Affordable Care ActA special report in the New England Journal of Medicine finds that Obamacare enabled 10.3 million uninsured Americans to get health insurance.

According to a study by the federal government and Harvard University published recently in the New England Journal of Medicine, researchers estimated that the uninsured rate in U.S. declined by 5.2% in the second quarter of 2014, corresponding to 10.3 million adults gaining coverage by the Affordable Care Act.

In the first quarter of 2014, a Bloomberg report was released finding that the challenge that the Obama administration face as far as health insurance is concerned is to convince young people about the value of having insurance in their lives.

But in April 2014, a survey conducted by RAND American Life Panel has estimated a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014.

The recent report found that the number of Americans without health insurance declined significantly since the ACA open-enrollment period began in October 2013. So far, 26 states and the District of Columbia have expanded Medicaid. Along with Medicaid eligibility to citizens and legal immigrants with incomes at or below 138% of the federal poverty level in participating state, the act also offered tax credits for private insurance purchased through exchanges for people who do not qualify for Medicaid and who have incomes between 100% and 400% of the federal poverty level.

Utilizing the largest national daily poll on health issues, the Gallup–Healthways Well-Being Index (WBI) and HHS data, the researchers used three approaches to test the associations between the ACA open-enrollment period and coverage changes. The WBI is a daily telephone survey that asks a national sample of adult’s questions about health insurance, access to care, and health status. The survey sample included more than 420,000 adults aged 18 to 64 years from January 1, 2012, through June 30, 2014.

In the first approach, based on employment, income, and demographic characteristics, coverage changes in the fourth quarter of 2013 and the first two quarters of 2014 were assessed. Next they tested for differential effects in the subgroups most likely to gain insurance under the ACA and finally an association between survey-reported coverage changes and state-level marketplace and Medicaid enrollment statistics from the Department of Health and Human Services (HHS) were tested.

Researchers found that:

  • Most of the people who gained coverage were either low-income residents of states that expanded their Medicaid programs or individuals who qualified for government-subsidized plans purchased through Obamacare’s insurance exchanges.
  • The biggest gains in coverage were for Latinos, blacks and adults ages 18-34.
  • The biggest improvements in coverage occurred among Hispanics, blacks, and adults aged 18 to 34 years, as well as in states that expanded Medicaid.
  • By the second quarter of 2014, the rate of uninsured people with incomes at or below 138% of the poverty level dropped 6 percentage points in states with Medicaid expansion compared with a non-significant decline of 3.1 percentage points in the population among states without Medicaid expansion.
  • In the next income range (139% – 400% of the federal poverty level), the uninsured rate dropped 9 percentage points in states with Medicaid expansion and 5.5 percentage points in those without Medicaid expansion

However, the coverage gains in this study do not include the 3 million young adults who were able to remain on their parents’ plans.

According to the HHS Secretary Sylvia Mathews Burwell, “We are committed to providing every American with access to quality, affordable health services and this study reaffirms that the Affordable Care Act has set us on a path toward achieving that goal. This study also reaffirms that expanding Medicaid under the Affordable Care Act is important for coverage, as well as a good deal for states”.



Asthma Care Provision for KidsNowadays, healthcare cost is surging considerably in the United States. It is quite evident from the fact that most patients need to contribute a good amount of money towards their Medicare payments. While considering employees with health insurance coverage, many employers or insurers require that they cover a greater share of the total medical costs through increased co-payments and deductibles. These out-of pocket costs can be large especially for those patients with chronic medical conditions such as asthma that need regular and timely medical checkups. A new study reveals that low income families who had opted for high health insurance co-pays in the United States were not proactive in seeking medical care for children especially those suffering from asthma. They will fail to benefit from preventive medications and important doctor visits.

It was found that parents with higher co-pays are changing over to less expensive drugs and providing fewer medications than prescribed, thereby reducing the total number of doctor visits to the emergency room or department.

The study published in the May 2014 edition of the journal JAMA Pediatrics signifies that asthma is one of the most chronic conditions prevalent among children, especially the low income group. According to the U.S. Centers for Disease Control and Prevention, more than 9% of US children suffer from critical chronic respiratory syndrome. Children who get treated at an early stage and consume medicines to prevent asthma flare-ups do better than kids who are treated only when an attack occurs. With health insurers requiring people to pay more out-of–pocket medical costs, many people (even with insurance coverage) find it difficult to manage and pay for healthcare.

As part of the survey, researchers telephoned 769 parents of children (ages 4 to 11) with asthma. An attempt was made to identify the role costs played in accessing care for child.

The major findings of the survey are as below -

  • About one-quarter of children had publicly funded Medicaid or the Children’s Health Insurance Program
  • About 22% of people opted for private insurance coverage and about 18% had high co-pays for all services.
  • Parents at or below 250 percent of the federal poverty level having high co-pays were less likely to take their children to a doctor than similar parents with lower co-pays.
  • Parents with high co-pays have fewer chances to provide care for their children than those with higher incomes or those with Medicaid subsidies.
  • Because of the higher cost, about 3 % of parents admitted that they chose cheaper medicines and 10% percent gave fewer medicines to their children than what was prescribed.
  • About 8% of parents said they made a delay in taking their children to the physicians and 5% delayed or avoided going to the emergency room.
  • 38 % of people who avoided doctor visits said that it significantly affected their child’s asthma care or control.
  • 16% of people reported that they borrowed money or cut down on necessary expenses to pay off their medical coverage.

Even though the Affordable Care Act (ACA) focuses on expanding the health insurance coverage to millions belonging to the low income group, (especially with chronic health conditions like asthma) certain policies are proven to be expensive or need cost – sharing. However, certain rules exclude certain families from availing these benefits. Therefore, it is crucial to incorporate discussions about costs and the medical billing process during clinical encounters, particularly when there are potential barriers to care even for patients with insurance coverage.



National Health IT WeekThe US healthcare IT system is rapidly forging ahead with the prominent technological advancements occurring in the field of medicine. These major developments in the medical field have resulted in significant benefits such as early detection of diseases, introduction of new drugs or new procedures which in turn enhance overall patient care.

US legislation is encouraging the rapid adoption of electronic health records (EHRs) across primary care and hospitals through the use of financial incentives. EMRs not only improve the quality of medical care delivery, but also minimize medical record errors, boost patient safety and strengthen interaction between patients and providers. Moreover, providers and insurers can put up a combined effort to improve quality and reduce costs.

The 9th National Health IT Week (NHIT week) is a collaborative forum for key medical care constituents to discuss and promote the value of health information technology (IT) for the US healthcare system. The virtual awareness week campaign that starts from September 15 – 19 features the theme – “One Voice, One Vision”. With an estimated 400 partners, NHIT week projects this important cause to the forefront through various local and regional events hosted by HIT week partners.

Sponsored by HIMSS, this campaign offers a unique platform to recognize the vital role of HIT in transforming healthcare delivery and promoting high quality and efficient care. This week long celebration is the perfect opportunity for the community to unite together under one banner to raise awareness about the role and prominence of HIT in improving care quality. The selected themes for each day of this celebration include -

  • Patient Engagement
  • Advancing Interoperability through Meaningful Use
  • Advancing Interoperability across the Care Continuum – Beyond
  • Advancing Interoperability through Standards
  • Clinical Quality & Safety

More than 400 partners, (compared to 368 last year) will join the celebration that highlights the value of health IT. Physicians, hospitals, non-profit organizations, colleges and universities, state and regional extension centers and corporations will participate in various events in Washington, DC and other locations.



Medical Billing ErrorsAccording to the 2013 Bloomberg ranking of nations having the most efficient healthcare systems, the United States finished in the 46th position among the 48 countries included. A study published in the Journal of General Medicine in 2013 says that around 25% of all senior American citizens are bankrupt because of high medical expenses while 43% are in a grave situation being on the verge of mortgaging or selling their primary residence to pay their medical bills. It is partly because even if you are insured, some amount should be paid from your own pocket in the form of coinsurance, co-payments and deductibles. However, the real culprits that create chaos in the U.S. healthcare system are medical billing errors and fraudulent practices.

The errors that cause a surprisingly large hospital bill with the insurer saying ‘no’ to pay all of it may be accidental mistakes. Such errors can create real problems for both patients and hospitals. The common billing errors are as follows.

  • Duplicate Billing – Sometimes hospitals may charge twice for the same procedures, supplies or medications. An itemized bill will help to identify such kinds of mistakes.
  • Duration of Stay – Most hospitals charge patients for the day they arrive, but not for the day they leave. Thoroughly check the dates of patient admission and discharge and make sure that you are not charging them for the day they checked out from the hospital.
  • Price Charged for the Room – Ensure that you are charging patients the right price for the type of room. Sometimes patients staying in a shared room are charged the rate for a private room.
  • Time Spent in the OR – The average time required to perform an operation is often taken as the criterion for billing. Ensure that patients are being charged accurately for the same so that no discrepancy is noticed in case a comparison is made with the anesthesiologist’s records at some stage to determine the OR charges.
  • Up Coding – At certain times, providers may change an order for an expensive medication and/or service to one that costs less. Check whether patients are being billed at a higher rate even after that or billed for both the expensive and cheaper versions.
  • Overlooked Keystrokes – If the medical staffs slipped or overlooked some keystrokes while typing on the keyboard, significant mistakes including overcharges can happen.
  • Canceled Services – In certain cases, a pre-arranged medication, procedure or service canceled later may be shown in the patient’s final invoice. Be vigilant to such kind of mistakes.

With the help of a professional medical billing and coding company that provides the service of experienced AAPC certified coders, healthcare providers can avoid these kinds of errors to a great extent and relieve their patients from cost burden. Such a company would handle the billing tasks more efficiently and accurately with a good revenue cycle management team.

Fraudulent Billing Practices – A Nightmare for the U.S. Healthcare System

The federal Health Care Financing Administration (authority which oversees Medicare) estimates that the government loses 30 cents to every dollar because of the fraudulent practices in the medical community. The famous TIME Magazine article ‘Bitter Pill: Why Medical Bills Are Killing Us’ by Steven Brill gives a clear insight into such malpractices. The most common fraudulent practices prevalent are:

  • Unbundling – The federal Health Care Financing Administration cites certain hospitals are indulging in practices such as unbundling to raise the cost of their services. Unbundling means billing treatments separately when they should be billed as a single combined charge.
  • Overcharging – There are allegations that several not-for-profit hospitals in the United States deliberately overcharge uninsured and underinsured patients although maintaining their tax exempt status. These hospitals would take oppressive collection practices to recover this inflated medical debt while providing relaxation to Medicare or Medicaid patients. Steven Brill says in his article that certain hospitals would charge $283.00 for simple chest X-rays if the patients have no coverage whereas a Medicare patient would pay only $20.44 for the same.

However, Brill gives some suggestions that would curtail medical billing frauds and allow U.S. to provide better healthcare services at lower costs. These measures include restricting the prices of prescription drugs, recapturing the profits from hospitals having expenses of about a third of healthcare costs, implementing 5% cut on hospital and physician costs, reducing the spending on outpatient clinics and labs owned by doctors, using transparency and emboldening comparative – effectiveness evaluations in decisions to prescribe drugs, tests and medical equipment.



CMS Not to Review Billings of Overpayment

Posted by on September 10, 2014 7:13 am

BillingsDespite the report from the HHS Inspector General pointing out the Medicare overcharges of $6.7 billion, the Centers for Medicare and Medicaid Services (CMS), which runs Medicare is not ready to investigate overpayments to doctors. CMS says it doesn’t plan to review the billings of doctors who almost always charge for the most expensive visits because it isn’t cost-effective to do so.

A review by the Office of Inspector General (OIG) found that Medicare inappropriately paid almost $6.7 billion for Evaluation & Management services in 2010. Released in May 2014, the review estimates that overpayments account for 21 percent of the $32.3 billion spent on Part B claims for E/M services.

A medical record review was conducted of a random sample of Part B claims for E/M services from 2010, stratifying claims from physicians who consistently billed higher level codes for E/M services and claims from other physicians. 657 Medicare claims were gathered for review. Certified professional coders determined whether the E/M service documented in the medical record for each sampled claim was correctly coded and/or sufficiently documented.

The investigation found that 42 percent of claims for E/M services in 2010 were incorrectly coded, which included both upcoding and downcoding, and 19 percent lacked documentation. It was also found that claims from high-coding physicians were more likely to be incorrectly coded or insufficiently documented than claims from other physicians. Based on the findings, OIG has advised CMS to consider making the E/M claims submitted by high-coding physicians a priority in their medical review strategies.

It’s not the first time. Earlier in 2012, another study from OIG reported that physicians increased their medical billing of higher level codes, which yield higher payment amounts, for E/M services in all visit types from 2001 to 2010.

Other 2012 cases on Medicare overpayments reported by REUTERS include:

  • Medicare paid doctors $457 million in 2012 for 16 million tests to detect drugs – from prescription narcotics to heroin.
  • Medicare administrators paid Three Connecticut doctors a total of $1.4 million for nearly 24,000 drug tests in 2012 – on just 145 patients.

Are the physicians billing properly? This is the main concern here. Errors in payment often results from wrong medical codes, duplicate submission of the same service or claim, payment for excluded or medically unnecessary services and inaccurate documentation. Whether CMS reviews billings of overcharges or not, it is crucial for any healthcare entity to ensure accurate health record documentation and follow the correct medical billing standards.



MedicareThe Centers for Medicare and Medicaid Services (CMS) recently released a proposal to increase Medicare payments to hospitals for the care that they provide on an outpatient basis. The new proposal provides an increase in hospital outpatient payments by 2.1% in the year 2015, while ambulatory surgery centers would receive a 1.2% boost. Both the proposed increases are quite higher than what CMS had recommended and finalized for the year 2014.

Reports suggest that Medicare (the health program for the elderly and disabled) paid about $37 billion in 2013 for outpatient treatment in hospitals and $139 billion for admissions. The proposed increase for 2015 emphasizes a trend of discouraging unnecessary admissions.

Presently, hospitals are struggling with health insurance expansions under the Patient Protection and Affordable Care Act (ACA) or Obamacare. Insurers negotiate aggressively for plans that they sell in government-run exchanges serving about 8 million people.

The 2.1% increase for hospitals was arrived from a 2.7% increase in market base minus a 0.4% productivity adjustment along with 0.2% cut required by ACA. As per the new rule, those hospitals that fail to meet the outpatient quality reporting needs would continue to have their Medicare reimbursements reduced by 2%. It also suggested continuing increased payment rates for cancer hospitals and rural facilities.

CMS is proposing to add one claims-based quality measure and refine the norms for determining when a measure is “topped out”. Moreover, several previously adopted measures are to be updated.

The proposal included payment of a bundled rate for ancillary services with an average cost of $100 or less. The exceptions to this payment system consist of preventive services, psychiatric related services and drug-administration related services. CMS has been stressing the need for comprehensive ambulatory payment classifications (APCs) since 2014 which would lead to a single Medicare payment to providers instead of several separate charges. For the year 2015 about 28 comprehensive APCs have been included.

It is expected that the new rule would significantly affect more than 4,000 hospitals and 5,300 ambulatory surgery centers in the US. It is estimated that Medicare under the new policy in 2015 would pay hospitals $ 56.5 billion, a considerable increase of 5.2 billion from 2014. On the other hand, ambulatory surgery centers would receive $4.1 billion, an increase of $243 million compared to 2014.



Diabetes EpidemicAccording to a report released on May 2014 by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy, one in three hospitalized people age 35 years or more in California has diabetes, which increases the complexity and cost of their care. The report is prepared on the basis of a study which analyzed all 2011 hospital discharge data and annual financial data from the Office of Statewide Health Planning and Development (OSHPD). In the opinion of a study author, diabetes affects most body systems in one way or another and this makes it more challenging to treat the disease. Since this disease also affects the healing ability of the body, its costs go higher.

The major findings mentioned in this report are:

  • An extra $1.6 billion dollars adds to hospitalization costs in California every year with hospital stays for patients with diabetes costing nearly $2,200 more than stays for patients without diabetes. As per the study, three-quarters of that care is paid through Medicare or Medi-Cal (California’s health plan for the poor and disabled) with $254 million in costs paid by Medi-Cal alone.
  • Though diabetes was found to be the primary cause in only 1.7 percent of all hospitalizations, patients with diabetes have a higher risk for diseases that lead to significant expenses such as kidney and heart disease, blindness and limb amputations. Two third of diabetes patients who were estimated to have had at least one of these complications resulted in around $23 billion in medical costs nationally in 2006.
  • Around 60 percent of hospitalizations for diabetes included people aged 65 years of age or more.
  • The medical records analyzed during the study showed that ethnic communities are most dramatically impacted by diabetes. Around 43.2 percent of all Latino hospital patients in California aged 35 years or more have diabetes compared to the statewide average of 31 percent. While 40.3 percent of American Indians/Alaska hospital patients have diabetes, 39.3 percent African-Americans and 38.7 percent Asian-Americans/Pacific Islanders have diabetes.

The interesting part of this study is that it found approximately 90-95 percent diagnosed diabetes among adults is type 2 diabetes (associated with obesity and inactive lifestyle) and it is preventable. With early diabetes education and better preventive measures, it is possible to reduce hospitalizations and drive down healthcare costs. The report recommends that policymakers should consider the following options to reduce the surge in healthcare costs related to increasing diabetes cases.

  • Promote Appropriate Diabetes Management – With diabetes care guidelines, self-management education and healthcare provider supervision, providers and patients can manage and control diabetes better by controlling blood sugar, blood pressure, and cholesterol levels, taking regular foot exams and dilated eye exams, smoking cessation and weight loss. Diabetes patients can thus avoid costly hospitalizations due to complications.
  • Improve Access to Quality Primary and Specialty Care – Lack of continuous health insurance coverage or sufficient benefit packages remains a significant financial barrier to primary and specialty care access. A medical home that encourages good relationship with providers and the healthcare team is also essential to manage diabetes in primary and specialty care settings.
  • Encourage Healthy Eating – The food and beverage environment should be improved by expanding access to fruits and vegetables; moreover, the availability of safe and low-cost drinking water needs to be ensured. In addition to this, educational strategies should be developed to improve the knowledge of consumers regarding food and beverage choices.
  • Promote Regular Physical Activity – Lack of physical activity can lead to diabetes and obesity and therefore it is very important to promote building environments that encourage regular physical activity (for example, safe parks). Worksite programs that facilitate regular physical activity are also effective options.

Family practice physicians should prepare and maintain the records of their patients accurately so that they can constantly analyze the health status of the patient (for example, how blood sugar, blood pressure, and cholesterol levels vary), give valuable suggestions to reduce diabetes risk and thereby avoid hospitalizations. Accurate clinical documentation is also important from the point of view of medical billing and helps to receive the correct reimbursement in time.



Cardio-respiratory FitnessIn a research conducted by the National Center for Health Statistics (NCHS), it was found that the percentage of adolescents aged 12 to 15 years with adequate cardio-respiratory fitness (CRF) level has reduced significantly in 2012 compared to the statistics of 1999-2000. The data obtained from the National Health and Nutrition Examination Survey (NHANES), 1999-2004 and the NHANES National Youth Fitness Survey, 2012 showed CRF levels have declined among U.S. teens. Cardio-respiratory fitness, an important component of physical fitness is the ability of the circulatory and respiratory systems to supply fuel (oxygen) at the time of sustained physical activity and eliminate fatigue products once the fuel is supplied. As the CRF levels continue to fall among adolescents, the need for physical rehabilitation is gaining importance.

The major findings of this study related to pediatric healthcare are as follows.

  • The number of adolescents aged 12 to 15 years with adequate CRF levels fell from 52.4% in 1999–2000 to 42.2% in 2012.
  • The percentage of boys with adequate CRF levels decreased from 64.8% in 1999–2000 to 50.2% in 2012 while the percentage of girls decreased from 40.5% to 33.8%.
  • The percentage of adolescents aged 12 to 15 years with adequate CRF levels did not differ by race and Hispanic origin or by family income-to-poverty ratio.
  • A higher percentage (54.1%) of normal weight teens had adequate CRF levels compared to overweight (29.9%) or obese (20%) teens in the age group 12 to 15 years.

Adequate CRF levels are very important for fitness. Several studies have shown that a low fitness level is closely associated with the risk for cardiovascular diseases including coronary artery disease, stroke and more. It is evident from these findings that obesity/overweight and low fitness levels are correlated. Therefore, physical activities are essential to improve the CRL levels in adolescents. A 2013 study by American researchers suggest adolescents require higher intensity physical activity to maintain or improve cardiorespiratory fitness.

Comprehensive and accurate documentation of the symptoms, medications, past and current illness, usual level of physical activity and other personal details of patients has to be made to determine whether the cardio-respiratory fitness levels are adequate. Adequate levels of cardio-respiratory fitness are based on age and sex specific standards and established according to how fit children or adolescents need to be for good health. Once the pediatricians confirm the CRF levels from the clinical documentation, they can conduct screening (for example, obesity screening) and recommend preventive measures to reduce weight or they can refer them to rehabilitation physicians for advice regarding a good diet and effective exercises. The Affordable Care Act (ACA) considers screening under preventive care services which is among the ten essential health benefits that must be covered by insurance policies.



Americans Newly Insured Under ObamacareA new study reports that an estimated 10.3 million American adults have gained health insurance coverage under the Affordable Care Act (ACA) since open enrollment started last October, with the major gains among young adults and Hispanics.

The study was jointly funded by researchers from the Harvard School of Public Health, Brigham, Women’s Hospital in Boston, and the federal government. The researchers’ findings are based data indicating a 5.2 percentage drop in the U.S. uninsured rate since last September for Americans aged 18-64 years.

The key findings of the study are as follows

  • States that expanded eligibility for Medicaid had the biggest gains. Under Obamacare, it was not mandatory for states to expand eligibility
  • The percentage of uninsured people aged 18-64 fell from 21 percent in 2013 to 16 percent in 2014
  • The study found vital evidence that substantiates that more than 4.4 million American adults had access to a personal doctor
  • It was found that 5.3 million adults encountered difficulties in paying for a medical care within the first six months of achieving health coverage

The Patient Protection and Affordable Care Act (ACA) focuses on expanding health coverage to millions of Americans and the study by the Harvard researchers seems to reaffirm that the country is on the path to achieving this goal. Expanding Medicaid seems crucial for coverage expansion, with 26 states moving forward with the federal insurance program for the poor.

The researchers compared national survey results with Census data as well as government figures on marketplace enrollment in private insurance and Medicaid. However, some industry watchers point out that the data analyzed was not comprehensive enough to display a casual relationship between the ACA and the uninsured rate, and that it found only “suggestive associations”. Moreover, the data did not include about 3 million young adults estimated to have achieved coverage by joining their parents’ insurance policies under the ACA.



SchizophreniaSchizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the world. Several observational studies have investigated the association between vitamin D status and schizophrenia. The November 2013 issue of Schizophrenia Research carries a study that found vitamin D deficiency to be linked to the first episodes of psychosis (FEP).

Another very recent study, published online on July 22, 2014 in the Journal of Clinical Endocrinology and Metabolism highlights the role of vitamin D in psychiatric health. The researchers found a strong association between vitamin D deficiency and schizophrenia.

More than 2800 participants were included, showing that those with vitamin D deficiency were more than twice as likely to be diagnosed with schizophrenia compared to their counterparts who were not vitamin D deficient. The study also found that 65% of the patients who had the condition also had lower levels of vitamin D.

Most cases of schizophrenia appear in the late teens or early adulthood. In rare cases, schizophrenia can even affect young children and adolescents with slightly different symptoms.

ICD-9-CM Codes that are used to report this diagnosis for medical billing purposes are as follows:

  • 295.10 Disorganized type schizophrenia, unspecified
  • 295.20 Catatonic type schizophrenia, unspecified
  • 295.30 Paranoid type schizophrenia, unspecified
  • 295.40 Schizophreniform disorder, unspecified
  • 295.60 Schizophrenic disorders, residual type, unspecified
  • 295.80 Other specified types of schizophrenia, unspecified
  • 295.90 Unspecified schizophrenia, unspecified

The findings support the importance of vitamin D in brain function and psychological health. According to the authors, “As vitamin D deficiency is a global issue, more attention should be drawn to the assessment of serum vitamin D levels in order to screen and support individuals that are at higher risk of having deficiencies. Moreover, our findings might help psychiatrists in the healing process of patients with schizophrenia”, It was also noted that more randomized clinical trials are required to confirm the findings.



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