Insurers Lobbying to Keep Rules Loose on Medical Loss Ratios to Maintain Profits

The current rules are calling for refunds from the insurance companies if they do not meet the amounts in the new laws for spending 85% of premiums payments on medical costs.  As noted here Senator Rockefeller wants to ask that fraud detection be excluded from the area of medical costs.  He might be on to something here too as this is where the big transactions occur and make millions for subsidiaries and 3rd parties.  United as an example could be using their subsidiary Ingenix to run fraud detection and of course they would get their normal transaction fees, so thus the money goes right back into the till of United if that is is the case.  United also owns a bank where HSA, health savings accounts are kept, so does that qualify for medical costs in helping support the bank?  

UnitedHealth Group Owns a Bank With Deposits Surpassing a Billion – OptumHealth Bank FDIC Insured

There are also many 3rd parties that offer fraud protection and business intelligence software that make big profits in selling their algorithms to insurers and those profits might be contained a bit and money saved it if in fact were not be churned and turned around.  One company is owned by a private equity firm in the UK and actually uses Ingenix products and pays for the software so here we go again with the big circle circulating back into United. 

Business Intelligence and Enhanced Claim Processing Goes to Puerto Rico With TriZetto for Medical Claim Processing and Algorithmic Analysis Services

The word “fraud” detection opens the doors to a ton of analytical services that make millions and billions on the stock market and granted we need some of these services but where do they fall into medical care, do they?  I actually wonder how much fraud is really caught when I read the stories in the news and how much of it is perhaps denials by the algorithms with the clause of “searching for fraud”.  The crooks always swim by as they know the claim game and how to avoid the intelligence that would put them into a fraud parameter report. Do premiums go to cover venture capital investments?

BlueCross BlueShield Venture Capital Firm invests in Phreesia

This will be interesting to see how this all shakes out with what is medical care in the classifications.  We might as well make an algorithm for it so we are all on the same path and have the insurers run their accounting functions through it so we can determine which accounting functions are allowed under the rules and which are not.

WellPoint Rate Increase Math Error – Time For a “Department of Algorithms” So Everybody Knows the Formulas?

If we had this more clearly spelled out we wouldn’t have to deal with “whoops” as the rules for hospitals and doctors they issue are clear and to the point or no compensation.  When someone needs care there’s no time for “whoops” when human lives are on the line.  BD   

WASHINGTON, July 22 (Reuters) - Insurers are trying to undermine the healthcare reform legislation by lobbying the rule writing process that would limit insurers' spending on non-medical costs, a consumer advocacy group said on Thursday.

The group Health Care for America Now issued a report saying insurers are waging a battle to make the rules as broad as possible, simply to maintain their profits.

"The insurance companies want to change the definition of medical care to include things that aren't medical, and to include things that never were considered to be medical," said Ethan Rome, director of Health Care for America Now, at a press conference also hosted by two Democratic lawmakers.

"The reason they don't want stricter regulations is simply because so many companies have been making outrageous profits by gouging American families," Sen. Al Franken said at a press conference announcing the report.

Nearly $1.9 billion would have been refunded in 2009 by the six largest for-profit health insurance companies had the rules been in effect, according to an Oppenheimer & Co analysis cited in the report.

UnitedHealth (UNH.N) would have spent $867 million in refunds last year, the report said.

On Tuesday, Sen. John D. Rockefeller IV wrote a letter to the president of the National Association of Insurance Commissioners -- which is drafting the rules -- urging the exclusion of services, such as fraud detection.

Insurers' lobbying threatens spending rules-report | Reuters

Johns Hopkins Acquired All Children’s Hospital in St. Petersburg Florida For Little or No Cost

Many physicians have sold their practices to Children’s Hospital and are a little unsure about how things will run with Johns Hopkins as the new owner.  The name affiliation I am thinking would stand to draw more patients with the reputation that Johns Hopkins has.  Some physicians mentioned that they have been through more than one change in ownership with hospitals in Florida.  BD 

ST. PETERSBURG — The news that All Children's Hospital is becoming part of Johns Hopkins Health System has caused a major splash in the Tampa Bay area medical community.

"It's an acquisition," he said, saying the Baltimore group is assuming about $240 million in debt in exchange for a hospital with about $200 million in cash on its balance sheet. "In essence, All Children's is giving its hospital to Johns Hopkins for nothing. But if you're going to give up control to somebody, you may as well give it up to one of the finest medical centers in the world."

Though doctors who have sold their practices to All Children's and have become its employees are reportedly nervous about being replaced by Johns Hopkins, Nemzoff said after three decades of handling hospital acquisitions, he's never seen widespread physician turnover.

"Organizations are amenable to mixtures of relationships that would not have been doable a few years ago," he said.

The reason: money. With Medicaid cuts coming and the health reform bill affecting how and how much providers will be paid, everyone's looking for ways to reduce costs.

Ripples from All Children's-Johns Hopkins merger could touch many - St. Petersburg Times

Florida Hospital System Threatening to Drop United HealthGroup Over Rates – Last Contract Was in 2001

There are always 2 sides to a story but 9 years indicates there’s a lot to talk about as a lot has changed during the last 9 years and if there has not been any increases in that amount of time, the hospital may have a good case to play a bit of hardball here.  This is pretty large as the Florida Hospital chain has 18 regional hospitals.   We have one chain in California that will not see patients who are covered by employer based plans from United. 

Employers in Orange County Looking for New HMO Contracts as St. Josephs and Some Others Begin Cancelling Agreements with Pacificare (UnitedHeatlhCare) – Employer Capitation Contracts

In New York there are also problems with contracts and the 24 hour notice rules.

United Healthcare to Hospitals – Notify Within 24 Hours of Patient Admittance or Reimbursement Will Be Cut in Half

It’s all about fitting into the rules and parameters of the “algorithms” of compliance for payment in the New York situation.  We are finding this becoming more apparent in many areas as the actual work flows of hospitals are having difficulties meeting some of the requirements needed in order to get paid.  At the link below the peer group, hospitalists and board could not figure out how to comprehend the parameters United needed.

Hospitalists, Peer Committees and Utilization Struggle to Comprehend United HealthCare Algorithms

In the Florida Hospital case the article states that letters of warning have been sent.  One of the administrators from the hospital said it is affecting care as the co-pays have risen too high and patients are not getting their medications and not seeing their doctors for screenings and lab tests.  BD 

The Florida Hospital system and United Healthcare are embroiled in a contract standoff. If the two companies cannot agree on new terms by Aug. 15, about 170,000 United Healthcare customers in Central Florida would be unable to go to the 18 regional hospitals in the Florida Hospital network for non-emergencies or visit doctors employed by and acilities owned by the chain.

Executives from both sides have been meeting since November, trying to negotiate a contract. But they remain at an impasse.

At issue are the rates the insurer pays the hospitals for services. Florida Hospital officials say they want United Healthcare to pay the same rates as other major insurers. But a United Healthcare spokesman said Florida Hospital wants to raise rates 63 percent during year period — and calls that kind of hike "unreasonable."

For example, the average cost for an outpatient service such as arthroscopic knee surgery would increase by about $700 next year, United Healthcare spokesman Daryl Richard said.

Florida Hospital officials, on the other hand, say the hospital chain's contract with United Healthcare has not been renegotiated since 2001.

"In the last few years, employers have tried to share the costs with employees, but they're getting to the point where they can't ask employees to shoulder any more of the burden," said Cherney, noting that copays are getting so high that some employees are now skipping medications or tests because of the cost.

Florida Hospital might dump United Healthcare if contract negotiations fail - OrlandoSentinel.com

FDA Is Sued By Non Profit Doctors Group – Failure to Notify Diabetic Patients Of Alternatives for Avandia – Bar Coding and Scanning Product With A Cell Phone Could Solve the Problem

The Medical Quack is somehow turning into a blog about bar coding, why, because the news is full of articles about recalls, fake drugs, stolen drugs, defective devices, you name it.  We need the technology right now to be able to get the word out.  Would you not like the availability to scan either a product or a bar code and immediately read it on your smart phone?  If so, take time and vote.  The would have helped find the stolen Advair.

Stolen Advair Demonstrates Need for Tag Bar Coding of Drugs – Encrypted Bar Codes Could Identify Stolen and Counterfeits When Scanned With a Cell Phone

This same technology can also authenticate a physician with the new DEA rules, video at the link below.

RAZCODE (Microsoft Tags) Using Smart Phones to authenticate MDs When e-Prescribing Controlled Substances

People want this, read the tweets below from consumers and Health IT CIOs.  The demand is here for the information and it’s only going to stand to grow. 

The video below will show how it works, simple.  Wonder how many more lawsuits will be filed?  The solution is here today and it would make it easier for the FDA to work with compliance.  People die with implanted defective devices so it’s time to get to the solution of communicating with the technology that can fix the problem. 

Washington, DC—A nonprofit doctors group filed a lawsuit against the U.S. Food and Drug Administration (FDA) this month, after they failed to notify patients of dietary alternatives to dangerous diabetes drugs such as Avandia, a highly scrutinized diabetes medication. The group, Physicians Committee for Responsible Medicine (PCRM), alleged they petitioned the FDA to require that such alternatives be included on labels for the drugs, but to no avail, according to a Monday, July 19, 2010 PCRM news release.

The lawsuit contends, “PCRM’s petition requested that FDA require a disclosure in the labeling of drugs, such as Avandia, used to manage blood glucose in diabetes treatment. The disclosure would state that a low-fat plant-based diet has an efficacy and safety profile that can be as favorable as, or more favorable than, oral diabetes medications. FDA has failed to provide a substantive response to PCRM’s petition in a reasonable time, in violation of the Administrative Procedure Act.”

FDA Sued for Failure to Alert Diabetics to Effective Drug Alternatives | Justice News Flash | JusticeNewsFlash Release

Portion Sizes: How Much Are You Really Eating?

It’s the worst when you pick up a bag of something delicious, and check out the back nutrition label. Only 100 calories, you think. Awesome! Oh, wait — 100 calories for 1/10 of the bag. Great. Women’s Health put together some photos showing how much a single portion of some of our favorite foods really is. Proceed with caution, because what you’re about to see, you can’t undo. From now on you’ll actually know how many calories you’re ingesting when you reach for that refreshing Arizona Green Tea:

Arizona Green Tea

Calories per serving: 70
Serving size: 1/3 can

Snyder’s of Hanover Mini Pretzels

Calories per serving: 110
Servings size: 20 pretzels

Post 100% Natural Grape-Nuts Cereal

Calories per serving: 200
Serving size: 1/2 cup

Seneca Crispy Apple Chips

Calories per serving: 150
Serving size: 12 chips

Amy’s No Cheese Roasted Vegetable Pizza

Calories per serving: 270]
Serving size: 1/3 pizza

Sunkist Premium Mandarin Oranges

Calories per serving: 70
Servings size: 1/2 cup

Uncle Wally’s Fat Free Gourmet Corn Muffins

Calories per serving: 130
Serving size: 1/2 muffin

Tribe Hummus Snackers

Calories per serving: 50
Serving size: 2 Tbsp

Blue Bunny Personals Premium Ice Cream (Banana Split Flavor)

Calories per serving: 170
Serving size: 1/2 container

Annie Chun’s Garlic Scallion Noodle Bowl

Calories per serving: 310
Serving size: 1/2 bowl

via Women’s Health

Post from: BlissTree

Portion Sizes: How Much Are You Really Eating?