health insurance subsidies in 2014.

Pharmaceutical companies, which were among reform’s earliest supporters, oppose repeal, even though analysts say it will cost them $100 billion in government rebates.  The upside is that the industry will obtain new customers who were previously uninsured and unable to afford the latest brand-name medications.  Even the much-maligned insurance companies – who will have more than 15 million new customers – oppose repeal.