Category Archives: Healthcare Insurance

5 Questions about the American Healthcare System

Healthcare reform is a contentious issue in American politics.  While a few presidents—Lyndon Johnson, Bill Clinton, and Barack Obama—have signed laws that changed the American healthcare landscape, the system is still imperfect.  With the new Trump administration, the future of healthcare policy remains unclear.  Some of the changes (i.e. Medicare and the Affordable Care Act) may be in jeopardy.Picture-1000words(442x400)

Below are answers to some important questions about the American healthcare system.  In order to play a part in the continuing conversation about healthcare reform, it’s important to understand the current status of the American healthcare system.

Question: What makes the American healthcare system different than other healthcare systems?
Answer: The American healthcare systems offers a lot of choice for potential insurance coverage, private plans, and public plans including Medicare, Medicaid, Veterans benefits, and the Children’s Health Insurance Program.  Despite all of those choices, America is the only wealthy country without universal coverage.   Additionally, the American healthcare system has higher usage of expensive medical technologies—like MRI machines.

Question: Where does the American healthcare system rank on the list of world healthcare systems?
Answer: The World Health Organization’s 2000 report ranks the American healthcare system as 37th in the world—behind every other wealthy country.

Question: How much does the United States spend on healthcare every year?
Answer: In 2013, the United States spent approximately $9,000 per resident (or 17.1% of the gross domestic product) on healthcare costs.  France spent the second highest amount of money on healthcare, approximately $4,300 per resident and 11.6% of its GDP.  With the lowest healthcare spending levels, the United Kingdom spent 8.8% of its GDP or approximately $3,300 per resident.

Question:  Doesn’t higher spending means that Americans get better healthcare?
Answer:  Not necessarily.  The American healthcare systems provides quality care that is similar to the care provided by other wealthy countries.

Question: If the care is comparable, what are the higher costs for?
Answer:  There isn’t one answer to this question.  There are a range of contributing factors including: widespread use of expensive medical technology, the fee for service model, and higher volumes of patients.

Healthcare policy continues to be a contentious issue in American politics.  Citizens, experts, and politicians have spent decades debating what changes will reform the system.  Yet this is not simply an issue for the politicians.  Stay informed about the discussion surrounding healthcare reform.  These changes will eventually impact the lives (and futures) of many Americans.

Baribault, Maryann and Casey Cloyd. Health Care Systems: Three International Comparisons. EDGE: Ethics of Development in a Global Environment, 26 July 1999, Accessed January 22, 2017.
Comparing International Health Care Systems. PBS News Hour, 26 October 2009, Accessed January 22, 2017.
Murray, Christoper J.L., D Phil, and Julio Frank. Ranking 37th—Measuring the Performance of the U.S, Health Care System. The New England Journal of Medicine, 14 January 2010, Accessed January 22, 2017.
The U.S. Health Care System: An International Perspective. Fact Sheet 2016. DPE. Department for Professional Employees. AFL-CIO,, Accessed January 22, 2017.
U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries.  The Commonwealth Fund, Accessed January 22, 2017.
World Health Organization’s Ranking of the World’s Health Systems. The Patient Factor: Your Voice in the Health Care Equation, Accessed January 22, 2017.

How To Quickly Capture Health Insurance Changes

Jobs change; marriages happen; children are born; open enrollment starts. Throughout the year, a patient’s health insurance coverage can change via these four options or many more. Although most organizations focus on updating insurance information each January, it’s important to do it year round. Capturing accurate insurance information ensures smooth clinical operations and medical billing. Use these five resources to prioritize catching health insurance changes as they happen.

Image by Wellness Corporate Solutions ( line staff: Staff the front desk with smart, well-trained healthcare administrative employees.  Since they frequently talk with patients, these staff members play a vital role in capturing a patient’s insurance. Instruct these staff to ask the patient to confirm their insurance when scheduling appointments and at check-in.  Train these staff members on how to properly update a patient’s insurance, either in the patient’s file or in the electronic medical record.  Also teach these staff members how to use resources to

The patient: Most patients come to the doctor’s office prepared.  They should be able to tell you which insurance they have, and what their identification numbers are.  If they are unable to provide proof of active insurance (i.e. a health insurance card), front line staff should be aware of the preferred course of action.  For example, some organizations will allow the patient to check in with the promise that the patient will update it later.  Other organizations will instruct staff not to check in the patient without proof of insurance.

The patient’s insurance card: Although they like to change things all of the time, there is one thing that healthcare organizations can count on.  And that is the fact that a patient’s health insurance card will be a treasure trove of information.  Typically, this is where you can find information about a patient’s member and group identification numbers as well as the billing address to send the bills to the insurance company for processing.

An updated list of health insurance changes:  Create a list (or another tool) that captures the insurances that an organization is contracted with and the ones that the organization is not contracted with. This tool should be available to all staff members who update or work with a patient’s insurance.  Since changes frequently happen, regular updates to this tool are required.

Access to an eligibility portal: Investigate if there are online eligibility portals that staff can use to confirm eligibility or referral authorization.  These are time saving tools, because it minimizes the number of times that staff have to call a patient’s insurance.

Regardless of size, it is important for all organizations to quickly capture any insurance changes for a patient.  After reading the list, take a moment to consider what is working well and what could be better.  Adjust as needed.

How to Understand 3 Types of Health Insurance Changes

Open enrollment, contract negotiations, and documentation changes impact a patient’s health insurance.  Sometimes the changes are big; sometimes they’re small.  Since healthcare organizations see hundreds or thousands of patients, it’s important that to understand and prepare for each type of change on a large scale.

Open Enrollment:  During open enrollment, patients can change their insurance plans or coverage levels through an employer sponsored plan or through a health insurance exchange.  Employers may also announce that they’ve changed the company that provides benefits to their employees.  In this scenario, the patient is aware of the voluntary or involuntary change.

Contract Negotiations: Annually, many healthcare organizations may renegotiate contracts with insurance companies for the following year. These discussions frequently relate to changes in reimbursement rates and patient coverage levels. Proactive patients will often be aware of the upcoming changes, but other insurance plan members may not be aware of the changes.  When organizations and insurance companies terminate their contracts, it’s important to identify all affected patients as soon as possible.  Although this is rare, it may mean that the patient needs to transfer their care elsewhere in order for the insurance company to pay for it.

Minor Documentation Changes: Although the biggest changes happen early in the year, insurance companies regularly make changes.  These minor changes often impact a slim percentage of patients in a particular situation.  With these month-to-month changes, the insurance companies are typically requesting more or different documentation from healthcare offices before the company will authorize a particular aspect of the patient’s care.

Responding to these Insurance Changes

Front line staff can capture most insurance updates by asking the patient about their insurance information.  Anyone who schedules or checks in patients should routinely confirm the patient’s insurance coverage with every visit.  If possible, staff should also copy the insurance card to store in the electronic medical record or in the patient’s file. Generally, staff should copy a patient’s insurance card at least once per year or more frequently if it changes.  A few organizations copy the insurance card at every visit.  Since patients won’t be aware of contractual or documentation changes, offices should have a resource to track monthly and annual insurance changes. This system should be easy for front line staff to use in real time. Also, it should be detailed enough for billing or pre-authorization staff to use as a resource. Larger organizations may choose to go with a searchable web resource while smaller offices may choose to create a simple list.  Organizations will tailor the resource to fit their institutional needs.

4 Important Provisions of the Affordable Care Act

The 2010 passage of the Affordable Care Act changed the landscape of American healthcare. On a large scale, it addressed longstanding systemic concerns while also attempting to bring down costs.  Nearly everyone has an opinion on the bill, yet few people really understand some of the significant changes that it ushered in.  Since 2010, much of the media coverage of the bill and the associated outcry has been reduced to 140 character summaries and soundbites.  Before forming an opinion, take time to learn about some of the things the bill did.

Young Adult Coverage: Before the Affordable Care Act, health insurance companies could remove enrolled children when they turned 19.  Some insurance plans allowed for enrolled children to stay on the insurance plan while they were enrolled as a full time student.  Under the Affordable Care Act, children can remain on a parent’s insurance plan until they turn 26.

Pre-existing Conditions: Prior to the Affordable Care Act, health insurers could deny (or charge more for) coverage because of a pre-existing condition.  Often this meant that people with chronic health conditions, like cancer, had significant trouble getting new health insurance coverage.  Some insurers even classified pregnancy as a pre-existing medical condition and would refuse to pay for related care.  Under the Affordable Care Act, health insurers can no longer charge more for or deny coverage for pre-existing health conditions.

Annual and Lifetime Limits: Health insurance plans used to be able to set annual and lifetime limits for coverage as long as someone was enrolled in the plan.  If a participant exceeded the limit, they would be responsible for all charges.  Under the Affordable Care Act, health insurance plans can no longer place limits on medically necessary care.  Limits on “non-essential” health benefits are still allowed.

Plain Language Benefits Information: Details about health insurance plans used to be hidden behind small fonts and legal language.  For many people, it was tough to understand and even tougher to compare plans side-by-side. The Affordable Care Act requires that health insurers provide participants with an easy-to-understand summary.  This mandatory standardization now allows people to easily compare the benefits and costs of medical plans.

Without realizing it, all Americans already know someone who has benefited from these four changes made by the Affordable Care Act.  Teenagers can now keep health insurance until age 26.  People with chronic conditions no longer fear being denied health insurance—or the associated extra costs of medically necessary treatment that isn’t covered.  Annual and lifetime limits are gone.  Insurances now explain their benefits and costs in an easily understandable format.  The Affordable Care Act has changed the American healthcare system in ways that have already benefited all Americans, regardless of political opinion.

U.S. Department of Health and Human Services. “Lifetime & Annual Limits.” December 5, 2014. (
U.S. Department of Health and Human Services. “Plain Language Benefits Information.” September 8, 2014. (
U.S. Department of Health and Human Services. “Pre-Existing Conditions.” November 18, 2014. (
U.S. Department of Health and Human Services. “Young Adult Coverage.” March 12, 2013 (

8 Common Questions about Medicare

Medicare is another popular health coverage provider.  As most Americans already know, Medicare is a federal program that provides insurance coverage to adults ages 65 and older.  There’s so much more to the program than can be summarized in one sentence.   The article below answers some common questions that people have about Medicare.

  1. What is it? Medicare is a federal insurance program that covers adults ages 65 and older, people with certain disabilities, and people with End-Stage Renal Disease.
  2. When did it start? After its 1965 passage, Medicare began on July 1, 1966.  On that date, all adults ages 65 and older were automatically covered under Medicare Part A.   The voluntary Medicare Part B program started at the same time.
  3. Why are there so many letters? In the past 50 years, Medicare has morphed into a four part program.  The letters represent the different parts of the program.
  4. Medicare Part A: Offered since 1966, Medicare Part A provides insurance that covers medically necessary hospital visits and skilled nursing home stays.
  5. Medicare Part B: Also offered since 1966, Medicare Part B provides health insurance that covers medically necessary doctor’s visits and many other services.  Enrollees pay a monthly premium for this coverage.
  6. Medicare Part C (a.k.a. Medicare+Choice, or Medicare Advantage): These plans began after the passing of the Tax Equity and Fiscal Responsibility Act of 1982.  The plans were created as a partnership between private insurance companies and the federal government.  Enrollees in these plans pay their premiums to private insurance companies who contract with the federal government to provide Medicare coverage.
  7. Medicare Part D: Part D began with Medicare Prescription Drug, Improvement, and Modernization Act of 2003.  Effective in 2006, it provides prescription drug coverage to those enrolled in Medicare.   Participants can get prescription drug coverage by signing up for a Prescription Drug Plan as an add-on to original Medicare.  Some participants may choose to get prescription drug coverage through their Medicare Advantage Plan.
  8. How many people use it? As of 2015, over 55.5 million Americans are enrolled in Medicare which is almost equal to the 2013 population of the Northeastern states.  (In 2013, approximately 55.9 million people lived in Massachusetts, Connecticut, New Hampshire, Maine Rhode Island, Vermont, New York, Pennsylvania, and New Jersey.

In its 50 years of existence, Medicare has provided medically necessary health insurance coverage to adults ages 65 and older and certain populations with disabilities.  With the addition of Parts C & D, Medicare has expanded its reach to assist eligible participants to provide more health coverage.  As a federally run program, Medicare is susceptible to political will.  It will be interesting to see where the program is after the next 50 years.

Kaiser Family Foundation. “Medicare Beneficiaries.” (
Kaiser Family Foundation. “Medicare Timeline.” March 24, 2015. ( “How to get Prescription Drug Coverage.” ( “Medicare Advantage Plans.” ( “What’s Medicare?” ( “What Medicare Covers.” ( “What Does Medicare Cover?” 2016. (
McGuire, T.G., Newhouse, J,  & Sinaiko, A. “An Economic History of Medicare Part C.” US National Library of Medicine. National Institutes of Health. June 2011. (
Wikipedia. “List of states and territories by population.” July 6, 2016. (


Talking to Health Insurance Companies

Image by Wellness Corporate Solutions ( of your role, health insurance is an unavoidable part of working in healthcare. Schedulers ask for insurance information when a patient makes an appointment. Front desk staff ask for insurance cards at check in. Nurses use it for medication pre-authorizations. Doctors write appeal letters to convince an insurance organization that something is medically necessary. In clinical settings, all staff are guaranteed to encounter health insurance questions, concerns, or issues frequently.
Some ways that clinics structure themselves to be able to handle the barrage of insurance related questions are listed below.


  • Have an Expert: Many clinics have one staff member who designated as the insurance expert. Larger healthcare organizations may have a centralized department that is responsible for getting authorizations. Since health insurance is a complex and perpetually changing, it benefits organizations to designate a staff member or a department to serve as experts. This allows the people in those roles to gain a deep knowledge in insurance, rather than a broad knowledge in all areas of clinic operations.
  • Be Prepared: When calling an insurance company, know what to request. Most insurance companies will need to know the full name of the requested service along with any associated CPT codes. Be prepared to offer the full name of the provider making that request and the provider’s NPI number. This information is normally required before an insurance company will be able to authorize a visit.
  • Take Notes: When talking with an insurance company agent, write down their name, the time and date of the conversation, and a summary of the discussion. It’s important to have notes particularly if there’s a question about the insurance authorization later.
  • Appeal: If an insurance denies an authorization request, there may be options for the patient to appeal the decision. Specific information varies depending on the plan.
  • Take Responsibility: Encourage patients to directly contact their insurance to confirm that services will be covered. Staff at most clinics will do their best to find out what an insurance plan covers. Due to the complexities of insurance and high volumes of patients, this may not be possible in every scenario.

Regardless of job position, all healthcare staff will be presented with insurance questions, issues, and challenges. It’s important for staff to be aware of this, and prepared to assist. Each organization had different policies, but all of them face similar challenges due to the complexities of health insurance. These are simply some tips to make contacting health insurances easier.


Health Insurance 101: Introduction to Healthcare Insurance

By Emily Manahan

It’s important for all people who work in healthcare to be familiar with the different types of health insurance.  Even if your position doesn’t routinely deal with it, all staff—particularly those in clinical settings—will encounter health care questions, concerns, and challenges.  To build your knowledge, use this list of common health insurance categories.

Types of Insurance Plans

Health Maintenance Organization (HMO)  Patients with these types of insurance plans have to see their primary care doctor to get a referral.  Unlike their PPO counterparts, these people would not be able to go straight to see a specialist.  Instead, they would have to be examined by their PCP first.  Then they could be referred, if deemed appropriate.

Medicare is a federal insurance program that covers people 65 years and older.  It also covers people with specific disabilities.

Medicaid offers insurance to people who meet certain income requirements.  Medicaid programs are jointly operated by the state and federal governments.

Motor Vehicle Claims are selected as insurances for patients who have been injured in a motor vehicle accident.  Typically the clinic will require written or verbal confirmation that the particular claim is still open and billable.

Preferred Provider Organizations (PPO).  Patients with these type of plans usually have more flexibility.   Unless required by a particular office, this patient can typically go to any provider in their preferred insurance network without a referral.

Self pay patients pay the entire cost of their medical care out of pocket.

Veterans Administration and Tricare are health insurance plans offered to active and retired military and their families.  If a patient is seeking care outside of the VA system, their health insurance plan will often require a written authorization.  Different requirements vary.

Worker’s Compensation comes in a variety of forms including private, state, or federal claims.  These plans cover patients who had a job related injury or accident.
Within these eight categories of health insurance, there are many different plans.  Each individual plan has different requirements.  If patients have specific questions about their type of health insurance, please encourage them to call their company directly.

Blue Cross. Blue Shield. Blue Care Network of Michigan “What’s the Difference between HMO, PPO, and EPO Plans? “Medicaid
Social Security Administration. “Medicare” October 2015
US Department of Veterans Affairs. “I am an Active Duty Servicemember.”  November 10, 2014. (

An Introduction to the Health Insurance Portability and Accountability Act

HIPAA – The Basics

Most people are already aware of HIPAA because of the annual privacy consent forms. HIPAA changed more than privacy consent forms. In the twenty years since it was signed, the Healthcare Health Insurance Portability and Accountability Act has changed how healthcare organizations operate. Here’s what you need to know.

Was It Always Called HIPAA?
No. The bill was originally named the Kennedy-Kassebaum bill after its two authors, Senator Edward Kennedy of Massachussets and Senator Nancy Kassebaum of Kansas. It is now known as the Healthcare Insurance Portability and Accountability Act, or HIPAA for short.

When Was It Passed?
President Bill Clinton signed this bill in 1996. Major provisions of the bill were implemented between 1999 and 2006.

Why Was It Written?
In the mid-1990s, it became clear that the healthcare industry needed to modernize and standardize how they kept records. The authors also included provisions to make it easier for employees to keep health insurance after leaving a job. The original intent of the bill was to address these concerns.

What Did People Think?
Three years earlier, a comprehensive healthcare reform bill failed.
When this bill passed, opinions were split. Although it wasn’t exactly what they wanted, proponents felt that this bill was still a win. Opponents were skeptical of the need for the bill. Many felt like it set new standards for the healthcare industry that were too high.

How Many Components Are There?
There were four sets of rules included in the original HIPAA regulations: The Privacy Rule; The Transaction and Code Sets Rule; The Security Rule and The National Provider Identifier, or Unique Identifiers, Rule; and the Enforcement Rule.

What Did That Mean For Healthcare Organizations?
Here are some of the major structural changes that healthcare organizations had to make to comply with HIPAA. Please note that this simply an overview and not a complete list.
An organization must have a trained HIPAA Compliance Officer who is aware of all regulations and ensures that the company is following all HIPAA requirements.
Organizations must teach and train employees about HIPAA and the pertinent policies. Usually, organizations make an annual commitment to training their staff.
Organizations must safeguard patient health information against unauthorized access and disclosure. If there is a security breach, organizations are required to report the incident and inform the patients who may have been affected.

The Healthcare Insurance Portability and Accountability Act of 1996 massively changed the healthcare industry and will always be remembered as a turning point. It will be exciting to see what changes the future has in store for healthcare.

• Department of Health and Human Services. Centers for Medicare and Medicaid Services, “HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules.” May 2015 (
• Indian Health Service: The Federal Health Program for American Indians and Alaskan Natives, “Healthcare Insurance Portability and Accountability Act.” (
• Paul Starr, “The Signing of the Kennedy-Kassebaum Bill,” August 22, 1996 (
•, “Congressional Concealer. Rumor: HIPAA Laws started because a senator wanted to cover up his wife’s plastic surgery.’” April 3, 2015. (
• “History and Background of HIPAA.” (

Replace ObamaCare With BernieCare?


Bernie Sanders makes a strong case that healthcare should be a right.

Eliminating health insurance companies sounds good to me. The expense for our Obamacare ‘affordable healthcare’ insurance plan for my small company with older employees was very high, and that was WITH a $7,000 per year per person deductible – aka, a ‘catastrophic’ plan. Can’t live with it. Can’t live without it.

We all know people who are working for their insurance. Or looking for a job that provides insurance. Imagine the freedom to choose a cup-filling job, or simply leave a lousy employer, rather than staying based on your insurance.

So what would that mean to our hospitals and clinics? Many (most?) are already using Medicare rates as the plumb line for managing their expenses. Many private providers refuse to process insurance forms, offering discounted fees in their place. Can you imagine the impact eliminating insurance processing?! That alone could make #BernieCare a net gain for hospitals.   

As for all the laid-off employees? Let’s offer training for a career in healthcare! I hear it’s a growing field with a decreasing supply and increasing demand.   

What do you think? If Obamacare is the Galactic Empire, is BernieCare the Resistance, or the First Order?


ACA: 2015 Trends and 2016 Questions


ACA Trends (positive):

  1. In just two years the percent of uninsured adults fell from 18% (2013) to 11.9% (Apr, 2015 Gallup Poll)
  2. Medicare patient readmissions fell 8% between Jan, 2012 and Dec, 2013
  3. Many say these trends validate the ACA’s worth

ACA Trends (negative):

  1. 25% of U.S. employers offer only high-deducible health plans to employees, double the number from 2012 (2015 PricewaterhouseCoopers survey)
  2. It’s getting more difficult to sign up the remaining uninsured who tend to be young, without funds for insurance, and unaware they can qualify for subsidies (per HHS, 2015)
  3. Only a slight overall increase in enrollment is expected in the 2016 open enrollment (Obama administration, Oct, 2015)
  4. 2016 will see big cost increases for uninsured individuals, employers and insurers.
  5. 45 states and Washington D.C. are requesting premium increases insurers in for 2016 (federal government, Jun, 2015). Many increases exceed 20%, with some topping more than 50% (Washington Examiner).
  6. “If enrollment plateaus, we may see a growing discussion of whether the law is fulfilling expectations in covering the uninsured and whether subsidies for low-and-middle-income people are sufficient to make coverage truly affordable.” (Kaiser Family Foundation)
  7. Many say these trends validate the ACA’s failure

Presidential Election:

  1. There seems to be plenty of reasons to support or vilify the ACA in 2016.
  2. What’s the fulcrum for the election? ISIS? Immigration? Wall Street? ACA?
  3. Is the ACA so entrenched that it can never be repealed?

ACA Won’t Help or Harm Our Healthcare Employment Problems:

  1. Scarcity of healthcare professionals will continue, as will the aging population
  2. What do you envision? Telemedicine? More PAs and NPs? More ADNs and LPNs? Return to Masters level #PTs?
  3. One thing’s for sure: Healthcare is and will continue to be an excellent profession!