Archive for the ‘Blog’ Category

Is Medical Debt Different from Educational Debt


Recently, there has been much media attention about educational debt forgiveness. Like most issues of this type there seems to be much political posturing around the topic.


Interestingly, several weeks ago NPR and The Kaiser Family Foundation (KFF) along with several national television outlets reported on how the health care system “is systematically pushing patients into debt on a mass scale.” The topic of educational debt seems to have grabbed the headlines away from medical debt.


According to an internet website, student loan debt is nearly $1.75 trillion, owed by approximately 48 million Americans, 4.7% are delinquent and the average monthly payment is $300.


With significantly less robust accounting, medical debt is estimated at $195 billion as of 2019. It will be difficult to estimate new debt levels post COVID because many peoples’ employment was impacted and most health insurance coverage is tied to employment. While proportionately much smaller than educational debt, health care debt seems more consequential on peoples’ financial conditions. According to a KFF poll, “half US adults don’t have the cash to cover an unexpected $500 bill.” While the dollars are smaller, the estimated number of people with medical debt is estimated to be more than 100 million people or more than double the number with educational debt.


Supposedly, politicians attempted to solve an ever-growing issue related to health care with the passage of the 2010 Affordable Care Act. An interesting unintended consequence, however, were record profit levels for hospitals according to the Medicare Payment Advisory Committee. And at the same time debt levels soared.


Let’s make some quick comparisons between medical and educational debt. First, many will argue medical care is a right and higher education is a privilege. Medical debt typically results from the provision of medical treatment in excess of medical insurance or in some cases the lack of insurance or financial resources. Educational debt is entirely based on choice, access to cheap debt and inadequate financial resources to repay the loans.


Interestingly, educational debt is looking and acting more like the subprime mortgage debt crisis and the related 2008 housing crash than health care debt. In fact, the only aspect lacking to complete the comparison is a government bailout. Will a government sponsored program of educational debt forgiveness initiate the demand for the same for health care debt? Enter the concept of moral hazard. What will the long-term impact of a debt forgiveness program be on the higher education system? Might this be the tipping point for those supporting socialized medicine?


For a number of years, the education and health care industries have shared notable factors placing both in economic peril. Most significant is the unabated rise in costs in both industries,  both rely heavily upon various forms of government subsidies, both are provided significant tax benefits, and neither face any type of challenge from foreign competition. These factors have resulted in bloated budgets and unquestioned waste in both industries. Both industries are critical to the US infrastructure but long-term viability under the aforementioned structures present significant challenges.  Conventional output and productivity measurement have proven very difficult to implement. Employers in the case of health care and lenders in the case of education are feeling similar financial pressure.


On the surface today, there’s seemingly no connection between these two industries but inevitably attempting to fix one will impact the other because both are on very slippery financial slopes.


How to Find a Telemedicine Provider

The genesis of this post was a question my neighbor asked. How do I find a telemedicine provider in Texas? Candidly, I didn’t have a very good answer. So off to the internet I went.


(I’m personally not a regular telemedicine user. Admittedly, my telemedicine knowledge was very dated because my best memory was of the public opposition various Texas Medical groups had prior to COVID.)


Especially for Texas. The COVID pandemic will go down in history as the single largest contributor to the launch of telemedicine despite parts of the medical community’s strong resistance. Prior to the pandemic in my home state of Texas, various medical groups were adamantly opposed to any sort of electronic based medical delivery. On April 10, 2015, the Texas Medical Board (supported by the Texas Medical Association(TMA)) voted to restrict the practice in Texas. This was the culmination of a four-year battle between the Medical Board and Teladoc, a Texas-based company providing telephone or video consultations for routine issues like sore throats, urinary tract infections, rashes, etc.


Then COVID happened and on March 13, 2020 in response to the Governor’s Statewide Disaster Proclamation, the Texas Department of Insurance issued an emergency rule mandating telemedicine services “receive parity with the payment and documentation requirements applicable to in-person services.” I won’t detail everything that has occurred between then and now but suffice it to say the TMA now has a section on their website “Telemedicine in Texas” which provides step by step resources on developing a Telemedicine practice.


All of this, however, does not answer the question of how to find a telemedicine provider.


Here’s my list of recommendations:


  • Teladoc is an established provider of telemedicine services. If you’re not interested in doing a great deal of research and have a relatively simple and straightforward issue, this is a good starting point.
  • Your insurance company.
  • A major healthcare system within the community. Since COVID, many major Systems have developed telemedicine call centers.
  • Specialty Societies: Just a few examples

Academy of Allergy, Asthma & Immunology

Academy of Dermatology

Academy of Orthopaedics Surgeons

Academy of Pediatrics

American College of Cardiology

  • State Medical Associations


Depending upon where you’re located can have a significant impact on what resources you will be able to find relative to Telemedicine. Some areas will be advanced and others will still be very much developmental. Like most things competition will have an impact on how advanced programs will be.


You would be well advised to seek references if you’re unfamiliar with the provider you’ve contacted.


Finding a Telemedicine provider requires the same level of due diligence finding a provider you plan to meet face to face.




Attention Retirees and Tax Payers

Today’s post has a dual purpose, for a somewhat small group of readers and at the same time a very large group. The small group consists of retirees having employer provided healthcare benefits. HR consultants have discovered another way to save employers money and subtly change the employees’ healthcare benefit plan. What I mean by “subtly” change the benefit plan is best depicted by another benefit plan change occurring since the 1980s in the pension plan arena. The change occurred when employers shifted from defined benefit retirement plans to defined contribution plans. At the time, employers were dealing with significant unfunded liabilities and unpredictable expenses which were impacting profitability. Adopting this new form of retirement benefit immediately addressed these issues.


So let’s fast forward to the present. Similar to defined benefit pension plans, retiree healthcare plans have similar challenges for employers. Those being large, unpredictable costs and continually growing liabilities. Like everything associated with healthcare, when promises were made by employers to employees related to healthcare insurance coverage, no one envisioned the out of control, multi-trillion dollar healthcare industry we now have.


Again, enter the HR consultants with employer solutions. Some of you will be familiar with Medicare Advantage plans. If for no other reason they’re constantly being advertised on television. Some of you may even be members in these plans because AARP, along with their business partner, UnitedHealthcare, has been an active advocate of such plans for a number of years. Let me pause and as background information let you know Advantage Plans are not new. They were part of the original Medicare legislation. However, a perfect storm of sorts has created a new environment for these plans.


Rather than bore you with rabbit-trail details. Let me hit the highlights and you can decide for yourself if more education is needed. First, remember when someone was promoting the adoption of Obama Care, and said you won’t have to change your doctor? Well, you may hear the same thing when your employer replaces their existing retiree health plan with a Medicare Advantage plan. You might experience the same result as those enrolling in Obama Care. You also might find your current hospital is not included in the new plan. In the health care community, the terminology you will hear describing where you can go and who your Doctor can be is “network.” And more importantly, the description, “out-of-network” will be used to describe those providers no longer covered by the new insurance plan. An old adage, “if it sounds to good to be true, in all likelihood it probably is,” might be applicable at this point.

Advantage Plans have undergone significant transformation since the 1980s because of attempts by the government to gain more “control” over Medicare costs. Demonstration projects attempting to encourage improved quality, reduce government expenditures, add additional benefits and promote innovations in health delivery have resulted in the hyper-growth of Advantage Plans.


Not surprisingly with billions of dollars at stake, insurers have rushed to the “Medicare Payment Trough.” With the explosion of Medicare Advantage Plans it’s no surprise enrollments have increased accordingly. Here, however, is the interesting part of the story. Since 2008, enrollment in employer-sponsored, Medicare Advantage Plans has gone from 1.6 million to over 5 million. Why, you might ask? Let’s look at a recent situation that highlights the good, the bad and the ugly.


As promised, here’s something for you taxpayers reading this. As many similar things, Medicare Advantage is not new. In fact, corporate America has been making the changes in retiree healthcare benefits for over a decade. What raised the attention level most recently, however, is New York City’s decision to shift more than 200,000 retirees to an Advantage plan with proclaimed savings of $600 million/year. How some skeptics have asked? Improved efficiencies? Better clinical control?  Not unexpectedly, some folks within the New York City infrastructure have taken issue with the conversion and have sued to delay implementation. Decisions related to the lawsuit are in process.


Here are some interesting facts. In the last decade, enrollment in Medicare Advantage Plans has more than doubled. Medicare spending was $321 higher in 2019 and growing faster per person for enrollees in Medicare Advantage vs. traditional Medicare. In total, this resulted in $7 billion in additional spending. (Source Kaiser Health News) Medicare program solvency continues to be a major issue. As part of the Obama Care Act passage a little publicized tax, The Net Investment Income Tax (NIIT) of 3.8%, was included. This tax was created to help fund Medicare expansion. So beware Medicare has been a financial drain on the government budget for decades, it continues to be a financial drain, and there will continue to be “taxes” levied to cover the drain until something is done about healthcare in this country.


KEEPING THE CONSUMER SAFE: Where is Daniel Ellsberg When We Need Him; Segment 15

Many of you are wondering who the hell is Daniel Ellsberg? Mr. Ellsberg was ground zero for a monumental media firestorm during the summer of 1971 about the Vietnam War. I won’t rehash what became known as the Pentagon Papers. I am hoping someone emerges with the “real” COVID-19 story.

As last reported, new studies are surfacing challenging the efficacy of various forms of COVID mitigation. This has heightened the polarization of what practices are going to be continued and what will be discontinued. The “science” seems to be waning in importance.

In the state of Texas, Omicron cases are on the decline. Fauci even recently announced the “U.S. is exiting the full-blown pandemic phase.” In an unconfirmed internet story, it was alleged during the HIV/AIDS epidemic Fauci was a strong advocate for vaccine development and almost anti-therapy development. This may or may not connect the dots to the current lack/shortage of COVID therapy development and explain the full-court press on vaccine participation (currently there are no HIV vaccines licensed for the market).

In what has been extremely limited local reporting, a February 5, 2022 Dallas Morning News article, “Approved virus treatments, and how to find them,” the sketchy existence of COVID-19 treatments was outlined. The good news is The Food and Drug Administration has given emergency authorization for 4 treatments. The only access to the treatments is by prescription or referral from a health care provider. The article goes on to state the “treatments are in short supply in North Texas.” Some of you have probably heard or seen mention of COVID “monoclonal antibody treatments and wondered what they are and where to get them. My random sample of four health care providers in Dallas/Fort Worth resulted in zero availability.

I’m not a scientist so am not going to try and explain what monoclonal antibodies are. However, here’s where things get murky. In December 16, 2020, CNBC reported, “antibody drugs used to treat Trump and others could cut Covid-19 hospitalizations by half, but they’re not being used by the general public.” According to Alex Azar, Health Secretary, “ what’s happening is people are waiting too long to seek out the treatments.” What?

Being skeptical, after reading the aforementioned stories, I decided further investigation was necessary and was surprised by my discovery. First, the monoclonal antibodies Trump received were not approved by the FDA. I for one was amazed at the speed Trump recovered and some even wondered if he actually was infected. Second, a federal “right to try” law was passed in May 2018. Simply, this law allows patients to “try” experimental drugs not yet approved by the FDA. This enabled Trump’s physicians to access the drugs from the company, Regeneron. Interestingly, Regeneron had developed the “approach and technologies” for these antibodies from work related to the treatment of Ebola.  Third, to add to the confusion, The Food and Drug Administration issued a statement on January 22, 2022, revising the use of monoclonal antibodies, bamlanivimab, etesevimab, casirivimab, imdevimab to only situations where the patient has been exposed to the Delta variant. Apparently, it’s been determined these antibodies are ineffective against Omicron. A peculiarity to this announcement is the testing kits being distributed by the government don’t determine which COVID variant a person has.

In summary, certain monoclonal antibodies have had their FDA authorizations revised. Seemingly, the FDA by their announcement has declared the COVID Delta variant over. Does the FDA ruling make the use of the aforementioned antibodies illegal in light of the “Right to Try” law? Are organizations treating patients using these antibodies subject to legal action? We’ve seen the NIH and CDC attempt to silence individuals with an alternative position, will the FDA exert the same type of influence?  Earlier during the pandemic, there was a surplus of monoclonal antibodies and currently they’re in short supply. On January 30, the Dallas County Health and Human Services reported 183 deaths for the week. This made it the deadliest week since the pandemic began.

As someone once said, there’s a fly in the ointment. The inconsistencies are mounting and explanations are getting fewer and further between.

As background, I was a junior in high school following the summer when the Pentagon Papers were released. Each day during my history class, we examined the inconsistencies between what had been reported about the Vietnam War and what the reality was. I realize the Papers did not end the War but they shed light on many questionable decisions Presidents made that cost thousands of American lives. Our conversations left an indelible imprint on me about the importance of reliable reporting. Fool me once, shame on you. Fool me twice, shame on me. I’m hoping someone is writing the COVID Papers.

Vietnam cost 58,000 American lives. COVID has taken 918,000 deaths and counting!


KEEPING THE CONSUMER SAFE: The Politicization of COVID: Segment 14

A couple weeks ago, Salvador Rizzo of The Washington Post wrote an article about the confrontational exchange between Anthony Fauci and Senator Rand Paul during a Senate health committee hearing. Several things in the article were interesting. First, COVID has escalated into a serious political issue. I say serious because few things other than war have as serious life and death consequences as COVID. Second, why has the The Great Barrington Declaration become so polarizing?

In the article, Rizzo refers to the 3 authors of the Barrington paper as “three conservative academics who opposed lockdown measures in 2020.” This has become a much more interesting topic as of late but more later.

How quickly the COVID world changes. In searching social media. the first thing I noticed was the NHL announced asymptomatic players were no longer going to be tested. With the NFL playoffs upon us and the Super Bowl only days away, the NFL followed with a similar decision. The NFL’s once a week testing of all players and personnel has now been changed to only testing players displaying symptoms. In the Friday edition of The Dallas Morning News, I noticed a brief note, “The Association of State and Territorial Health Officials has called on governments to stop conducting widespread contact tracing, saying it’s no longer necessary.” What?

Another significant social media event occurred Friday evening, January 24, 2022, on the episode of “Real Time With Bill Maher.” Both Bill Maher and his guest, Bari Weiss, disclosed their personal frustrations with living under COVID restrictions. This brought on a social media firestorm. On a more personal note, my local school district closed for two days because of a COVID caused teacher shortage. Anyone see conflicting messages but me?

Canada has a nation-wide trucking demonstration in opposition to mandates going on. Johns Hopkins University recently released a 60+ page “Meta-Analysis of the Effects of Lockdowns on COVID-19 Mortality.” The paper comes to the conclusion that “lockdowns in Europe and the United States only reduced COVID-19 mortality by 0.2% on average. Shelter-in-place-order studies were also ineffective, only reducing COVID-19 mortality by 2.9% on average.” For those familiar with The Great Barrington Declaration, the Johns Hopkins study seemingly supports the recommendations of the Declaration. This document came under intense challenge by Fauci and Collins who challenged the scientific validity of the document.

Needless to say I’m getting more confused as I attempt to stay informed about what’s going on with COVID and trying to provide meaningful/helpful commentary.  Amidst all of the aforementioned seemingly contradictory information the following headline appeared in The Dallas Morning News, “Omicron pushes death toll higher.” So from a logical perspective one would think there’s a pretty significant reason for people to consider any and all approaches to stop the dying. I can categorically say this is not the case. In the aforementioned article, it’s suggested even though omicron is “milder,” it’s highly contagious, causing more to become ill and die.

I’m not a biostatistician so my following conclusion is not based on any technical skill or training. Based upon a vaccination website on Google, 211 million Americans are vaccinated representing 64% of the population. Our mortality numbers seem to be gaining on the peak mortality numbers during last fall. Common sense would suggest with more than half the population vaccinated and some additional percentage of the population being previously infected and surviving, we shouldn’t be experiencing this type of outcome unless something else is going on. Is the vaccine not working on Omicron? What are we learning about immunity? Does having the Delta variant provide immunity to the Omicron variant? Are the risk factors identified for the Delta variant the same as Omicron? Are there new or different risk factors impacting mortality? Are mandates working? What are the unintended consequences of the mandates and are there mortality impacts associated with these? What are the most effective treatments? Where should people go for treatments?

I spend my days searching for answers to these and other seemingly important questions. What’s frustrating is the lack of consistency in how the Press is reporting on the evolving information. I’m getting the sense if the information does not conform to the political context or the reporting outlet’s viewpoint, it may or may not be reported. This is dangerous! In fact, it’s starting to remind me of a time when the Pentagon Papers were the headline of the day.

As discussed before, we’re living in real-time, scientific discovery mode that is being exposed via social media to the entire world. As stated before, history shows us the scientific discovery process is complete with much trial and error as well as pure serendipity. Politicians intent on making public policy on unproven, untested or changing scientific discovery are going to be wrong some of the time. This is going to require real-time course corrections. It’s going to require people to admit they were wrong and move forward. It’s going to require politicians with courage and backbone to make decisions and then make better decisions based upon new information. Hiding information because it conflicts with existing public policy will not end well for anyone.






Healthcare Consumer Navigator Center is a Healthcare Consumer Advocate Organization that helps consumer navigate the healthcare maze. The following Series “KEEPING THE CONSUMER SAFE; LIVING WITH COVID”.  Our goal is to provide a commonsense approach to living with covid with general healthcare information.

In a previous article, I compared medical innovation and making sausage. For those never seeing how a hotdog is made, consider yourselves lucky. I’ve decided having the whole world exposed to seeing how medicine/science is dealing with COVID is very much the same as making a hotdog. On the simplest level, we experience medicine by going to our doctor, getting a diagnosis, getting a prescription, and picking it up at the drugstore. Presto with have a fix. In more complex circumstances we go to our doctor, who sends us to a specialist who sends us to a hospital for some type of intervention. In either case, history and experience have created accepted algorithms of treatment and care. Things are predictable. Not so much with COVID.

Because COVID is occurring real-time and in the context of an advanced social media world. We are all seeing how scientific discovery happens. At times it does not always follow a straight line. So now we are dealing with a different version of COVID. In a matter of a few months we’ve gone from vaccinating those with compromised immune systems and over 65 to 5 years old and older.

I can only vaguely remember the beginning of COVID, as I recall the warning symptoms were, temperature, loss of taste, loss of smell, difficulty breathing and a scratchy throat. So now the CDC website lists the following as symptoms: fever or chills; cough; difficulty breathing; fatigue; muscle or body aches; headache; loss of taste or smell; sore throat; runny nose; nausea; diarrhea (the CDC is careful to note this is not a complete list). Complicating factors are now the Omicron variant and the impact of vaccination. More people are now asymptomatic. It doesn’t take a medical degree to realize there are many physical abnormalities that have the above mentioned symptoms.

I live in the great state of Texas. For 20 plus years in December and January, I have the displeasure of being extremely allergic to juniper pollen. I don’t know how many of our readers share this unfortunate condition, but I do know a number of colleagues. It is more commonly known here as “cedar fever.” The symptoms are fatigue, sore throat, runny nose, partial loss of smell,  temperature (usually not higher than 101.5), sneezing, itchy and watery eyes. Needless to say, to the layperson cedar fever bares an awful lot of similarity to COVID-19. In addition, we’re also entering a time of year the medical community refers to as the “flu season.” Because these symptoms are generally more common to everyone, I won’t delineate. Let me just say they are also very similar to COVID.

So combine the aforementioned medical conditions along with exploding COVID cases and a perfect storm for COVID-19 testing has been created. In very limited circulation is a document, “The Great Barrington Declaration,” written by 3 epidemiologists and public health scientists and as of this writing signed by over 916,000 supporters. Simply stated (you’re encouraged to read it for yourself) the document presents alternative approaches the writers call “Focused Protection” as opposed to COVID current strategies and was released to the public on October 5, 2020. What’s contributed to the notoriety of this document is the apparent opposition it’s created from the CDC and FDA and the political reaction to the document and the authors.

I’m more sensitive to the document now that I’ve been vaccinated, infected, recovered, boosted and surrounded by a circle of friends that share similar experiences. In all cases, vaccinated, they’ve not been hospitalized, minimal to no symptoms, recovered in 3 to 5 days without medical intervention other than over the counter cold and flu remedies. So as I read and hear stories on social media of people spending in excess of 8 hours waiting to be tested, I wonder why? Are all this people in the high risk categories? Are they responding to a panic being created by social media? It appears the majority of media is focused on the “vaccine or bust” agenda. There is almost no mention of the potential for infection despite vaccination, no significant messaging of infection and short recoveries and continued coverage of the outrageous demand for testing and the craziness this is causing.

I have lived with cedar fever for 21 years. I don’t look forward to it but have learned how to manage the 2 months when it impacts me. There seems to be a general feeling in the media there will be a complete eradication of COVID sometime in the near future, and we just need to live through these fire drills until that day arrives. Given my observations of the past 2 years, I think we’re more likely to be dealing with COVID for a much longer time horizon and should be adjusting to life-style changes that aren’t reactionary but permanent. Are we really going to make our children wear masks for the next 20 years? Are we really going to wear masks every time we get on an airplane? If we go to concerts, are the entertainers all going to be speaking through masks? Many of you aren’t old enough to remember the nuclear bomb drills we went through in the early sixties at school when we all were instructed to crawl under our desks.

Currently, I’m not spending my time waiting in line to be tested to see if I have cedar fever or the flu. I’m also not spending $20 on a home test kit to see if I have cedar fever. Because I have one of the top four comorbidities I take my temperature every day. I’m also very aware of any change in my physical well being.

I’m awaiting for my TSA-like vaccination card that enables me to live a more normal life. We need someone to start developing longer term approaches without the political influence, soon!




Healthcare Consumer Navigator Center is a Healthcare Consumer Advocate Organization that helps consumer navigate the healthcare maze. The following Series “KEEPING THE CONSUMER SAFE; LIVING WITH COVID”.  Our goal is to provide a commonsense approach to living with covid with general healthcare information.

This is now the latest COVID-19 hot button. Today, President Biden announced the administration was buying another 500 million at-home-COVID-19 tests. This was in

Addition to the 500 tests ordered last week. In addition, “high-quality masks are also going to be made available. Here’s the real bonus! All this stuff is “free.” Only politicians can give out millions of dollars of stuff for “free.” When you’re in Washington long enough everything seems to be free. But that’s a topic for another day.

Social media is now full of stories of people unable to find home testing kits in stores, waiting in public testing lines for hours, waiting days/weeks for tests to come back from labs and I am wondering why? Testing seems to be the latest craze in the COVID-19 saga.

When did this craziness happen and why? For me personally, in 2020, the only time I was tested was when my wife and I were traveling to Alaska and a negative test was required to leave the airport in Anchorage. As I think back, other than this trip, I can’t ever recall being tested as a topic of concern. Ironically, we went through the same process of being tested prior to the 2021 trip not because of a State of Alaska requirement but because of a requirement by the lodge we were staying at. As I previously reported, I was tested while at the lodge and was positive for COVID. I was 100% asymptomatic, however, due to airline requirements I needed to quarantine for 10 days before I could fly home. Interestingly, if this happened today, according  to new CDC guidelines, I’d only need to quarantine for 5 days.

I’m repeating myself to illustrate things do change relative to our COVID measures and I’m now wondering when this current craziness will subside? However, here’s something that I believe is very important. I’ve covered this before but not to the extent I now find necessary. On the CDC website is a section titled, “People with Certain Medical Conditions,” which summarizes all the comorbidities which place people at higher mortality risk with COVID. Frankly, in my humble and medically, un-educated opinion, the list most likely covers somewhere around 80% of the US population. So while very accurate it’s pretty much useless in saving lives.

Sometime in early 2021, folks at Griffith University, published an analysis of 375,859 participants from 14 countries. They found “chronic kidney disease was statistically the most prominent comorbidity leading to death.” Other comorbidities were cancer, diabetes or hypertension. As in all medical studies, there are a bunch of caveats and other mumbo-jumbo to protect the study’s authors from litigation, but the essence of identifying just four comorbidities goes a long way toward providing a much more manageable approach to treating a select group of COVID patients differently.

In summary, again I’m not a physician, but feel comfortable in saying if you or a loved one has any of the aforementioned health challenges special attention is important. I strongly recommend consultation with your personal physician. Monitoring symptoms becomes very important. While I personally hate wearing a mask, one might take this added precaution more seriously. In addition, being aware of one’s environment and the people in it is also more important. Consulting with your physician is important regarding being vaccinated and boosted.

Finally, I don’t get the current and overwhelming need for individuals to be tested. I’ll grant the aforementioned group of people should be cautious and careful in monitoring symptoms. We now are fully aware there will be “breakthrough” cases (myself included) of the vaccinated. We also are learning the Omicron version of COVID is different. We are attempting to keep our readers apprised of the most non-political, current, scientifically-based information we can find. It becomes challenging to sift through the information because COVID has become one of the most politicized diseases scientists have had to deal with.

In a future articles, I’m covering symptoms and an alternative view of dealing with COVID-19.

KHN Bill of the Month: NICU Bill Installment Plan: That’ll Be $45,843 a Month for 12 Months, Please

By Victoria Knight   DECEMBER 21, 2021 Kaiser Health News

Close to midnight on Nov. 12, 2020, Bisi Bennett was sitting on the couch in her pajamas and feeling uncomfortable. She was about seven months pregnant with her first child, Dorian, and the thought that she could be in labor didn’t even cross her mind.

Then, she felt a contraction so strong it knocked her off the couch. She shouted to her husband, Chris, and they ran to the car to start the 15-minute drive to AdventHealth hospital in Orlando, Florida. About halfway through the trip, Bennett gave birth to Dorian in her family’s Mitsubishi Outlander. Her husband kept one hand on his newborn son’s back and one hand on the wheel.

Born breech, meaning his head emerged last, Dorian wasn’t crying at first, and the terrified new parents feared something was wrong. Chris Bennett turned on the SUV’s flashers and flagged down a passing emergency vehicle. The EMS team escorted the family to the hospital.

“He was still connected to me with the umbilical cord when they rolled the two of us together into the hospital,” Bisi said. “They cut the cord, and the last thing I heard was, ‘He has a pulse,’ before they wheeled me away.”

“I just cried tears of relief,” she said.

Dorian stayed in the neonatal intensive care unit until Jan. 7, 2021, for almost two full months. While Dorian was in the hospital, Bisi wasn’t worried about the cost. She works in the insurance industry and had carefully chosen AdventHealth Orlando because the hospital was close to her house and in her insurance network.

Then the bills came.

The Patient: Dorian Bennett, an infant born two months premature. He has health insurance through his mother’s employer, AssuredPartners, where she works as a licensed property insurance agent.

Medical Service: A neonatal intensive care unit stay of 56 days. Dorian needed highly technical, lifesaving respiratory and nutritional care until his organs matured. He also received laboratory, radiology, surgery, cardiology and audiology services and treatments.

Service Provider: AdventHealth Orlando in Orlando, Florida. It is a part of the AdventHealth system, a large nonprofit and faith-based group of health care providers with locations across Florida and several other states.

Total Bill: AdventHealth Orlando billed $660,553 for Dorian’s NICU care. Because of an insurance snafu, the “patient responsibility” portion of the bill sent to the Bennetts was $550,124. They were offered an installment payment plan of $45,843 a month for 12 months.

View note

What Gives: Under the 2010 health law, nonprofit hospitals are required to provide financial assistance to help patients pay their bills, and payment plans can be part of that assistance. But the Bennett family’s experience shows the system is still far from friendly to patients.

The installment amount offered to the Bennetts — $45,843 — resembles an annual salary more than a reasonable monthly payment. The laughably unrealistic plan was apparently automatically generated by the hospital’s billing system. A spokesperson for the hospital, David Breen of AdventHealth, did not answer KHN’s questions about its billing software or why a five-digit monthly payment was not flagged by the hospital as a problem that might need extra attention.

The size of the Bennetts’ bill stems from two overlapping issues: Baby Dorian was born in 2020 and needed hospital care into 2021, and Bisi Bennett’s employer shifted its health plan to a different company in January 2021. She informed AdventHealth about the change.

As someone who works in the insurance industry, Bennett was pretty sure that she understood the mix-up and that the charge of more than half a million dollars was unjustified.

But as Dorian turned a year old last month, the family still had bills pending and a tangle of red tape to fight.

AdventHealth bundled the 2020 and 2021 dates of Dorian’s NICU stay and then billed both insurance plans for the whole stay. Both insurance plans said the bill contained dates of care when Dorian was not covered, so neither paid the hospital. The shift from one year to the next flummoxed three large business entities, which seemed unmotivated to resolve the problem quickly.

“A bill this large is a huge crisis for the family, but it’s not a huge crisis for the insurance company or for the hospital,” said Erin Fuse Brown, an associate professor of law at Georgia State University who studies health care policy.

In 2020, Dorian was covered under a UnitedHealthcare plan, which for in-network providers had a $6,000 deductible and $6,000 out-of-pocket maximum for the family.

In 2021, Bisi Bennett’s employer switched its third-party administrator of its self-funded plan from UnitedHealthcare to UMR. The deductible and out-of-pocket maximum did not change.

Although UMR is owned by UnitedHealthcare, the two companies did not communicate well about the case.

“It’s indicative of all the ways the system fails the patient,” Fuse Brown said. “Even the one who does everything right.”

Through the nearly yearlong fight over the bill, the Bennetts were also caring for Dorian, who left the hospital with lingering gastrointestinal issues, and managing Chris’ treatment for stage 4 neuroendocrine cancer, which was diagnosed in April. At one point, Bisi said, she felt she was going crazy.

“They’re in charge of billing, and I shouldn’t be the one having to tell them, ‘Bill my one insurance for dates in 2020 and bill my other insurance for dates in 2021,’ but I did,” she said. “I kept having the same conversation over and over.”

Resolution: Bisi Bennett immediately noticed and understood the calendar issue when she received the billing statements in spring 2021. She started by calling the hospital and was told the problem would be corrected in March. Yet, in September, she got the same half-a-million-dollar bill.

UnitedHealthcare spokesperson Maria Gordon Shydlo, who also fielded KHN’s questions for UMR, said the insurance company told AdventHealth to revise the bill with correct dates in the spring.

Breen, the spokesperson for AdventHealth Orlando, confirmed to KHN that the billing error stemmed from the change in insurers from 2020 to 2021. In a statement, Breen said medical billing can be a complex process and the hospital “understand[s] this has been a confusing and challenging experience for Ms. Bennett, and we apologize for the frustration this has caused.”

AdventHealth Orlando did not submit a revised bill with corrected dates until KHN contacted the hospital in October 2021.

After UHC and UMR reprocessed the 2020 and 2021 claims, the original bill of more than $550,000 was knocked down to $300.

In his statement, Breen said that the Bennetts’ case sparked AdventHealth to identify and address issues in its system and that the hospital plans to improve the billing and communications process for future patients, particularly when there is a change in insurance.

The Takeaway: Much of our fragmented health care system is on autopilot, with billing software that generates confusing or, in this case, absurd bills and payment

No Surprises Act Implementation: What to Expect in 2022

Karen Pollitz
Published: Dec 10, 2021….KFF

The No Surprises Act (NSA) establishes new federal protections against surprise medical bills that take effect in 2022. Surprise medical bills arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose. Peterson-KFF and other studies find this happens in about 1 in 5 emergency room visits. In addition between 9% and 16% of in-network hospitalizations for non-emergency care include surprise bills from out-of-network providers (such as anesthesiologists) whom the patient did not choose. Surprise medical bills pose financial burdens on consumers when health plans deny out-of-network claims or apply higher out-of-network cost sharing; consumers also face “balance billing” from out-of-network providers that have not contracted to accept discounted payment rates from the health plan.1  The federal government estimates the NSA will apply to about 10 million out-of-network surprise medical bills a year.

The NSA will protect consumers from surprise medical bills by:

  • requiring private health plans to cover these out-of-network claims and apply in-network cost sharing. The law applies to both job-based and non-group plans, including grandfathered plans2
  • prohibiting doctors, hospitals, and other covered providers from billing patients more than in-network cost sharing amount for surprise medical bills.

The NSA also establishes a process for determining the payment amount for surprise, out-of-network medical bills, starting with negotiations between plans and providers and, if negotiations don’t succeed, an independent dispute resolution (IDR) process.

Federal agencies published two interim final regulations and another proposed rule this year to implement the law.3 This brief summarizes key provisions that will take effect in 2022.

New federal protections apply to most surprise bills

Protections will apply to most surprise bills for specific types of services provided in certain settings.

Emergency Services  – Surprise billing protections4 apply to most emergency services, including those provided in hospital emergency rooms, freestanding emergency departments, and urgent care centers that are licensed to provide emergency care. The federal law also applies to air ambulance transportation (emergency and non-emergency), but not ground ambulance.5  Emergency care includes screening and stabilizing treatment sought by patients who believe they are experiencing a medical emergency or active labor.

The federal government estimates there are 39.7 million emergency visits annually by patients with private job-based or individually purchased insurance, and of these 18% (or about 7.1 million visits) will involve at least one out-of-network claim.

Post-emergency stabilization services – The NSA defines emergency services to also include post-stabilization services provided in a hospital following an emergency visit. Post-stabilization care is considered emergency care until a physician determines the patient can travel safely to another in-network facility using non-medical transport, that such a facility is available and will accept the transfer, and that the transfer will not cause the patient other unreasonable burdens. The NSA also requires patients must receive written notice and give written consent to be transferred.6 The federal government estimates each year 4.1 million emergency department visits result in a hospital admission, and that 16% (or about 660,000) of these admissions will involve at least one out-of-network claim.

Non-emergency services provided at in-network facilities – Finally, the NSA covers non-emergency services provided by out-of-network providers at in-network hospitals and other facilities. Often, the doctors who work in hospitals don’t work for the hospital; instead they bill independently and do not necessarily participate in the same health plan networks.  The federal government estimates that 16% of 11.1 million (or about 1.8 million) in-network non-emergency facility stays for privately insured patients each year involve at least one out-of-network claim.

The regulation broadly defines covered non-emergency services to include treatment, equipment and devices, telemedicine services, imaging and lab services, and preoperative and postoperative services, regardless of whether those services are provided within the facility itself.

The interim final regulation defines “facility” to include hospitals, hospital outpatient departments, and ambulatory surgery centers. It requests public comment on whether additional types of facilities should be added to this definition. Meanwhile, consumers do not have federal protections against surprise bills for non-emergency services provided in other facilities such as birthing centers, clinics, hospice, addiction treatment facilities, nursing homes, or urgent care centers.  Patients seeking care at such facilities may want to ask whether doctors bill independently and whether they are in network.

Doctors and hospitals must not bill patients more than the in-network cost sharing amount for surprise bills

For services covered by the NSA, providers are prohibited from billing patients more than the applicable in-network cost sharing amount; a penalty of up to $10,000 for each violation can apply.

Today, many out-of-network doctors and hospitals bill patients directly for their full, undiscounted fee, leaving to patients to submit the out-of-network claim to their insurance and collect what reimbursement they can. That common billing practice will change starting next year. Providers will need to first find out the patient’s insurance status and then submit the surprise out-of-network bill directly to the health plan. Providers are “encouraged” to include information about whether NSA protections apply on the claim itself (including, whether the patient has consented to waiver her balance billing protections, described below.)  Health plans must respond within 30 days, advising the provider of the applicable in-network cost sharing amount for that claim; cost-sharing generally will be based on the median in-network rate the plan pays for the service.7 The health plan will send an initial payment to the provider and send the consumer a notice (called an explanation of benefits, or EOB) that it has processed the claim and indicating the in-network cost sharing amount the patient owes the out-of-network provider. Only at this point is the out-of-network provider allowed to send the patient a bill for no more than the in-network cost sharing amount.

How will consumers know if a bill or claim constitutes a surprise medical bill? – It is up to both providers and health plans to identify bills that are protected under the NSA. The regulations also request public comment on whether changes to federal rules governing electronic claims (so-called HIPAA standard claims transactions) are needed to indicate claims for which surprise billing protections apply.8

Providers and plans also must notify consumers of their surprise medical bill protections. Providers and facilities must post a one-page disclosure notice summarizing NSA surprise billing protections on a public website and give this disclosure to each patient for whom they provide NSA-covered services.  (Appendix 1) This notice must be provided no later than the date when payment is requested, though the regulation specifies it is not required to be included with the bill, itself. Health plans are also required to provide consumers the disclosure notice with every EOB that includes a claim for surprise medical bills.

If a health plan or provider (or both) fail to properly identify a surprise bill, it will be up to the patient to recognize that NSA protections should apply and seek relief.

Some providers can ask consumers to waive rights

An exception to federal surprise billing protections is allowed if patients give prior written consent to waive their rights under the NSA and be billed more by out-of-network providers.  Providers are never allowed to ask patients to waive their rights for emergency services or for certain other non-emergency services or situations described above. Consent must be given voluntarily and cannot be coerced, although providers can refuse care if consent is denied.

Notice and Consent Waiver Not Permitted for:

  • Emergency services
  • Unforeseen urgent medical needs arising when non-emergent care is furnished
  • Ancillary services, including items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology
  • Items and services provided by assistant surgeons, hospitalists, and intensivists
  • Diagnostic services including radiology and lab services
  • Items and services provided by an out-of-network provider if there is not another in-network provider who can provide that service in that facility

Federal regulations provide for a standard waiver consent form, improbably titled the “Surprise Billing Protection Form,” (Appendix 2) that must include key information, including

  • a statement that the patient is not required to waive protections, and can try to find an in-network provider/facility instead (for post stabilization care, the notice must indicate the name of available in-network providers)
  • a statement that the out-of-network provider/facility can refuse to treat if the patient refuses to waive surprise billing protections
  • a statement that waiving protections could cost the patient more money in out-of-network charges
  • a description of the out-of-network services to be provided, along with billing codes and a good faith (nonbinding) estimate of costs the patient may owe

The law requires that consent must be given at least 72-hours in advance or, if the patient schedules a service less than 72-hours in advance, no later than the day the appointment is made. For same-day scheduled services, regulations permit consent to be given at least 3 hours in advance. It is possible, for example, that an out-of-network doctor could ask an already-hospitalized patient in the morning to waive her NSA protections for a service the doctor schedules to be given later that afternoon.

Providers should not seek consent to waive protections from patients who are impaired or otherwise limited in their ability to make informed decisions.  The waiver form must also be provided in the 15 most common languages in the geographic region where consent is sought; and if the patient’s own language is not among those, qualified interpreter services must be provided. The patient’s signature is required to give consent; no provider signature is required. Consent can be revoked prior to services being provided. The out-of-network provider or facility is required to notify the health plan that patient consent to waive balance billing protections for the claim(s) was appropriately given.

The Departments express the view that consent to waive NSA protections should be obtained only in limited circumstances – where the patient knowingly and purposefully seeks care from an out-of-network provider – and not to circumvent the law’s consumer protections. Even so, the regulation estimates that consumers will give consent to waive NSA protections in 50% of post-stabilization claims and for 95% of non-emergency services provided at in-network facilities. The regulations do not require any data reporting to regulators on the number of consent waivers given or for what services or providers. Agencies asked for comment on whether further limits on the notice-and-consent waivers are advisable.

Some state laws either do not allow waiver of protections or requiring greater advanced notice.

How will enforcement work?

For consumers to be protected, both the health plan and the surprise billing provider will need to comply with the law. If problems arise, consumers might need to seek help from more than one enforcing agency. And, though the NSA is a federal law, states will also have a role in enforcement.

Enforcement against health plans and insurers – The federal government has exclusive enforcement responsibility for most private health plans, though different federal agencies may be involved. States will lead enforcement for state-regulated plans.

  • Most Americans under age 65 are covered by private employer-sponsored health plans, with nearly 2/3 of covered workers in self-insured plans that states are preempted from regulating. Enforcement authority over private self-insured employer-sponsored group plans rests with the U.S. Department of Labor (DOL) and Department of Treasury. Fully-insured group plans will be primarily regulated by states
  • For fully insured group health plans and individual health insurance, states have primary enforcement authority, with federal fallback enforcement by HHS triggered when states do not substantially enforce. Any information (e.g., complaints, news stories) can serve as the basis for HHS investigating state enforcement.
  • For self-insured plans sponsored by non-federal public employers, the U.S. Department of Health and Human Services (HHS) has primary enforcement authority. Agencies estimate 3 million people are enrolled in these plans.
  • For the Federal Employees Health Benefits Program (FEHBP), enforcement authority rests with the U.S. Office of Personnel Management (OPM). The FEHBP is the largest employer-sponsored group health plan, coving nearly 9 million federal employees, annuitants and family members.

The NSA requires DOL to conduct audits of claims data from up to 25 group health plans annually to monitor employer-sponsored plan compliance with the NSA and to report to Congress annually on audit findings. HHS also will conduct up to 9 audits annually of compliance by state and local government employer plans and other issuers in states that are not substantially enforcing the NSA. These annual audits will focus primarily on whether plans are following the methodology for calculating QPAs.9

Enforcement against providers – States have a primary role in enforcing NSA rules against health providers, with federal enforcement as back up. This is true even when the consumer is covered by a federally-regulated health plan. It is yet to be determined which agency(ies) in each state will enforce NSA provider requirements, for example, the attorney general, department of health, hospital commission, or medical licensing boards. In addition, to “proactively identify and address issues of noncompliance,” HHS has proposed that it will conduct on average 200 random or targeted investigations per month into potential violations of NSA requirements by providers, starting in 2022.

Federal vs. state enforcement – This fall, the federal government surveyed states to learn about their authority and intention to enforce each of the major provisions under the NSA. The survey asked states if they will elect or decline to assume enforcement authority on a provision-by-provision basis. States can also enter into a collaborative enforcement agreement with the federal government, under which the state would seek voluntary compliance from health plans or providers and, when it cannot obtain that, refer cases to the federal government for enforcement action. Many states have already enacted some surprise billing protections for consumers in state-regulated plans. Depending on limits of their laws and authority, it is possible some states might decline to enforce NSA protections for certain services (e.g., post-stabilization) or for certain types of health plans (e.g., PPOs vs. HMOs), or with respect to certain providers (e.g., air ambulance). In addition, state laws may be more protective than the NSA in certain respects (for example, a state law might apply to ground ambulance services) in which case a state would enforce its own stronger protections, at least with respect to state-regulated health plans.

It is expected that HHS will make survey results public or otherwise publish a directory of applicable state and federal enforcement agencies. Health plans and providers must give consumers a disclosure notice summarizing protections under the NSA and state laws, and this must include the name and contact information for applicable enforcement agencies. (Appendix 1)

If problems do arise, it is conceivable that a patient might need the help of multiple agencies – federal, state, or both. For example:

  • If a US DOL-regulated group health plan incorrectly denies a claim for an out-of-network service to which the NSA applies, and as a result, if the provider then incorrectly bills the patient for the entire charge, the consumer might need to rely on US DOL to enforce against the group health plan and on a state agency to enforce against the provider.
  • If a patient requires post-stabilization care following an emergency visit and her state surprise billing law covers emergency services only, she might need to rely on the state to enforce protections for the emergency claims and on the federal government for claims involving the post-stabilization care.
  • If a patient receives an out-of-network emergency surprise bill while traveling in another state, he might need to request help from the federal government if his home state, which would otherwise enforce NSA rules on providers, declines to enforce against out-of-state providers.

What can consumers do in case of problems?

Health plans, providers and facilities will most likely work in good faith to comply with NSA requirements. Even if compliance rates are high, with 10 million surprise medical bills annually, hundreds of thousands of problems could nonetheless arise. In such cases, it could fall to the consumer to recognize when surprise billing protections should apply and to seek help.

Consumers can appeal health plan denials – NSA gives consumers the right to appeal health plan decisions to incorrectly deny or apply out-of-network cost sharing to surprise medical bills, first to the health plan, and then, if the plan upholds its decision, to an independent external reviewer. NSA interim final regulations added surprise bills to the scope of claims eligible for external appeal, which is otherwise limited to only denials based on medical necessity. NSA regulations made no other changes to current federal standards and processes that can limit consumer access to external appeal, including those that:

  • require the health plan to determine which claims are eligible for external appeal
  • require employer-sponsored health plans to contract with the external reviewer
  • limit access to denial notices in another language for consumers with limited English proficiency

Federal appeals standards apply to most private health plans sponsored by employers, although in some states appeal rights are stronger for consumers in state-regulated health insurance.

Beyond these limitations, appeal rights may not help in many cases because consumers rarely appeal adverse determinations by their health plans. Data reported by qualified health plans sold on show less than 2/10 of 1% of denied claims are appealed internally to the health plan, and less than 3% of those appeals make it to external review. There is no reporting requirement specific to surprise medical bill claims and appeals for QHPs, and at present, federal law requirements on employer-sponsored health plans to report data on denied claims have never been implemented.

Consumers can contact “the applicable enforcement entity” when providers incorrectly bill – Providers are required to give consumers written notice describing their federal protections each time they provide a service protected under the NSA. The notice must include contact information for the applicable federal and state enforcement entities; although a provider that inappropriately balance bills for a service subject to the NSA might also fail to provide the required disclosure notice.

A national consumer complaints system will be established – The NSA requires HHS to establish a national complaints system for surprise medical bills, which is currently under development and scheduled to go live on January 1, 2022.

The toll free number for the “No Surprises Help Desk” will be 1-800-985-3059.

A central, no-wrong-door system is contemplated where consumers can register complaints regarding suspected violations by providers and facilities. The HHS system will also accept complaints related to suspected violations by health plans.  It will coordinate with complaints systems operated by US DOL for group health plans and by OPM for the federal employee health plan and with state insurance regulators. Federal agencies are contemplating requirements to include contact information for the national Help Desk on other key documents, such as health plan EOBs, provider bills, or consent waiver forms.

The interim final regulations say HHS will respond to filed complaints within 12 weeks (60 business days), though agency staff have indicated that consumers will receive real-time confirmation when a complaint is filed.  Agency staff also indicate plans to conduct preliminary review of complaints within 3 to 5 days of receipt to determine any additional information that may be needed to process the complaint. Once processed, HHS will refer the consumer to another Federal or State regulatory agency to investigate or, if applicable, inform the complainant of action HHS has taken to resolve the problem or refer the matter for enforcement. It is still to be determined whether HHS will track the outcome of complaints it refers to other agencies, or whether or how HHS will use the complaint system to track compliance by plans and providers or enforcement activities of states. HHS estimates the system will receive 3,600 provider-related complaints annually; it will cost an estimated $16 million to build the online complaints system and ongoing operating costs of $10 million annually.

Consumers can contact their state Consumer Assistance Program (CAP) – The Affordable Care Act (ACA) provided for the establishment of state ombudsman programs or CAPs to educate privately insured consumers about their health coverage and rights and to help consumers resolve problems with health plans, including filing appeals. Forty CAPs were established in 2010, though no federal CAP funding has since been appropriated. Most remain in operation today, at least at reduced levels, and help patients with medical bill problems, including surprise medical bills.  Other legislation pending in Congress – the Build Back Better Act and the FY 2022 Labor-HHS appropriations bill – together could provide $75 million in new funding for CAPs in 2022, enabling states to establish new or expand existing programs. In addition to helping individual consumers resolve problems, CAPs are required to report to HHS on the kinds of problems consumers encounter. This data can inform oversight, as well as policy changes that can prevent problems from happening again.  CMS staff indicate that the national surprise medical bill complaints system will also be able to refer complainants to the CAP in their state for local assistance.10

How will payments for surprise bills be determined?

The amount paid for surprise out-of-network surprise bills will likely end up close to the median rate that plans pay in-network providers in a geographic area, also known as the qualifying payment amount, or QPA.11  Under the law, the patient’s cost sharing for a surprise medical bill must be based on the QPA.  Health plans and providers can negotiate privately over the amount to be paid for the surprise bill, and if they can’t agree, either party can ask for an Independent Dispute Resolution (IDR) process to decide the payment amount. However, there are strong incentives for both plans and providers to either rely on the QPA or on private negotiations.

The federal IDR process will be conducted by certified entities chosen by HHS and will resemble so-called baseball-style arbitration.12,13 The plan and provider will each submit their best offer for the out-of-network payment amount for a claim.  The IDR entity begins with the presumption that the QPA is the correct amount but can consider other factors, including patient acuity, the level of training and expertise of the treating provider, the market shares of both parties, and past good faith efforts of both parties to reach a network agreement. The IDR entity then chooses the offer it determines to be most appropriate, which becomes the out-of-network payment for that bill. The IDR will charge a fee for each arbitration and the losing party must pay that fee. (IDR fees can range from $200 to $500 for a single case, and $268 to $670 for multiple or “batch” determinations.)14

In light of this process and incentives, HHS estimates the IDR process will be invoked for just over 17,300 surprise medical bill claims per year, and for another roughly 4,900 surprise air ambulance bills per year. The Congressional Budget Office also estimates this process will tend to have a dampening effect on the cost of surprise bills; CBO estimates the NSA will reduce private health plan premiums by 0.5% to 1% on average, and reduce the federal deficit by $17 billion over 10 years.  Studies have found that surprise medical bills otherwise increase overall health insurance costs because the ability to balance bill gives certain providers and facilities leverage to negotiate much higher prices with insurers. To the extent that NSA moderates that dynamic, it can reduce health plan costs overall in addition to reducing out-of-pocket costs for individual patients.

Organizations representing providers and air ambulance companies have objected, however, and filed lawsuits urging that regulations should not have created a ‘rebuttable presumption’ in favor of the QPA. It remains to be seen if these actions may result in delayed implementation of the NSA or in changes to regulatory standards and procedures that could result in greater use of the IDR process or the determination of higher out-of-network payments.

The regulations also require detailed monthly reporting to HHS by IDR entities on the cases they receive. Data required to be sent to HHS includes specific information on the parties involved in each arbitration – including their names, market share, and other characteristic – and on the services involved – including the dollar amounts offered by each party, also expressed as a percentage of the QPA. HHS will compile data into quarterly reports that will be publicly available. These reports could provide an additional degree of transparency around surprise medical bills and the characteristics of plans and providers involved in surprise billing disputes.


The No Surprises Act creates important new federal protections against surprise medical bills – a leading cause of affordability concerns for consumers. That this law passed with strong bipartisan support is an indication of the need for these protections. That federal agencies moved swiftly to implement the new law signals intent to make it work as effectively as possible.

The law is highly complex, however, setting coverage and billing standards for a specific subset of private insurance claims that could number 10 million annually. Providers are permitted to ask consumers to waive their NSA protections in some cases. Oversight and enforcement will be conducted by an array of federal and state agencies, some of which are still to be determined, and more than one of which could be involved in any given case of noncompliance.

Monitoring of the law’s impact, as well as compliance, will be accomplished in various ways.  Data reporting by IDR entities will provide some information about prices for surprise bills and the characteristics of plans and providers using the IDR process. Annual health plan audits conducted by federal agencies can also yield information about prices charged and paid for surprise bills. Other targeted audits and investigations can yield information about compliance generally, as can new federal consumer complaints systems. State systems may also yield important data as to how the law is working, such as state complaints systems and analysis of data from all-payer-claims databases. It remains to be seen how these new systems will work, independently and in coordination.

To a large extent, oversight and enforcement will rely on complaints. In order to complain, though, consumers will need to understand that they should not be overbilled for emergency services or for non-emergency out-of-network services while they are in in-network hospitals and facilities.  How public education will be conducted, and how public understanding of new rights will be monitored is yet to be determined. The responsiveness of new complaints systems and how they coordinate will also be important to watch.

Finally, it remains to be seen if any other tools will be employed to monitor trends in the incidence of surprise medical bills, and how effectively the law may work to protect consumers from surprise bills and reduce their out-of-pocket costs. For example, might the federal government exercise its broad authority under the ACA to require transparency data reporting by private health plans? This authority could be used to monitor the incidence of surprise medical bills over time, as well as differences between the QPA and billed or paid out-of-network charges; it could also be used to monitor how frequently providers use consent waivers. Or, will state consumer assistance programs be employed to play a role in educating the public, reporting to regulators on problems that arise and how they might be prevented in the future?

As implementation proceeds (and as federal courts consider legal challenges to the regulations) it is also possible that NSA standards and procedures will be modified further

KEEPING THE CONSUMER SAFE; Segment 11: To Boost or Not Boost and Omicron

Healthcare Consumer Navigator Center is a Healthcare Consumer Advocate Organization that helps consumer navigate the healthcare maze. The following Series “KEEPING THE CONSUMER SAFE; LIVING WITH COVID”.  Our goal is to provide a commonsense approach to living with covid with general healthcare information.

So here are a couple of updates. Yesterday, I received my Moderna booster shot. Supposedly, I’m now in very exclusive company as a vaccinated, breakthrough and now a boosted case. While this sounds pretty good, I asked the person giving me the shot where I could find data on what my immunity level would be and they didn’t know. So off to find some research I went.


I continue to find quotes from Anthony Fauci, the Chief Medical Advisor to the President, referring to our need to follow the science. In one exchange I saw Fauci claimed “to question

him was to question science.” I’ve been on the CDC website, the WHO website, numerous medical research websites looking for simple interpretations about immunity, breakthrough cases and what’s the profile of who is being admitted to hospitals with COVID now. As I’m continually finding mixed information. One article indicated currently unvaccinated, middle-age people were more common to be admitted to hospitals. Another article indicated in Texas, fewer people over 70 were being admitted to hospitals in recent surveys.


I’m still researching getting an Antibody Test. LabCorp is one organization offering the test. QuestDirect is another organization offering the test. According to several other articles there are supposedly dozens of immunity tests on the market. However, the Food and Drug Administration “does not currently recommend antibody tests to assess immunity.” So my questions are “why can’t we figure out a way to measure immunity, doesn’t immunity ultimate determine when we can return to normal and who’s working on these type of questions?” Being a little cynical, I fully understand the economic motivation that accelerated Operation Warp Speed. What motivation exists for gaining a more thorough understanding of the day to day nuances of COVID?


I recognize I’m unskilled in the field I’m inquiring about but as we now are dealing with the Omicron variant and before this it was the Delta Plus mutation, shouldn’t there be a longer range game plan being developed? Our strategies are starting to feel very episodic to me. Wear a mask, avoid groups of people etc it’s starting to feel like a merry-go-round.


I Googled how many people had a breakthrough case of COVID-19 in the US. Here’s what I found. In May, the CDC stopped tracking all reported breakthrough cases not resulting in death or hospitalization. (Now this is truly ironic if you recall my last article indicating we’re not doing autopsies on C      OVID deaths). In addition, there isn’t a government data survey measuring the likelihood vaccinated people would get a test. Well, isn’t that just peachy. I live in a metropolitan area that in 2014 experienced Ebola. When I compare the hysteria of that time to our current environment it seems like we’re monitoring COVID like the common flu.


If it’s not the CDC, who is doing the data gathering on COVID? As a person that seemingly has experienced all of the precautions currently available, what benefits does that afford me? For example, I have a TSA account that let’s me avoid the more intense security checks at airports. Doesn’t it make sense if a person has the triple option of vaccination, having COVID and the Booster there would be some perks available? It seems as I read about the various incentives to encourage people to become vaccinated there are more “sticks” than “carrots.” It’s becoming more and more obvious COVID is going to become just a part of our way of life. So it seems there should start being a concerted effort to make living with it as tolerable as possible.


Writer’s Note: In researching COVID for my own personal use, I found there is an enormous volume of information on the topic. It’s not possible to review all the different sources. Unfortunately, I’ve also discovered differing opinions exist on some of the more significant aspects of the virus. I’ve attempted to seek different viewpoints on the topics I’m covering, but fully understand I’ve not found them all. I can’t emphasize enough if you have underlying health issues such as obesity, diabetes, cardiac disease, chronic liver disease, lung diseases and cancer extra precautions are imperative.


Next up will be new warnings related to Boosters.

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