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In another example of financial incentives attracting fraud, Kaiser Health News reported on agents and brokers who have signed up clients for the insurance marketplace without the clients' knowledge or consent. Agents and brokers have their places, especially when consumers are dealing with complex insurance topics. Commissions to agents and brokers are mainstream, and perhaps all the more expected when the government is trying to increase adoption. At the same time, it is probably not surprising that some unscrupulous agents and brokers have tried to take advantage of the situation.

In another example of financial incentives attracting fraud, Kaiser Health News reported on agents and brokers who have signed up clients for the insurance marketplace without the clients' knowledge or consent. Agents and brokers have their places, especially when consumers are dealing with complex insurance topics. Commissions to agents and brokers are mainstream, and perhaps all the more expected when the government is trying to increase adoption. At the same time, it is probably not surprising that some unscrupulous agents and brokers have tried to take advantage of the situation.

Enrollment in the healthcare insurance exchanges is a special case in that people whose income falls below a certain threshold do not need to pay the insurance premiums (the government will pay it as part of the Affordable Care Act). In contrast, other types of insurance are not as generously subsidized, meaning that it is much less likely for this particular fraud to be perpetrated in those other industries, since insurance companies know much sooner when the premiums are not being paid. The article reports that the department of Health and Human Services is rolling out changes to their process, presumably in an effort to curb the potential for this type of fraud.

Kaiser Health News reported on more than 1,000 clinics filing a lawsuit against the state of California regarding a new plan called Medi-Cal Rx. The premise behind the plan is that by centralizing drug purchases, the state will be able to negotiate meaningful cost savings. Clinics are unhappy about this program because they typically receive a markup on the drugs that they buy for their patients, and by having the state provide the drugs, clinics will no longer receive the profit on each drug dose. The program does earmark $105 million for the clinics, but apparently, that amount does not offset the profit that the clinics originally received.

Kaiser Health News reported on more than 1,000 clinics filing a lawsuit against the state of California regarding a new plan called Medi-Cal Rx. The premise behind the plan is that by centralizing drug purchases, the state will be able to negotiate meaningful cost savings. Clinics are unhappy about this program because they typically receive a markup on the drugs that they buy for their patients, and by having the state provide the drugs, clinics will no longer receive the profit on each drug dose. The program does earmark $105 million for the clinics, but apparently, that amount does not offset the profit that the clinics originally received.

It seems that the state might have been trying to profit both ways: save on prescription drug costs, and save on healthcare services. Given that Medicaid patients already frequently have difficulty finding providers that accept Medi-Cal insurance, perhaps the state should have shared the savings with clinics. Even if doing so might not have been necessary to secure the clinics' participation, it might have bolstered their finances and increased access.

Kaiser Health News published a frustrating story about one woman's difficulties in having her provider correctly bill insurance companies. The gist is that the woman gave birth before the end of the year, but her son needed services after the start of the new year. At the same time, the woman's health insurance company changed at the start of the new year. The health system billed both insurance companies for the full amount, and both insurance companies rejected the bill, because the bill contained one date that was outside of covered time period. Eventually, the health system broke apart the bill into two: one for services rendered in the previous year, and one for services rendered in the new year. The resolution took ten months, meanwhile saddling the woman with a bill for about half a million dollars.

Kaiser Health News published a frustrating story about one woman's difficulties in having her provider correctly bill insurance companies. The gist is that the woman gave birth before the end of the year, but her son needed services after the start of the new year. At the same time, the woman's health insurance company changed at the start of the new year. The health system billed both insurance companies for the full amount, and both insurance companies rejected the bill, because the bill contained one date that was outside of covered time period. Eventually, the health system broke apart the bill into two: one for services rendered in the previous year, and one for services rendered in the new year. The resolution took ten months, meanwhile saddling the woman with a bill for about half a million dollars.

The situation seems less common (services rendered to a patient across year boundaries when the patient changes insurance companies), but it seems that a large health system would encounter these circumstances periodically. However, the health system's billing software was not well-equipped to bill correctly these types of cases correctly. More frustrating is that even after the health system indicated that the problem would be fixed in March of the new year, it was not actually fixed until October, when a Kaiser Health News reporter contacted the health system. The inability or apathy towards correcting the bill seems to be extremely poor customer service, and if the bill were sent to collections, could have had very disruptive effects on the family. Ironically, the health system probably would have done better financially by getting the bill correct early on, but even self-interest seems to be insufficient in this case. Regardless, it seems unfair that the patient would have so little recourse in this case if a reporter did not get involved.

2021 has come and gone with its share of challenges and triumphs. Hoping for an even better 2022...

2021 has come and gone with its share of challenges and triumphs. Hoping for an even better 2022...

Happy new year!

Hope you have a merry Christmas!

It feels like a lot has happened this year and there's a lot for us to be grateful for.

Hope you have a merry Christmas!