cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
By Adam V. Russo & Ron Peck
As avid readers of this article are aware, every month we write from the perspective of a self-funded plan, address how the health insurance industry should work, and what needs to be done to lower the cost of health care. Generally, we represent self-funded benefit plans and their third party claims administrators (“TPAs”). You may also know, specifically, that we have been spending a lot of our time dealing with conflicts that arise between these benefit plans and the health care service providers (“Providers”) that treat the plan participants. In this article, we want to look at these issues from the Providers’ perspective. You may be surprised by the differences in opinion regarding the value of preferred provider organizations (“PPOs”), and more shockingly, our common ground. (more…)
Category: Balance Billing, PPOs, Usual and Customary |
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Adam V. Russo | October 22, 2010
While researching various resource tools prevalent to the health care industry, I came across Healthcare Blue Book, a resource tool used to find the average pricing for medical services based on one’s geographical location. I found this site to be somewhat helpful when seeking the usual and customary pricing of a service and thought that my readers would too.
I am gathering feedback from our clients, partners and blog readers on what you may like or dislike about the Healthcare Blue Book.
If you don’t mind, please visit www.healthcarebluebook.com, choose a service from the main navigation, enter your zip code, and you will receive an estimate on the average pricing for a particular service in your area. Once you have played around on this site, we would appreciate if you would email your feedback of likes, dislikes, what you found helpful, what you found confusing, etc. to bhoffman@phiagroup.com.
Thank you so much!!
Category: News, Usual and Customary |
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Adam V. Russo | October 4, 2010
By Jane E. Brody of The New York Times, www.nytimes.com
In times like these, the last thing you need is a hospital bill that can wreck an already fragile budget. This is often the fate of elderly patients who incorrectly assume that Medicare will cover everything.
Not so, as my aunt discovered early last year after a two-night, two-and-a-half-day stay at a for-profit hospital in Florida. There is a lesson for all of us from the following tale: no matter who is footing the bill, hospital charges should be carefully vetted by someone who, with the Internet and perhaps professional help, can decipher the codes and uncover unreasonable and erroneous charges. (more…)
Category: Claims Procedures, Claims Review, Medicare, Never Events, Usual and Customary |
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Adam V. Russo | March 15, 2010
Atlanta, GA — CNN aired a report by reporter Elizabeth Cohen on inappropriate charges by hospitals for various items used for patient care. Among the examples cited were a single toothbrush billed at $1,000 and a single Tylenol caplet billed for $140. The report details how these are not isolated incidents, but rather part of how hospitals regularly bill patients and insurance companies. Mike Dendy of AMPS and Adam Russo of Phia have responded to this report. (more…)
Category: Health Care Legislation, Usual and Customary |
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Adam V. Russo | January 20, 2010
Sixth Circuit Court of Appeals, No. 04-4067, March 21, 2006
The Sixth Circuit Court of Appeals reversed a district court’s order that a health benefit plan must pay a hospital the full amount billed for services rendered to a plan beneficiary, and remanded for further proceedings.
A beneficiary of South Lorain Merchants Assn. Health & Welfare Benefit Plan and Trust (the “Plan”) was admitted to University Hospital of Cleveland (“UHC”) in 2000. For services rendered, UHC sent a bill in the amount of $195,000 to the Plan. Without notifying UHC, the Plan audited the bill and provided payment in the amount of $107,000, a reflection of both a $49,000 preferred provider network discount (“Discount”) and the audit’s finding that the charges exceeded the usual, customary and reasonable (“UCR”) amount for such services by $39,000. (more…)
Category: 6th, Federal Circuits, Usual and Customary |
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Adam V. Russo | July 29, 2009
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.
by Emily Berry, American Medical News, www.amednews.com
The Tennessee Medical Assn. has filed a lawsuit against a collections company working in several states to take back reimbursements paid to doctors. The lawsuit alleges fraud and asks a state court to block the company from trying to collect any more money from physicians. (more…)
Category: Usual and Customary |
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