Healthcare Services – Why is Our Role As Consumer Being Denied?

The fact is we need to either ask the office manager, the plan administrator, the network provider, or the doctor how much it is for a particular health service. The reason is that prices for healthcare services are not easily accessible. They are difficult to compute, assess and manage. For this reason, we as consumers do not feel empowered to make good decisions with respect to our healthcare. The cards are stacked against us.

In recent times, it has come to light that many hospitals and providers charge special lower rates for services rendered to policy-holders of large insurance companies. Whereas, uninsured patients are charged the highest rates for the same services rendered. In addition, it is practically impossible to track and manage these costs. This is unfair and unjust.

Healthcare is not a transparent industry that caters to consumers. Most other industries that service consumers are focused on market conditions that drive their businesses. This means that promoting their prices is important. Imagine going to a gas station and not knowing how much they were charging for unleaded gasoline! Imagine attending a spa and just not knowing the cost of the services, but also later receiving the final bill that would be impossible to understand and that it would include items and services that you did not feel you received! There are not many businesses that could survive with this strategy.

As consumers, we are very disconnected from the healthcare services and costs that we receive. This is not a good model that entices good consumerism. Due to the fact that we are removed from the process of acting like a consumer, it is then easier to understand why we are not as focused on the costs. Yet, we complain and scream at our rising health insurance premiums. The truth is that it is not entirely our fault. We want to be better consumers, but the system doesn’t work to assist us. It is common practice to keep prices confusing to consumers and not to promote them.

All of us understand that healthcare is complex and includes many, many different goods and services, but it is definitely not as difficult as it is represented. American consumers are smart, intelligent, and able to make decisions with respect to their healthcare while also assessing a provider’s economic value for their goods and services. It is paramount that consumers are brought back into the healthcare model; they will drive up competition and quality service.

Like most of every other industry in the United States, pricing is an important gauge for goods and services. It is not acceptable that the healthcare industry does not provide its prices for goods and services to the users of those goods and services on a more formal and easier basis. As our healthcare industry matures, this will be a reform change that will come to the front of issues being raised.

As more and more health insurance plan designs incorporate consumer risk through high-deductible and health savings accounts, consumers will demand more transparency from their providers. It is only fair; it is only the right thing to do. There is no need to keep prices and costs behind locked doors where only a select group has readable access.

One may ask why government run businesses do not work, and they only need to look at our Medicare and Medicaid programs. In these cases, the consumer again has been removed from the equation therefore there are no checks and balances to guide the ship.


What Small Business Owners Need to Know About the Affordable Care Act

The Affordable Care Act, commonly called Obamacare, is affecting small businesses right now. As a small business owner you need to dispel the myths, be aware of your responsibilities, and you may need to take action before October 1, 2013. The good news is it may not be as bad as you think. Here’s what you need to know right now:

1) The Affordable Care Act is NOT a government insurance plan. It is a federal statute that [intends to] make health insurance more available and regulated, provides for certain government subsidies to reduce the cost of insurance, requires employer involvement, and charges fees to certain individuals and businesses in some cases.

2) Open enrollment begins October 1, 2013. Many employers will be required to give notice to their employees before October 1, 2013 and within 14 days of an employee’s start date thereafter. The notice is generally required for most employers whether or not they offer health insurance. The intention of the notice is to notify employees of the Health Insurance Exchanges. Additionally, employers who offer insurance are required to include basic information about eligibility for the employer-sponsored plan. Employers can learn more here.

3) The Affordable Care Act requires employers to report the cost of coverage under an employer-sponsored group health plan on the employees’ year-end W-2s, in Box 12 using the Code “DD.” Many employers were eligible for transition relief in 2012 and future years as the IRS has not issued final guidance for this reporting requirement. However, many payroll service providers began including this information in 2012 and will continue to do so in 2013 and beyond. The amount reported is informational only. Employers should check with their payroll service providers to determine what information they need to include.

4) No employer has to offer coverage. Let me say that again, NO EMPLOYER HAS TO OFFER COVERAGE. However, beginning on January 1, 2015 businesses with greater than 50 full-time equivalent (FTE) employees may have to make a shared responsibility payment. Businesses with fewer than 50 FTEs are not subject to Employer Shared Responsibility parts of the law and may use the Small Group Option Program (SHOP) to offer their employees coverage. For those with greater than 50 FTEs, you may need to make an Employer Shared Responsibility Payment if at least one of your full-time employees gets lower costs on their monthly premiums when buying insurance in the Marketplace. Employers can learn more about the Employer Shared Responsibility Payment here.

In summary, employers should be aware of the key items they may need to address. Employers who offer coverage may find the process quite different if dealing with products offered through the Marketplace. Employers can learn more by speaking with those professionals they already work with (insurance agents, attorneys, accountants, payroll companies, etc.) and can find a good deal of information on the web. is a great place to start and contains a section dedicated to small businesses.

Affordable Care Act – What Does it Mean For Medicare Fraud Whistleblowers?

Love it or hate it, the Patient Protection and Affordable Care Act, H.R. 3590, was passed on March 21 by the 111th Congress and signed by President Obama yesterday to thunderous applause. The President called it “a new season for America.” Opponents quickly began a campaign in opposition, and at least thirteen states, acting primarily through conservative attorneys general, joined in a lawsuit to block the new law.

Grandstanding might aptly describe such hyperbole on both sides of the debate. But amidst all the noise about healthcare reform, few are discussing or even aware of the details of the actual bill. As far as healthcare whistleblowers are concerned, these key changes among others written into the new law warrant mentioning:

For Healthcare Whistleblowers
Under Section 1558, workers who report healthcare violations to an employer, Federal Government, or a state Attorney General are protected from retaliation, including reporting violations of the new laws prohibiting denial of coverage based upon preexisting conditions. Such whistleblowers will receive remedies similar to those found in the federal False Claims Act, including among other things: reinstatement, back pay, special damages, and attorneys’ fees.

Whistleblower Requirements for Long-Term Care Facilities
Officers, employees, managers, and contractors of long term-care facilities that receive more than $10,000 in federal funding annually are required to report reasonable suspicion of a crime to law enforcement and can be fined up to $200,000 for failure to do so. Retaliation against whistleblowers in such facilities is subject to a fine of up to $200,000 and exclusion from federal funds for up to two years.

Whistleblower Requirements for Nursing Homes
Under Section 6105, nursing homes are required to implement standardized complaint forms and each state is required to develop a complaint resolution process to track and investigate nursing home complaints and protect against whistleblower retaliation.

Whistleblowers Remain Most Powerful Tool in Fighting Medicare Fraud
While the debate rages on about the viability of healthcare reform, two things are certain: (1) Medicare and Medicaid have been and will continue to be fertile grounds for fraud; and (2) whistleblower suits are the most effective tools for ferreting out false claims and healthcare fraud.

Since 2009, nearly $6 billion has been recovered in state and federal false claims act cases (including criminal penalties). Under the federal and False Claims Act, whistleblowers may file actions on behalf of the federal government to recoup Medicare false claims. Likewise, many states have false claims act that permit whistleblower suits for Medicaid false claims.

With a few minor differences most state false claims acts operate like the federal False Claims Act, requiring that treble damages be paid for fraudulent billing and up to $11,000 per false bill be levied as a penalty. Actions brought by whistleblowers are known as qui tam lawsuits and by statute result in a whistleblower award of between 15-25% of any recovery based on credible, first-hand knowledge by the whistleblower. In cases where the whistleblower is permitted to proceed alone, he or she may receive up to 30% of the recovery based upon her efforts and involvement in the suit.

While the Affordable Care Act provides many new criminal and civil penalties and new tools for fighting healthcare fraud, it is the whistleblower protection provisions that are likely to be the most used – and most litigated. As word of enhanced whistleblower protection spreads, more and more individuals with knowledge of healthcare fraud are likely to come forward. No matter what you think about healthcare reform, that’s a good thing.

Healthcare Fraud Prevention – A Medicare Fraud Enforcement Roadmap Under the Affordable Care Act

In a Youtube address just over a year ago, President Obama cryptically alluded to his administration’s acknowledgment of the healthcare fraud epidemic with phrases like “rooting out waste” and “unnecessary spending” and promises to “make drug makers pay their fair share,” calling on doctors and hospitals to cease “unnecessary treatments and tests-but like most politicians he offered no concrete plan for a solution. On March 21 of this year, he signed the Patient Protection and Affordable Care Act, H.R. 3590 – which contains a number of potential fraud-fighting measures-but still there was no stated benchmark and no roadmap from the White House to eradicate fraud and abuse in the healthcare system.

On June 8, however, a letter was sent by two of the President’s top cabinet members – Attorney General Eric Holder and Secretary of Health and Human Services (HHS) Kathleen Siebelius – unequivocally stating the first benchmark in the fight against healthcare fraud: cut the Medicare improper payment rate in half. The letter was sent to the attorney generals in every state, inviting them to coordinate healthcare fraud enforcement efforts and promising to use every weapon available to meet the goal. “Building on our record of aggressive action, we will use the new tools and resources provided by the Affordable Care Act to further crack down on fraud,” said Holder and Siebelius. “These include new criminal and civil penalties, enhanced information technology to track and prevent fraud in the first place, and new authorities to prevent bad actors from billing Medicare and Medicaid.”

Accordingly, we can expect to see efforts to combat healthcare fraud doubled and more regular cooperation among federal and state authorities. To that end, on July 16, the first in a series of fraud prevention summits will take place in Miami, co-hosted by the Department of Justice (DoJ) and HHS and designed to integrate state health care fraud enforcement with actions by the federal Health Care Fraud Prevention Enforcement Teams (HEAT), a program established a year ago as a joint task force between DoJ and HHS and rolled out in certain high-fraud areas throughout the country.

Likewise, DoJ has directed all 93 U.S. Attorneys to convene regular “health care fraud task force meetings” exchanging information with both private and public sector anti-fraud partners. The first such meeting in each federal judicial district is to take place by August 16, 2010. Presumably these meetings will include state Medicaid Fraud Control Units, state attorneys general, and members of the health care fraud bar.

This directive comes on the heels of the delegation of authority for issuing Civil Investigative Demands (CID) to the 93 U.S. Attorneys – a powerful tool that can, among other things, force the targets of civil fraud investigations to respond to document requests, interrogatories, and appear for deposition. The majority of state attorneys general in states with false claims acts already have CID authority, but such authority is a new arrow in the quiver of local federal law enforcement. CID authority is empowered through the federal and various state false claims acts, arguably the most effective statutory scheme in the fight against healthcare fraud.

Under the respective federal and state false claims acts, whistleblowers may file actions on behalf of the federal government to recoup Medicare false claims and on behalf of certain state governments to recoup Medicaid false claims. Most false claims act statutory schemes require that treble damages be paid for fraudulent billing and up to $11,000 per false bill be levied as a penalty. Actions brought by whistleblowers are known as qui tam lawsuits and result in a whistleblower award of between 15-25% of any recovery based on credible, first-hand knowledge by the whistleblower. In cases where the whistleblower is permitted to proceed alone against the fraudfeasor, the whistleblower share can be as high as 30%.

In the last 18 months, nearly $6 billion has been recovered in state and federal False Claims Act cases (including criminal penalties). As federal and state enforcement officials coordinate and redouble their efforts and commit to work together to fight health care fraud, we can expect to see more and more healthcare fraud litigation and larger and larger Medicare and Medicaid false claims act recoveries.

© 2010 James F. Barger, Jr.

Jim Barger, Jr. is a nationally recognized trial lawyer who handles complex federal litigation, particularly qui tam cases under the False Claims Act. Jim achieved his first seven-figure civil result within two years of practice and his first eight-figure civil result within five years of practice. One of the most often cited legal scholars on qui tam and False Claims Act litigation, Jim’s writing in some cases has actually shaped the law itself. He has been cited by state legislators in adopting state False Claims Acts, by other attorneys in court pleadings litigating False Claims Act cases, and by scholars in legal treatises and law reviews such as Alabama Law Review, Boston University Law Review, Cardozo Law Review, Columbia Law Review, and others. In 2009, Jim Barger represented nurse whistleblower Nancy Romeo in the largest Medicare Hospice case in U.S. history resulting in a record return of nearly $25 million.

ObamaCare Unlocked: The Affordable Care Act’s 10 Essential Benefits

Have you, or someone you know, ever had a health condition that required a trip to the doctor, only to be told that your health insurance policy didn’t cover it?

Many Americans have been shocked to have just that experience, finding out after the fact that they weren’t as protected by their health insurance as they thought they were.

Well, the Affordable Care Act will change that. Starting on January 1, 2014, all new small group and individual health plans sold in the United States must cover the following 10 essential health benefits in order to meet the criteria for Qualified Health Plans under the Affordable Care Act:

  1. Ambulatory Patient Services – This is a fancy way to say outpatient care, or any regular visit to the doctor.
  2. Hospitalization – you’re also covered for inpatient care, which is when your treatment requires hospitalization.
  3. Emergency Services – Trips to the emergency room are also covered.
  4. Maternity & Newborn Care – For pregnant women, the Affordable Care Act mandates care before and after your baby is born.
  5. Mental Health Services – This includes substance abuse treatment, as well as counseling and psychotherapy.
  6. Prescription Drugs – Every plan must cover at least drug in each class and category of the U.S. Pharmacopeia, the list of approved medication in the United States.
  7. Rehabilitative and Habilitative Services – This basically includes services and devices that will aid in your recovery if you are injured, if you have a disability or if you suffer from a chronic condition.
  8. Laboratory Services – Your lab tests are covered.
  9. Preventive and Wellness Services – This includes all 50 preventive services recommended by the United States Preventive Services Task Force. These services will be provided for free to the insured, and are expected to help lower future health care costs as people receive help and support to make healthier choices before they turn into health problems.
  10. Pediatric Care – The big news here is that the Affordable Care Act mandates dental and eye care coverage for children under the age of 19, which many current plans don’t include.

Although these 10 essential health benefits will be covered by every plan under the ACA, the cost to the insured will vary based on the level of plan purchased. And each state has a certain amount of leeway to interpret the exact meaning of each benefit and how they will cover it. To find out exactly what this means for you where you live, visit the Health Insurance Exchange for your state.

The Affordable Care Act: Financial Security for Divorcing Women

I have a lavender leather couch in my office. And a coffee table with a box of tissue. Countless women have sat on that couch, the color draining from their faces as we’ve worked through their post-divorce budget. In my twenty years as a practicing divorce lawyer, I have learned that nothing is more frightening to most divorcing women than facing the fact that there is a very real possibility that they cannot afford to protect their health and more importantly, the health of their children.

Divorce not only encompasses the separation of a wife and a husband, but often includes separating a woman from access to health insurance. And in many cases, they have to face the harsh reality that they can’t afford health insurance for their children.

Imagine yourself facing the loss of your marriage, your home, your financial security, and your health insurance. And what if you’re a breast cancer survivor or you have a chronic illness like arthritis or high blood pressure? Or what if your child has a chronic illness like diabetes? Now add this to the emotional upheaval that every divorcing woman feels. Overwhelmed yet?

It’s common knowledge that many divorced women find themselves having to enter the workforce for the first time in years. We all know the statistics. A woman makes seventy three cents for every dollar a man earns. And many, many women have to take jobs with no benefits.

So, there we sit on the lavender couch; itemizing the budget. And when we get to the line for health insurance and costs of health care,we both take a deep breath. Not only is the cost of health insurance incredibly expensive, but there are co-pays and deductibles. Even if a woman can afford the insurance, which can cost several hundred dollars a month, there are co-pays for each visit and there is typically a per person deductible – for her and each child. And what about birth control? Not cheap. Health care is simply not affordable for many divorcing women.

Of course I’d heard about the Affordable Care Act, but to be honest I didn’t really understand how it would work. But as I found myself working through budget after budget for my divorce clients, the name of the Act began to resonate with me. “Affordable.” Hmm. My friend, attorney Roberta Riley is an expert in women’s health insurance, so I called her up and took her to lunch to explore how the ACA might help my clients. Boy was I pleasantly surprised. Here’s what I learned:

There are three main ways that the Affordable Care Act will help divorcing women:

1. All preventative care will be fully covered and there will be no co-pays;

2. Insurance premiums will offered on a sliding scale based on a percentage of income for individuals with low to moderate incomes – Medicaid may be expanded to make care available to those with very low incomes – depending on the State; and

3. Children will be fully covered for dental and vision.

We all know that the co-pays can really add up for the average family. Most women have a yearly exam, a mammogram, and often there are other check-ups throughout the year for issues like blood pressure or cholesterol. Then there are the kids’ exams, and immunizations. Not only are there co-pays for every visit, but many plans have increasing deductibles, so the out of pocket expenses can equal the amount of the monthly premium some months. And not very many divorcing women have a few hundred extra dollars in their budget to keep up with these costs.

Under the Affordable Care Act, here are some of the preventative care visits that will not require a co-pay: pap smears, mammograms, maternity care, pediatric well child exams, blood pressure checks, diabetes checks, cholesterol checks, immunizations, and mental health treatment. And as of August 1, 2012, all contraceptive care is one hundred percent covered with no co-pay. This will be a huge relief for women facing the harsh reality of having to budget on a significantly reduced income.

So, how will this all work? Obviously, the system is going to be confusing at first. But there will be people available to help everyone find the best policy for their family. These folks will be called “navigators,” and anyone can talk to a navigator, in person, on the phone, or online. The navigator will help them go over all of the available options. Once the policy is chosen, the insurance can be purchased at an insurance exchange, which is like a supermarket for insurance.

For most people, their premium will be based on their income. So, for a woman going through divorce that finds herself in either the low or moderate income category, her insurance premium will be based on a sliding scale. For example, in the lowest income category, an individual’s insurance premium cannot exceed 3-3.5% of their income. (Someone making $2,000 per month would have a premium of about $70 per month!) For individuals with a moderate income, the premium will not exceed 9% of their income. (Someone making $4,000 per month would have a premium of about $360 per month.) As far as health care insurance for those with very, very low incomes, each state will have the option of expanding their Medicaid plan.

Children are given the best benefits of all. They are fully covered for all preventative visits, no co-pays and they have fully covered dental and vision care.

In addition, there are some other important benefits for divorcing women under the Affordable Care Act.

For example, under the ACA a woman going through a divorce can take her husband’s insurance with her. This is called “portability.” And when she is ready, she can contact a navigator and find a new affordable policy that meets her own unique health care needs.

And for a woman going through divorce who wants to open a small business, she will be able to offer health insurance to her employees by taking advantage of a new tax break. To find out about and fully understand these options, a small business owner can contact a navigator who can explain how this works.

Perhaps one of the best things about the ACA is the fact that pre-existing conditions are fully covered. Nothing is scarier for a woman facing divorce than knowing that her breast cancer may not be covered if it reappears, or that she may not have coverage for her diabetes, or high blood pressure. And the same holds true for her children. Everything is covered, no matter when it was first diagnosed. And some current insurance policies consider domestic violence to actually be a pre-existing condition. This will end under the ACA. Any health concerns stemming from domestic violence will be fully covered.

So, once the ACA takes full effect in 2014, women going through divorce will at least have the peace of mind in knowing that their family’s health care needs will not only be affordable, but they will have access to excellent care for all of their health care needs.