Wednesday, October 26, 2011

condition Care Reform and Coordination of Benefits

The current discussion of expanding health care options through federal legislation deals primarily with big issues - like how to pay for the new coverage and how proposed reforms would change the current healing care system. One of the smaller questions not showing up on many radar screens is how health care reform would impact coordination of benefits issues.

The current formula of paying for health care in the U.S. Is comprised of many different healing coverage "silos". Any given individual- depending on the nature of the disease or injury and how it arose- may be entitled to have healing medicine paid for by any one of many different plans that contribute for cost of healing expenses: group health, workers' compensation, automobile no-fault, homeowner's, liability and a government-sponsored plan like Medicare or Medicaid.

Health Care Reforms

When Uncle Larry was hurt in a motor vehicle collision while making a delivery for his employer, the hospital that treated his broken arm could have conceivably billed Larry or Larry's employers' workers' recompense assurance carrier or Larry's group health insurer or Larry's auto no-fault assurance carrier or Medicare. Traditionally, those possible payers have operated within detach silos, with minute or no sharing of data in the middle of them about who had coverage for Larry and about the circumstances of Larry's arm getting broken. Any one of those health coverage plans could have ended up being billed for and paying the hospital charges.

condition Care Reform and Coordination of Benefits

Under the existing Medicare Secondary Payer statute Medicare is not obligated to pay Larry's hospital bill and would only be responsible for cost if none of the other coverages was in force. Any workers' compensation, liability, no fault and group health plan or course in result for Larry must pay before Medicare is obligated to pay.

Currently, systems are in place for Medicare to witness what other health care coverages are in result for its beneficiaries, to find out what payments other health coverages have made on behalf of its beneficiaries and to recover reimbursement for Medicare payments made when a customary coverage is in effect. The Centers for Medicare and Medicaid Services, the federal agency tasked with administering the Medicare program, has a rather robust principles in place for enforcing the secondary payer rules and minimizing the amount of cases in which Medicare pays for medicine that other payer is obligated to pay.

Medicaid, on the other hand, is administered by state agencies. Due in part to very low-income-eligibility standards, the typical Medicaid beneficiary would not have other, hidden healing cost coverages in force. Accordingly, there is no single, sufficient process in place to coordinate benefits in the middle of Medicaid and any other healing medicine payers ready to a Medicaid beneficiary.

The health care reform proposals now being debated in Congress would -in very basic terms- strengthen health care coverage in four ways:

o increasing the amount of population who qualify for Medicare (e.g. Dropping eligibility age from 65 to 55)
o increasing the amount of population who would qualify for Medicaid (e.g. expanding maximum income levels to 150% of the federal poverty level)
o easing qualification requirements for existing hidden assurance policies, and
o creating a new publicly-administered health assurance plan.

Clearly, enactment of legislation expanding the amount of population covered by health assurance will growth the incidence of overlapping or duplicative coverage. That will growth opportunities for cost of healing expenses by the wrong payer. That will growth the need for sufficient data sharing among the payer silos and obligation of cost priorities.

One aspect of the health care reform movement that will be particularly helpful in the coordination of benefits is expansion of electronic data change in the middle of the health care payers. If the hospital that treated Uncle Larry's broken arm was able to put Larry's group safety amount and a few other key data elements into a web-based database accessed and fed by all possible health price payers, it could be a pretty uncomplicated process to conclude who the bill should be sent to, avoid cost by the wrong payer and find opportunities for reimbursement when cost is made by the wrong party.

Federal law (42 Usc 1320d-2) already requires Cms to develop a principles for electronic data change of health data for the purpose of enhancing the performance and reducing the costs of the health care system. The principle health care reform bill pending in Congress - H.R. 3200- covers over 1,000 pages of text. One sentence of that bill deals with coordination of benefits:

"Not later than 1 year after the date of the enactment of this Act, the Secretary of health and Human Services shall promulgate a final rule to develop a acceptable for health claims attachment transaction described in section 1173(a)(2)(B) of the group safety Act (42 U.S.C. 1320d-2(a)(2)(B)) and coordination of benefits."


Get everyone on the same (web) page, and make sure that includes Medicaid (since expanding eligibility for Medicaid will growth opportunities for duplicative coverage and need for coordination.)

condition Care Reform and Coordination of Benefits

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