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Search This Blog - Balance Billing--Election 2016

Consumer-friendly fixes to our healthcare system weren't "impossible," they were simply ignored part of the "deal" that was acceptable to the Federal government and that have failed consumers miserably. The healthcare crisis is decades old, it resisted federal legislation for many years because of the strength of the insurance company and provider lobbyists who did spend billions of dollars to enact laws that favored their money goals. The "free market," is NOT part of the healthcare industry. The only thing to consider is whether the laws work for or against consumers, and Obamacare falls squarely on the against side.

Any solution that omits a government input is not possible in the United States. However, that doesn't mean that BAD LAW is better for consumers than NO LAW, and Obamacare is bad law in many significant ways, bad law reflective of a government that ignored the consumer stakeholder, the consumer patient, the consumer taxpayer, the consumer poor--the consumer. And until consumers unite under a healthcare POLICY, rather than a healthcare "issue" there is little chance of pro-consumer, all consumer change.

Both Hillary Clinton and Donald Trump have put forth ideas for "change" in Obamacare, neither one is pro consumer overall while they carve out niches of preference continuing the legacy of preferences created by Obamacare and therefore should NOT be the deciding issue for 2016 voters. When it comes to which one is worse, that also is unclear, they are both that bad, (see,

But here the issue is BALANCE BILLING an issue ignored not only by Obamacare, and largely ignored by states, and by Hillary Clinton and Donald Trump, but one that shows little promise of being addressed removing one of the biggest consumer pitfalls of the "healthcare industry" that has bilked consumers for decades and continues to under Obamacare that COULD HAVE been addressed by government.

Balance billing- the practice where consumers knowingly or unknowingly are required to pay the amounts charged by out of network providers, less the miniscule reimbursement by insurance companies. This leaves consumers in financial jeopardy.

The practice is worsened by the fact that some participating providers purposely bring in non-participating providers and SHARE the bonus money that the non-participating providers can charge to patients, an unethical practice that is rarely discovered and prosecuted.

Such balance billing can range from the scam above to tests that are ordered to assistant providers to any number of other services.

In April, 2016, the National Academy for State Health Policy reported that though there's been some activity focused on reducing the risk of balance billing in emergency services and "notification" to consumers of the prices they'll be charged that…

"…within the past year, they [consumers] or someone in their household have had challenges paying medical debt. This includes 20 percent of individuals under the age of 65 who are insured. Also striking, 51 percent of insured individuals reported owing sums of over $5,000,"

More significantly this fact of having health insurance that leaves individuals in financial peril even after purchasing the consumer product is one of the reasons that people were opting out of the purchase of the consumer financial product of health insurance to begin with.

The prohibition against balance billing requires state or federal action, there is no free-market answer AND while it could have been made part of the thousand pages of the Affordable Care Act, while it could have been implemented as one of the ESSENTIALS or elements of a qualified health plan, it notably was NOT.

Instead we got a laundry list of "preventive" services, checkups, that not only are finite, cheaper coverages but the price of which has gone up under the Affordable Care Act because now they're covered by insurance. The frequency of testing also has gone up because people don't have to "pay" for the checkup so there is no hesitation for providers to insist their patients endure additional testing since it's "covered," and since it helps them practice defensive medicine they require it more often, [ignoring the meaningful risks individuals are exposed to in our country where Medical Error is the third leading cause of death, as well as the simple wear and tear and emotional stress of being tested as a "possible" patient.]

In other words, instead of addressing balance billing, the enormous endless risk of money we might owe if we need medical services, with Obamacare we got a law that supports a healthcare industry that focuses on getting money from treating those without illness, who go for checkups and tests and in the event they need care, suddenly find themselves paying MORE for that care in the form of out-of-pocket expenses, which take you out of the freebie mode. This danger falls squarely at the feet of the Obamacare "deal" and its tradeoff of free checkups instead of coverage for needed medical services.

Narrow Networks-Understanding what balance billing is, the payments we as consumers are responsible for when we receive care or services from "non-participating" or non-member providers, it's easier to understand why NARROW NETWORKS, the provisions of TOO FEW CHOICES OF PROVIDERS is a critical matter for consumers. The fewer participating providers the INCREASED likelihood that if you have needed medical services you'll be using a provider or service that's out of network, increasing your out-of-pocket expenses.

This problem was ALSO part of the original healthcare crisis, where people who BOUGHT AND PAID for health insurance found that they could not find a participating provider who best suited their medical needs under their plans and therefore did not feel compelled to purchase health insurance. Obamacare has worsened the problem because of its dogged attempt to pacify health insurers in order to get them to participate on "exchanges," often attracting insurance companies that had narrow networks because insurance plans with fewer options are cheaper.

As the government predicted in 2015, the tremendous increases in consumer prices this year charged by insurance companies is in part attributed to Obamacare's use of the old health insurance trick of narrow networks which generated much consumer outcry.

“CBO and JCT anticipate that many plans will not be able to sustain such low provider payment rates or such narrow networks over the next few years, placing upward pressure on exchange premiums," CBO, the government publication 49973 of March 2015.

In other words, people who purchase health insurance know that it's only as good as the ability to obtain affordable treatment in the event of illness, which in turn depends on who is included as a provider under your plan, so that too few providers means you cannot obtain treatment without going out of network and facing the risk of financial peril from balance billing. It's also noteworthy that there's NO UPPER LIMIT to these out of network costs.

Unfortunately, Obamacare ignored this healthcare crisis element by using the strategy of narrow networks itself in order to offer cheaper plans, as well as not only doing nothing to limit the amount that insurance companies could charge in copayment, coinsurance, deductible payments but in ENCOURAGING such insurance company practices by providing the excuse that if they (insurance companies) have to provide the laundry list of checkups then they (insurance companies) must cover less in the way of needed medical services and costs.

This is made worse because every year the government also arbitrarily determines how much more we'll have to pay out-of-pocket BEFORE we reach the magic maximum coverage under our plans--the infamous out-of-pocket maximum. Remember, the out-of-pocket maximum does NOT include the real money we pay for balance billing, only the amounts we pay for things that are "covered" under our plans.

The out-of-pocket maximum is a number the GOVERNMENT determines, which also could have been addressed by the thousand pages of Obamacare but was not. This year again, for 2017, that amount of money we have to lay out before getting the maximum coverage under our plans is up to $7,150 for an individual and $14,300 for a family, "Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017."

Once Obamacare focused on mandatory inclusion by insurance companies of checkups, which insurance companies adore as finite expenses, one-time deals, and providers adore because it promotes their interest in practicing defensive medicine but which consumers should be wary of because they become hurdles--tests and exams we're often forced to undergo even with our horrible US record of medical error deaths and casualties and testing misdiagnoses and any "additional" testing is NOT covered for "free," so we begin a cycle of treating the healthy instead of focusing on treatment of the sick, also using such laundry list of freebies as an excuse to RAISE prices charged to us, Obamacare went further and again, giving into insurance companies agreed to force people to purchase these new "preventive" plans, with the individual mandate, removing consumer choice in what kind of consumer financial product (health insurance) best suits our needs removing insurance company incentives from creating plans that suit us because after all, we have to buy them.

Under a faux-single risk pool theory, risk pool meaning mixing up who is insured under a plan to balance the healthier young people with unhealthier older and sicker people in order to "even out" what everyone is charged, faux because the exorbitant price of plans means as has occurred that younger and healthier people seek out cheaper insurance plans so that we hear insurance company whining that their plans have too many "sick" people, you know people who actually need the consumer financial product of health insurance, Obamacare perpetuates unevenness and therefore has been doing more to LIMIT choices for young people.

Even the plans on the exchanges were unaffordable for many young Americans who in fact do have health on their side. Under Obamacare, for those under 30, they could still "legally" choose catastrophic plans, which comply with the law but offer worse coverage than other health plans. And Obamacare shot itself in the foot with its failure to address the family glitch, where an employed person in some cases could no longer afford to insure his/her family because while self-only insurance charges to employees are limited, those amounts are not limited for families. For those up to age 26 children whose parents could no longer afford dependent coverage, they were left with Medicaid choice or cheapest plan choice, because after all, the fact that their parents were carrying them meant that they didn't have employment that provides health insurance.

By failing to fix the family glitch, Obamacare took these up to 26 year-olds out of the risk pools of these "better" and more expensive health insurance coverages that their parents would have paid for if they'd been able to leaving all those young people either uninsured or choosing cheaper plans.

Instead, Obamacare this June decided to try to force young people into Obamacare plans by tightening restrictions on the use of short-term health insurance,

Obamacare also is trying to even out those risk pools by favoring the silver plans on exchanges even more than before this last benefits year. Last year Obamacare exchange plans raised the rates of silver plans LESS than they raised the cost of Bronze plans, both types of plans went up, but the bigger increase in the cheaper bronze plans was intended to push young-healthies into choosing silver plans.

Prior to this price manipulation, Obamacare had believed that by offering cost-sharing for actual medical care, in addition to premium assistance, the Obamacare entitlement payments designed to get people to buy-in, would be enough to create the imaginary "even" risk pool. This didn't work as young people sensibly knowing that health insurance coverage is a year-only election and that youth is fleeting, opted for cheaper bronze plans, as the government stated, “Outlays for cost-sharing subsidies over the 2015–2024 period are currently projected to be $39 billion less than previously estimated, primarily because CBO and JCT now expect that more people will forgo those subsidies by choosing to enroll in a bronze plan instead of a silver plan,” CBO, 1/15/15, page13.

As you can see, this is also why the government paid out less in entitlement payments than anticipated, because people chose cheaper plans where possible, allowing the government with its only desired outcome as the perpetuation of Obamacare to go to court to fight to pay out MORE, (King v. Burwell) claiming that anyone who enrolled in an Obamacare would get a payout.

Still it hasn't worked and we've got insurance companies getting out of exchanges as yet another payoff paid to insurance companies, risk corridor and risk reinsurance payments are set to expire this year (

And so, insurance companies respond the way they always have--raising premiums again, this time offering less than ever as they've been permitted to under Obamacare because of the built-in features of Obamacare that create and perpetuate the opportunity to get more money from consumers by focusing on preventive rather than needed, narrow networks, increased out of pocket costs in the form of copayment, coinsurance, deductible and premium, increased government established out-of-pocket maximums and removing the motivation for insurance companies to provide a meaningful consumer product that meets the needs of its customers by FORCING the purchase of this financial consumer product under the individual mandate.

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