Some of the most controversial provisions of the Affordable Care Act (ACA) are those that require individuals to either sign up for health insurance or to pay a tax.  Differing interpretations of the statutory language regarding the tax credit or “subsidy” that would enable lower-income individuals to afford coverage have given opponents of ACA a hook on which to hang a small but powerful legal weapon.  Contrary to the claims (and hopes) of some observers, recent federal Appeals Courts decisions are not the death knell for Obamacare, however. The statute provides for a premium tax credit for “health plans offered in the individual market within a State which cover the taxpayer, the taxpayer’s spouse, or any dependent (as defined in section 152) of the taxpayer and which were enrolled in through an Exchange established by the State under 1311.”  The question is whether tax credits would only be available for policies purchased through...

  In a health plan featuring a “narrow network” (NN), the carrier substantially reduces the number of participating physicians, hospitals and other providers.  Limiting the panel to providers offering lower prices is nothing new.  In the mid-1990s, HMOs and PPOs sparked a backlash from patients and a multitude of state laws requiring that insurers include any willing provider in their networks. The dynamic has changed since the Affordable Care Act (ACA) went into effect, however. Previously, employers imposed NN plans on their workers.  In May, the National Business Group on Health (NBGH) conducted a poll of 46 large employers and found that 17 percent already have a narrow network in place.  The poll results, which were made available to NBGH members, also found that an additional 24 percent of large employers were considering narrow network health plans for 2015 and 2016, and another 20 percent were mulling narrow networks for 2017. With the...

It’s summertime and vacation plans are high on everyone’s list.  Sometimes arranging coverage is difficult and groups resort to using locum tenens.  Somewhat surprisingly, a recent survey by physician staffing firm LocumTenens.com revealed that 16 percent of the respondents who hire locum tenens physicians do not bill for their services, because they do not know how or because the exercise seems too complicated.  Medicare and most commercial payers allow payment for the use of locum tenens providers, however, and it is worth knowing the rules. Vacations are clearly appropriate for the use of locum tenens as long as the practice follows the applicable guidelines when filling the gaps.  It’s more than just determining who is working for whom; there are certain billing requirements depending on which carrier the claim goes to.  Don’t get stuck providing services and paying a locum tenens for cases that aren’t billed.According to Medicare’s locum tenens payment...

Keeping patient information confidential has become a major challenge since we all began storing so much of it in electronic form.  Computers, tablets and smart phones containing unsecured electronic Protected Health Information (ePHI) go missing and are reported in the press on at least a weekly basis. Last week a Long Island radiology practice informed 97,000 patients of a discovery that "an employee radiologist accessed and acquired protected health information from [the] billing system without authorization."  (Newsday, June 24, 2014.)  Other breaches in the past month include: A thumb drive with patient X-ray information was stolen from an employee’s locker during a burglary at a medical group office recently acquired by St. Joseph Health System in Santa Rosa, California, requiring notification of 34,000 patients. Health risk assessment results were mailed to the wrong patients, resulting in a potential compromise of the PHI of 3,675 patients covered by Highmark. A Penn State...

Two recent Alerts focused on the growing movement toward transparency of medical prices.  (How Much Did Medicare Pay Each of 32,641 Anesthesiologists in 2012?, April 21, 2014 and Private Payer Information on Anesthesia and Other Services: Claims Data to Be Available Next Year, May 19, 2014.)  The first of these discussed CMS’ April 9th release of a massive database with information on the approximately $77 billion that Medicare paid out to more than 800,000 physicians and other non-hospital providers in 2012.  The May Alert examined three large insurers’ announcement that they were establishing an online database of paid claims that would provide public information about the price and quality of healthcare services. Also evolving very rapidly are state-level All-Payer Claims Databases (APCDs).  APDCs are large databases that systematically collect medical claims, pharmacy claims and provider files from private and governmental payers to meet demands for multipayer data that allow states and...