HHS Resolves 99% of HIPAA Related Complaints

Since the compliance date of the Privacy Rule in April 2003, the U.S. Department of Health and Human Services Office of Civil Rights (OCR) received over 225,378 Health Insurance Portability and Accountability Act (HIPAA) complaints and initiated over 993 compliance reviews.

As of Dec. 31, 2019, the office resolved 99% (222,175) of cases. More than 27,600 cases were resolved by requiring changes in privacy practices and corrective actions by or providing technical assistance to HIPAA covered entities and their business associates. OCR settled or imposed a civil money penalty in 73 cases resulting in a total dollar amount of $111,855,582.00.

Various types of entities have been investigated to include national pharmacy chains, major medical centers, group health plans, hospital chains, and small provider offices. In another 12,094 cases, OCR investigations found that a violation had not occurred. Additionally, in 40,882 cases, OCR intervened early and provided technical assistance to HIPAA covered entities, their business associates, and individuals exercising their rights under the Privacy Rule, without the need for an investigation.

In the remainder of the cases (141,595), OCR determined that the complaint did not present an eligible case for enforcement. These include cases in which:

  • OCR lacks jurisdiction under HIPAA. For example, in cases alleging a violation by an entity not covered by HIPAA;
  • The complaint is untimely, or withdrawn by the filer; and
  • The activity described does not violate the HIPAA Rules. For HIPAA VIOLATIONSHHS Resolves about 99% HIPAA-Related ComplaintsHealth plans are among the least likely entities to violate the rule. For example, in cases where the covered entity has disclosed protected health information in circumstances in which the Privacy Rule permits such a disclosure.
  • From the compliance date to the present, the compliance issues most often alleged in complaints are, compiled cumulatively, in order of frequency:
  • Impermissible uses and disclosures of protected health information;
  • Lack of safeguards of protected health information;
  • Lack of patient access to their protected health information;
  • Lack of administrative safeguards of electronically protected health information; and
  • Use or disclosure of more than the minimum necessary protected health information.

The most common types of covered entities that have been alleged to have committed violations are, in order of frequency:

  • General Hospitals;
  • Private Practices and Physicians;
  • Outpatient Facilities;
  • Pharmacies; and
  • Health Plans (group health plans and health insurance issuers).
  • Referrals

OCR refers to the Department of Justice (DOJ) for criminal investigation appropriate cases involving the knowing disclosure or obtaining of protected health information in violation of the Rules. For additional information, click here: https://tinyurl.com/lgzxpye

News & Notes

Texas Makes it Easy

The Texas Medical Association (TMA) produced a seven-page summary of the surprise-billing law (Senate Bill 1264) passed by the Texas Legislature in 2019. TMA’s overview explains topics such as when the law applies, and how the arbitration process works. The summary is accessible here: https://tinyurl.com/tvyxhvy

Payback: West Coast Doc Pays Penalties

The California Department of Managed Care (DMHC) settled a lawsuit against Dr. Nancy B. Way, “requiring her to stop illegally balance billing California enrollees,” and to pay $13,000 civil penalties. In response to the action, DMHC Director Shelley Rouillard recommends that consumers check their bills and contact their health plan if they have questions. Additional information may be accessed here: https://tinyurl.com/vrtl7bg.

Congress Eyes Medical Debt in New Legislation

ACA continues to maintain open lines of communications with lawmakers as they consider moving forward with legislation that could impact the way the industry approaches medical debt collections.

House Legislation

In December, the House Financial Services Committee marked-up legislation titled, “Consumer Protections for Medical Debt Collections Act” (H.R. 5330), which would prohibit medical debt reporting for a year, and would ban reporting on debt arising out of “medically necessary procedures.”

Introduced by U.S. Rep. Rashida Tlaib (D-Mich.), the legislation would also prohibit collecting medical debt for two years.  These proposed restrictions would make it difficult for accounts receivable management industry professionals seeking to collect rightfully owed debt while creating a disastrous situation for medical providers caring for patients.

Senate Legislation

Meanwhile, ACA has had numerous discussions with lawmakers in the House and Senate regarding more reasonable delays in credit reporting such as 60 or 180 days—despite potential challenges posed by these delays. The Medical Debt Relief Act, introduced by U.S. Sen. Jeff Merkely (D-Ore.), and co-sponsored by Senators Richard Blumenthal (D-Conn.), Elizabeth Warren (D-Mass.), Bob Menendez (D-N.J.) and Dick Durbin D-Ill.), would prohibit credit reporting for one year.

However, unlike the House bill, the Senate version clarifies that the legislation does not impact when a debt collector may engage in activities to collect or attempt to collect any debt owed or due or asserted to be owed.

ACA’s Efforts

ACA is actively discussing this legislation and the many flaws associated with it, with both Democrats and Republicans, including lawmakers who sit on the House Financial Services Committee and the Senate Banking Committee.

ACA sent a letter opposing the legislation to both the House and Senate last fall and launched a grassroots campaign in early 2020 to allow ACA members to engage directly with their members of Congress about how this legislation would impact them and the medical providers they serve (the letter is accessible on ACA’s advocacy page or here:  https://tinyurl.com/wlm77d8).

ACA is also working closely with other trade associations representing medical providers and credit reporting agencies to ensure that Congress understands the broad impact this issue could have on the ability to provide medical care to consumers, the accuracy of the credit reporting system, and the economy.

As the industry continues to face an unprecedented number of attacks in the 116th Congress, it is critical for ACA to educate lawmakers about flawed policies and to work with the Senate to ensure that House bills such as H.R. 5330 do not move forward in the Senate.

ACA members are encouraged to attend the Washington Insights Fly-In May 19-21, 2019, in Washington, D.C., to discuss this bill and other issues with lawmakers. Watch for updates on the Fly-In!

Trump Extends Comment Period for Proposed Rule on Price Transparency

Two days after Christmas, the Centers for Medicare and Medicaid Services extended the comment period for the “Transparency in Coverage Proposed Rule” published Nov. 27, 2019 by the Department of Health and Human Services, the Department of Labor and the Department of Treasury, a statement from CMS said. The proposed rule delivers on President Trump’s Executive Order on Improving Price and Quality Transparency.

The new comment period deadline was extended to Jan. 29, 2020 in response to public feedback and in consideration of the holiday season. According to the Trump Administration, the proposed rule is “a historic step toward putting health care price information in the hands of consumers, advancing the administration’s goal to ensure consumers are empowered with the information they need to make informed health care decision.”

Additional information may be obtained here:


The State of Reporting

Aside from the Fair Credit Reporting Act—the federal law governing credit reporting practices—state laws can impose additional restrictions on credit reporting. For example, some state laws limit the type of information that may be furnished, require consumer notifications, or restrict the reporting period.

Furnishers of information to consumer reporting agencies (CRAs) should be aware of and comply with any applicable state credit reporting requirements.  Some state laws place restrictions on the reporting of a particular type of debt. For instance, California, Colorado, Minnesota, Texas and Washington are all states that place certain restrictions on credit reporting medical debt.

California prohibits hospitals and its assignees from credit reporting certain patients that lack coverage or have high medical costs for nonpayment at any time prior to 150 days after initial billing. Colorado law prohibits data furnishers from credit reporting medical debts that are only partially paid by insurance, unless the health care provider sends the consumer a written notice that includes particular information, as required by statute, to the person responsible for the debt.

In Minnesota, some health care providers signed a written agreement with the Minnesota attorney general covering issues associated with litigation practices, garnishments, collection agencies and billing the uninsured in relation to attempts to collect medical debt. Texas prohibits consumer reporting agencies from furnishing consumer reports that include debts owed for out-of-network medical services.

Washington requires data furnishers to refrain from furnishing information about medical accounts until at least 180 days after the original obligation was received by the licensee for collection or by assignment.  State laws may require furnishers to provide consumers with a notice of furnishing negative information disclosure prior to, or shortly after, reporting adverse information to a CRA.

For instance, California and Utah require creditors and debt collectors to send consumers a written notice prior to or within 30 days after furnishing negative information concerning the consumer.  Further, state laws restrict when information can be furnished to a CRA.  For instance, Colorado prohibits “[c]ommunicating credit information to a consumer reporting agency earlier than 30 days after the initial notice to the consumer has been mailed, unless the consumer’s last-known address is known to be invalid.

These requirements demonstrate the need for furnishers to review state-specific credit reporting requirements to ensure compliance with credit reporting expectations. For a more in-depth look at state credit reporting laws, ACA members can review ACA SearchPoint™ document #1255, State Credit Reporting Laws.

After 15 Years, New Federal Overtime Rule Advances Salary Thresholds

Accounts receivable management industry companies may want to begin reviewing overtime and scheduling policies as a new overtime rule took effect Jan. 1, 2020.

The new rule, which makes 1.3 million workers eligible for overtime pay, raises the “standard salary level” from the currently enforced level of $455 per week to $684 per week (equivalent to $35,568 per year for a full-year worker), according to a news release from the Department of Labor.

Additional changes in the new rule include:

  • “Raising the total annual compensation requirement for “highly compensated employees” from the currently enforced level of $100,000 per year to $107,432 per year;
  • Allowing employers to use nondiscretionary bonuses and incentive payments (including commissions) paid at least annually to satisfy up to 10% of the standard salary level, in recognition of evolving pay practices; and;
  • Revising the special salary levels for workers in U.S. territories and the motion picture industry.”

Tips for abiding by the rule changes are available through the Department of Labor’s Small Entity Compliance Guide, accessible here: https://tinyurl.com/y366mrmv

Additional information may be obtained by accessing the U.S. Department

Court Dismisses TCPA Violation on Text Messages Reportedly Sent Using ATDS

A group of plaintiffs lost their argument in a case based on the ongoing district court debate about the definition of an automatic telephone dialing system (ATDS) and the capacity to randomly or sequentially generate numbers.

According to an article from Drinker Biddle Partner Michael Daly and Associate Vijayasri Aryama, “Court Holds That Text-Messaging System Must Be Able to Randomly or Sequentially Generate Numbers to Qualify as an ATDS,” the Northern District of Illinois entered a summary judgment against the plaintiffs in Smith v. Premier Dermatology “because it found the system at issue was not an ATDS.”

Plaintiffs in the case brought a putative class action against the defendants claiming they used an ATDS to send text messages about medical marketing communications without the consent of their clients’ customers, according to the article.

The plaintiffs based their argument on Marks v. Crunch San Diego after the defendants moved for summary judgment, specifically “to claim the TCPA’s statutory definition would include devices that could not generate random or sequential numbers, but could ‘dial stored numbers automatically,’” Daly and Aryama report.

However, the decision in ACA International v. FCC swayed the court in this case.  “Based on ACA International v. FCC, 885 F.3d 687 (D.C. Cir. 2018), the Smith Court determined that, although ‘[t]here is a certain allure to the conclusion in Marks,’ the 2003 FCC order ‘is no longer binding or in force’ and the TCPA’s statutory definition did not support Plaintiffs’ interpretation of an ATDS,” according to the article.

Ultimately, the court determined the text messages from the defendants did not qualify as a TCPA violation.  Read the complete article here: https://tinyurl.com/y5o8kw4o

Healthcare M & A Volume Declines in Q3

Health care merger and acquisition activity slowed compared with the second quarter, according to a statement released by HealthCareMandA.com.  The number of deals announced fell 13%, to 408, compared with the previous quarter and was 15% lower than the 478 deals announced in the same quarter in2018.

Combined spending in the third quarter totaled $51.5 billion, down 63% compared with the previous quarter’s extraordinary $139.1 billion. It was 65% greater than the $31.1 billion reported in the same quarter in 2018, according to HealthCareMandA.com.

Healthcare technology deals accounted for 33% of the third quarter’s deal volume. The eHealth sector was the busiest, posting 53 deals and making up 13% of the quarter’s total. Year-over-year, eHealth was the only one of the technology sectors to post an increase in deal volume, up 43% compared with the second quarter of 2018.

Combined spending among the technology sectors was more than $31.9 billion, the statement said. Additional information may be obtained here: https://tinyurl.com/y46yquzw

SBA Encourages CFPB to Mitigate Rule’s Impact on Small Business

The U.S. Small Business Administration (SBA) Office of Advocacy submitted comments on the Consumer Financial Protection Bureau’s proposed rule for the Fair Debt Collection Practices Act (Regulation F) in line with ACA International’s suggestions on consumer communications and disclosure notices and noting the significant impact it could have on small businesses.

Here are a few top-level comments from the SBA Office of Advocacy:

•     Several provisions of the rule will be particularly difficult for small debt collectors and require consideration of alternative approaches. These include the requirement of compliance with the E-Sign Act for electronic disclosures, the requirement of an itemized validation notice, liability for an attempt to collect a debt that is time-barred and requirements for retention of records.
•     The initial regulatory flexibility analysis states that larger collectors may already have some of the proposed provisions in place. The small debt collectors may not. Some of the provisions may require expensive changes to technology and additional training. Advocacy encouraged the bureau to give small entities additional time to comply if they cannot be exempted from the requirements of the proposed rule.
•     The bureau is prescribing the rules pursuant to its authority under the FDCPA, as well as the Dodd-Frank Act’s prohibitions on unfair, deceptive or abusive acts or practices (UDAAP). The UDAAP provisions create uncertainty for first-party creditors who are not supposed to be regulated by the proposal. Advocacy encouraged the bureau to limit the rule to the FDCPA.
•     The rule imposes a limit on the frequency of debt collection calls and provides a safe harbor for debt collectors who comply with the call caps. Because small entities do not usually make calls that exceed the limits in the proposal, Advocacy encouraged the bureau to exempt small debt collectors from the call limit caps.

The SBA Office of Advocacy’s comment letter and fact sheet may be accessed on the SBA’s website at www.sba.gov or here https://tinyurl.com/y2fmelcf. Additionally, ACA International submitted a 154-page comment letter available on its website at www.acainternational.org.

Trump Executive Order Opens Door for Hospital Price Transparency

The Centers for Medicare & Medicaid Services in July proposed a rule that would require hospitals to make pricing information publicly available. It is CMS’s position that the rule would increase competition by enabling patients to shop for health care that meets their needs and budgets.

The proposed rule follows President Donald Trump’s June Executive Order that “lays the foundation for a patient-driven health care system,” according to a press release issued by CMS. Trump’s executive order states, “Opaque pricing structures may benefit powerful special interest groups, such as large hospitals and insurance companies, but they generally leave patients and taxpayers worse off than would a more transparent system.”

Indeed, a statement released by Alex Azar, secretary of U.S. Department of Health and Human Services, noted that “healthcare leaders across the political spectrum have been talking about this need for real transparency for years. This proposal is now the most significant step any president has ever taken to deliver transparency and put patients in control of their care.”

The proposals for calendar year 2020 include changes that would require hospitals to take the following actions:

• Make public “standard charges” for all items and services provided by the hospital.
• Publish standard charges on the internet in a machine-readable file that includes common billing or accounting codes and a description of the item or service. This provides a common framework for comparing standard charges from hospital to hospital.
• Publish payer-specific negotiated charges for common shoppable services (e.g., x-rays, outpatient visits).

To ensure that hospitals comply with the requirements, the rule proposes new enforcement tools including monitoring, auditing, corrective action plans and civil monetary penalties of $300 per day. Additional information, including a list of public comments submitted, may be found on the federal register website at www.federalregister.gov or (https://tinyurl.com/y5zywwhs, comments were due Sept. 27, 2019) or at CMS’s website at www.cms.gov.

To read President Trump’s executive order, visit www.whitehouse.gov and search for “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.”

Poll Shows a Majority of Americans Worry About Hackers

Given the constant news about data breaches that compromise personal information, it is no wonder that Americans are increasingly squeamish about being hacked. A new poll conducted by POLITICO and the Harvard T.H. Chan School of Public Health found that a majority of American adults worry about hackers gaining access to their Social Security number and credit card information.

When asked about which institutions they trust to protect their personal information, health care organizations such as doctor’s offices and hospitals ranked high, while most poll respondents expressed little trust that internet search engines and social media companies would keep their information safe, the study titled “Americans’ Views on Data Privacy & E-Cigarettes,” said.

More than half of adults said they were very concerned that unauthorized people may gain access to their Social Security number (63%) or their credit card number (57%). Among users of social media, 13% said they were very concerned that content they have posted on sites like Facebook, Twitter or Instagram in the past may come back to harm or embarrass them in the future, and 14% were somewhat concerned.

The poll also asked a series of questions about data privacy as it applies to health information or products that adults may have searched for privately online. Among adults who said they have searched for health information or health products online, 30% were very concerned that a company would use their search information to try to sell them medical products or treatments.

More than a quarter (28%) said they were very concerned such information may make it harder for them to get medical care, and one in four (25%) said they were very concerned that private search information may come back to hurt their chances of getting a job or health insurance, according to the study report.

Many Americans do not just search for health information online; they also obtain personal health information through patient portals. These secure websites give patients 24-hour access to their health information from anywhere in the world with an internet connection. The poll found that about a quarter (23%) of adults have ever set up a patient portal.

When asked what they use their patient portal for, the vast majority (81%) of adults said say they used theirs to see test results. More than half (59%) have used it to schedule an appointment, while 42% had requested a prescription refill and 40% received advice about a health problem using their patient portals. The study also showed that most respondents did not express a great deal of concern about potential hacking of patient portals.
About one in four (26%) patient portal users said they were very concerned that unauthorized people may be able to gain access to the private information contained in their portal. Meanwhile, 15% of users said they were not concerned about such a scenario at all.

The State of Medical Collections

Medical debt accounts for one of the largest markets in collections.  While the Fair Debt Collection Practices Act regulates debt collection in general, the American Hospital Association (AHA), the national organization that represents and serves hospitals, health care networks and their patients, created a set of guidelines for member hospitals to follow regarding their billing and collection practices.

Other state hospital associations have implemented their own guidelines as well. ACA members who collect medical debt should be aware of both state and federal guidelines for hospital billing and collections.  The guidelines introduced by AHA include several objectives member hospitals are to set into practice to better serve their patients. The guidelines include substantive criteria under the following headlines:

  • Communicating Effectively
  • Helping Patients Qualify for Coverage
  • Ensuring Hospital Policies are Applied Accurately and Consistently
  • Making Care More Affordable for Patients with Limited Means
  • Ensuring Fair Billing and Collection Practices

In addition to the AHA guidelines, state hospital associations have adopted their own guidelines for their members to follow. While the state association guidelines tend to mirror those of the AHA, each has added its own specific language or requirements. Not to be left out, some states have even enacted legislation governing hospital billing practices.

A few states have robust legislation concerning hospital billing. One state’s hospital billing act requires each hospital in the state to establish a written policy about when and under whose authority patient debt is advanced for recovery efforts.

Any debt collectors who contract with the hospital must follow its policy. Among other things, debt collectors in this particular state must have a written agreement with the hospital for which they are collecting.  The law also limits the ability of the hospital and its agents to use wage garnishments or liens on primary residences as a means of collecting unpaid hospital bills.  Other states with hospital billing requirements are not as robust as the one previously mentioned.

These states have requirements that can include things such as giving notice to the patient as to whether the hospital deems her to be insured or uninsured, and the reason for such determination; not employing a third-party to use physical or legal means to compel the patient or responsible party to appear in court; and not furnishing a negative consumer report or filing suit until 120 days have passed.

It’s imperative that debt collectors who collect medical debt ensure they are aware of the state laws concerning hospital billing. ACA SearchPoint document #2805, State Hospital Billing and Collection Practices, provides an analysis of state and federal laws that deal with state medical billing and collection practices.

Texas Enacts Healthcare Measures Impacting Credit Reporting and Surprise Medical Billing

The state of Texas recently enacted new healthcare measures related to medical billing and credit reporting of out-of-network care. While neither of the bills are specifically targeted at collection agencies, there are some implications regarding the billing of consumers for out-of-network care as well as the reporting of debts related to out-of-network care.

Senate Bill 1037 prohibits a consumer reporting agency from furnishing consumer report information related to “a collection account with a medical industry code, if the consumer was covered by a health benefit plan at the time of the event giving rise to the collection and the collection is for an outstanding balance, after copayments, deductibles, and coinsurance, owed to an emergency care provider or a facility-based provider for an out-of-network benefit claim. . .”

Though the bill does not technically prohibit a data furnisher from reporting debts arising from out-of-network care, debt collector’s may nevertheless want to consider refraining from reporting such debts in order to avoid claims by devious consumer attorneys that even furnishing such information to a CRA violates the FDCPA or state law. Senate Bill 1037 is effective immediately.

Senate Bill 1246 prohibits a nonnetwork physician, provider “or a person asserting a claim as an agent” from billing a patient covered out of network and receiving emergency care in any amount greater than the patient’s responsibility under the patient’s health care plan, including applicable copayment, coinsurance, or deductible.

The new law also requires a health maintenance organization to provide written notice of billing prohibitions in each explanation of benefits provided to an enrollee or physician or provider in connection with a health care service that is subject to the prohibitions. Notably, the bill allows the attorney general to bring a civil action against any individual or entity believed to be violating a law prohibiting balance billing. Senate Bill 1246 takes effect on Sept. 1, 2019.

Other Debt Collection Measures

ACA members should also be aware that Texas recently enacted House Bill 996, which requires certain notices to be provided when collecting debts that are beyond the applicable state statute of limitations. Bill 996 takes effect on Sept. 1, 2019.

For more information on those requirements, members can review ACA SearchPoint #1119, Statute of Limitations:

Collecting Out-of-Statute Debts.  ACA recommends members review these measures with clients and their own legal counsel to determine if any changes are required to current billing or credit reporting practices.

To track legislation in Texas, visit https://capitol.texas.gov/Texas

JAMA Study Finds 36% of Virginia Hospitals Garnishing Wages Over Unpaid Bills

Not every hospital sues over unpaid bills, but a few sue a lot, according to an article published by NPR.  While admitting there “are no good national data on the practice,” NPR writer Selena Simmons-Duffin notes journalists have reported on hospitals suing patients all over the United States– from North Carolina to Nebraska to a hospital in Missouri that sued 6,000 patients over a four-year period.

Simmons-Duffin’s article titled, “When Hospitals Sue for Unpaid Bills, It Can be ‘Ruinous’ for Patients,” focuses on a study published by JAMAThe Journal ofAmerican Medical Association that looks into 2017 Virginia court records on completed warrant-in-debt lawsuits filed by hospitals resulting in garnishment of a patient’s wages.

The JAMA study, led by Martin A. Makary, MD, MPH, of Johns Hopkins University in Baltimore, identified 20,054 warrant-in-debt lawsuits and 9,232 garnishment cases in 2017. Garnishing was conducted by 48 of 135 Virginia hospitals (36%), of which 71% were nonprofit and 75% urban, compared with 53% nonprofit and 91% urban among hospitals that did not garnish, according to the study titled, “Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Medical Bills.”

“Thirty-six percent of Virginia hospitals garnished wages in 2017, with a small number of hospitals accounting for most cases,” the Johns Hopkins researcher said. “Some characteristics suggest that hospitals with greater financial need (nonprofit, lower annual gross revenue) may be pursuing debt collection to the final stage of garnishment.”

The most common employers of those having wages garnished were Walmart, Wells Fargo, Amazon and Lowes, accounting for 8% of patients whose wages were garnished, the study said. This point was central to Simmons-Duffin’s article, which focused heavily on Mary Washington Hospital, a Fredericksburg, Va.-based hospital that’s part of the Mary Washington Healthcare network. (The JAMA study found that five hospitals accounted for more than half of the lawsuits, with Mary Washington suing the most.)

In response to NPR’s report, Mary Washington officials noted that lawsuits are rare (less than 1% of their patients go to litigation). Lisa Henry, communications director for the health care system, said: “It’s important to us, as a small community, and a safety net hospital, that we’re doing everything we can for our patients to avoid aggressive collections.”

Mary Washington has a months-long process for trying to reach patients before it takes legal action. “By phone, by mail, by email — any access point we’re given from them when they register.  “Unfortunately, if we don’t hear back from folks or they don’t make a payment we’re assuming that they’re not prepared to pay their bill, so we do issue papers to the court.

Because court records are public, Mary Washington officials noted that they are subject to more scrutiny than hospitals that use collection agencies.  “We’re really unclear as to why Mary Washington Healthcare in particular has become the face of this,” Henry says. “I don’t think we’re alone — all hospitals are struggling with, ‘How do we collect appropriately from our patients to stay open as a safety net hospital?’”

Meanwhile, Makary, the corresponding author on the JAMA study who is also a surgeon at Johns Hopkins, was so “outraged” over Mary Washington’s efforts to recoup unpaid debt that he formed an advocacy campaign to encourage the hospital to “stop suing low-income patients for bills that they simply can’t afford,” the NPR article stated.

In defense of Mary Washington, Henry noted that most patients who are eligible sign up for financial assistance and payment plans, the article said. According to its website, [Mary Washington Healthcare’s] “not-for-profit status drives us to be the kind of organization that provides care to those in need, regardless of their ability to pay. We provide significant financial assistance.”

Senate Health Committee Votes to Reduce Health Care Costs

Before heading off for the Fourth of July holiday, the Senate Health, Education, Labor and Pensions Committee approved legislation that ends surprise billing, creates more transparency and increases competition to reduce prescription drug costs. The bill, known as the “Lower Health Care Costs Act” was approved in a 20-3 vote.

“Altogether, this legislation will help to lower the cost of health care, which has become a tax on family Budgets and on businesses, on federal and state governments,” said Committee Chairman Lamar Alexander (R-Tenn.).

“A recent Gallup poll found that the cost of health care was the biggest financial problem facing American families. And last July, this committee heard from Dr. Brent James, from the National Academies, who testified that up to half of what the American people spend on health care may be unnecessary.”

Additional information may be viewed on the Committee’s website accessible here: www.help.senate.gov

Unforeseen Out-of-Network Charges Cause Concern Amongst Consumers

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published in June. On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims.

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. “Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017,” the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM’s MarketScan Research Databases, which include claims for almost 19 million individuals. Surprise medical bills are top of mind for American patients, with 38% reporting they were “very worried” about unexpected medical bills. Surprise bills don’t just come from the emergency room.

Often, patients will pick an in-network facility and see a provider who works there but isn’t employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices. “It’s kind of a built-in problem,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don’t know whether they are being treated by an out-of-network doctor while in a hospital.

“By definition, there are these circumstances where they cannot choose their provider, whether it’s an emergency or it’s [a doctor] who gets brought in and they don’t even meet them face-to-face.” The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don’t apply to most large-employer plans because the federal government regulates them.

“New York and California have very high rates of surprise bills even though they have some of the strongest state statutes,” Pollitz said. “These data show why federal legislation would matter.” Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study. Legislative solutions are being discussed in the White House and Congress.

Balance it Out

Working with consumers to explain and help resolve medical bills in collections is a complex process for accounts receivable management companies and their health care provider clients.  Add in the mix unexpected out-of-network charges on a consumer’s bill and all parties involved face challenges to find a solution.

State legislatures started to tackle the issue, known as balance billing, to prevent these charges from reaching the consumer after their bill is processed by a provider and insurance company. Bipartisan debate continues at the federal level to enact laws prohibiting balance billing.

A ‘balance bill’ is a term that refers to any time a consumer’s insurance pays part of the bill, yet they are responsible for paying the balance; and states with laws on balance billing indicate the circumstances when it is legal, according to The Commonwealth Fund.

Educate and Work Together

As lawmakers focus on the issue of balance billing at the state and federal level, it’s best for collection agencies in business partnerships with health care providers to learn together with the goal to help patients through the process.

In California, an amendment to the state’s health and safety code (added sections 1371.30, 1371.31 and 1371.9) AB 72, authored by Assemblyman Rob Bonta, D-Alameda, took effect July 1, 2017.  AB 72 applies to non-emergency care that is provided at an in-network facility but performed by a physician who is out-of-network with the patient’s insurance plan.

“The obvious problem that this has created is that it is difficult for the provider to know if the patient was in-network at the facility or if the services were part of some non-emergency treatment that would require AB 72 to be applied,” according to Courtney Reynaud, president of Creditors Bureau USA in Fresno, California, which works in medical collections.

Reynaud, who is also president of the California Association of Collectors Inc., said after the legislation took effect some provider clients stopped referring accounts to collection with charges that could potentially fall under AB 72.  Oftentimes, they had no mechanism to determine if the services were emergency or non-emergency and if the services were provided at an in-network facility.

Reynaud recommends staying informed on legislative issues and compliance through state and national medical associations such as the California Medical Association and Medical Group Management Association. Balancing Compliance California’s legislation is different than laws in other states and proposed bills at the federal level in that it doesn’t cover charges as a result of a patient’s emergency services.

For example, in Florida, legislation in effect since July 2016 protects patients from out-of-network charges at an in-network facility in emergency situations.  Before the legislation took effect, Matt Kiefer, chief officer of information, compliance and development at The Preferred Group of Tampa in Tampa, Florida, said his agency received medical accounts from unexpected charges due to balance billing.

“Covered charges, noncovered charges, coupled with high deductibles and copays can not only be confusing, but upsetting and only exacerbates the issue when out of network charges and balance billing

are allowed,” Kiefer said. “Legislation like HB 221 in Florida to prevent surprise charges helps the patient in an already uncomfortable position.”

If there is pending legislation in your state, or to stay informed about the topic at the federal level, Reynaud also suggests hosting a webinar for clients or coordinate office training for your provider client’s staff.  “The bottom line is to continue to train collectors to be empathetic when working with consumers with medical debt, especially when it comes to medical debt from surprise medical bills if there is not legislation in your state and the charges are from out-of-network providers.”

Million-Dollar Lawsuit Results from Insurer Sending Payment to Patients-Not Doctors

In a report released by CNN, a woman received nearly $375,000 from her insurance company over several months for treatment she received at a California rehabilitation facility. A man received more than $130,000 after he sent his fiancée’s daughter for substance abuse treatment.

Those allegations are part of a lawsuit winding its way through federal court that accuses Anthem and its Blue Cross entities of paying patients directly in an effort to put pressure on health care providers to join their network and to accept lower payments, the article revealed.

The insurance giant is accused of sending more than $1.3 million in payments to patients -- money, the suit claims, that is owed to the facilities that treated people with addiction and mental health problems.

The suit by Sovereign Health highlights part of an ongoing war between insurance companies and providers over payment and billing issues, one that puts the patient right in the middle of the fighting by sending payments straight to patients after they seek out-of-network care.

Patients are supposed to send the money on to providers. Many times, they do; other times, they don’t, according to CNN.

More information: https://cnn.it/2NA0P0U

HHS Payment Model Designed to Meet Beneficiaries’ Emergency Needs

Supporting ambulance triage options aims to allow beneficiaries to receive care at the right time and place.  Earlier this year, the U.S. Department of Health and Human Services (HHS), Center for Medicare and Medicaid Innovation (Innovation Center), which tests innovative payment and service delivery models to lower costs and improve the quality of care, announced a new payment model for emergency ambulance services.   It aims to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs, a press statement released by HHS said.

The new model known as the Emergency Triage Treat and Transport (ET3), will make it possible for participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth) and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics) to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services.

In doing so, the model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 model will have a five-year performance period, with an anticipated start date in early 2020.

The ET3 model encourages high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a 5 percent payment adjustment in later years of the model based on their achievement of key quality measures. The quality measurement strategy will aim to avoid adding more burden to participants, including minimizing any new reporting requirements.

Qualified health care practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered. The model will use a phased approach through multiple application rounds to maximize participation in regions across the country.

To ensure access to model interventions across all individuals in a region, CMS will encourage ET3 model participants to partner with other payers, including state Medicaid agencies.  CMS anticipates releasing a Request for Applications this summer to solicit Medicare-enrolled ambulance suppliers and providers. In Fall 2019, to implement the triage lines for low-acuity 911 calls, CMS anticipates issuing a Notice of Funding.

There is an opportunity for a limited number of two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate. For more information, please visit: https://innovation.cms.gov/initiatives/et3/ and https://bit.ly/2Ii9ZQD.

How Insurance Coverage Impacts Consumers’ Ability to Pay

New data on health insurance in the U.S. from The Commonwealth Fund reflects quality of coverage and the impact of coverage levels on consumers’ ability to pay medical bills and access care.

Among the findings in the Biennial Health Insurance Survey, The Commonwealth Fund reports that consumers who are “underinsured,” meaning they carry high health plan deductibles and out-of-pocket medical expenses compared to their income, are more likely to have challenges paying their medical bills or avoid medical care because of the expense.

Twenty-nine percent of insured adults qualified as “underinsured” in 2018, an increase from 23 percent in 2014.  “U.S. working-age adults are significantly more likely to have health insurance since the ACA [Affordable Care Act] became law in 2010. But the improvement in uninsured rates has stalled.

In addition, more people have health plans that fail to adequately protect them from health care costs, with the fastest deterioration in cost protection occurring in employer coverage,” said Sara Collins, lead author of the study and The Commonwealth Fund vice president for health care coverage and access, in a news release.

The survey offers a big-picture look at consumers’ health insurance, including the quality of their coverage, in 2018.

Key findings in the survey include:

Twenty-eight percent of U.S. adults who have health insurance through their employer were underinsured in 2018, an increase from 20 percent in 2014.

Consumers who purchased plans on their own through the individual market or the marketplaces were the most likely to be underinsured, with 42 percent reporting a lack of adequate coverage in 2018.

Forty-one percent of underinsured adults reported they held off on care they needed because of the expense, compared to 23 percent of consumers with “adequate insurance coverage.”

And, 47 percent of underinsured adults said they had medical bill and debt problems, compared to 25 percent of consumers who are not underinsured reporting these challenges.

More information: https://bit.ly/2GAEZsT