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Navigating Healthcare Reform: Issuing Rebates – Healthcare

The Minimum Loss Ratio (MLR) mandate contained within the Patient Protection and Affordable Care Act of 2010 (PPACA) has created a myriad of compliance requirements for health plans. The most complex and potentially costly of these will be issuing rebates to members when a plan’s MLR falls below the minimum threshold.Many carriers do not have the infrastructure in place to accommodate the rebate mandate. Exacerbating an already significant challenge is the very real possibility that pending legislation and ongoing legal skirmishes will modify the way in which the PPACA-and the MLR mandate-is implemented and enforced. As such, initial and ongoing compliance will require a comprehensive retooling of critical business processes and deployment of enhanced and highly agile systems and solutions.Market ImpactUnder the PPACA, beginning in 2011 the MLR standard is 85 percent for large group carriers and 80 percent for small group and individual carriers. Failure to meet these minimum thresholds triggers the requirement that carriers issue rebates to subscribers. Those rebates must be paid directly to consumers who purchase individual policies or through employers for those who are in group or employer-sponsored plans.The anticipated impact of the rebate requirement on the carrier market is significant. The U.S. Department of Health and Human Services (HHS) estimates that 45% of consumers who have purchased individual coverage are in plans that do not meet the MLR mandate. Were the mandate in effect today, an estimated 9 million people would be eligible for rebates averaging $164 per person. In 2012 alone, rebates are expected to cost the industry $1.4 billion.There are some exemptions to the MLR mandate. For example, carriers that offer “mini-med” or “expatriate” plans are able to calculate their MLR differently than traditional plans, at least for 2011. As such, these plans are able to meet the 80% threshold by spending as little as 40% on direct medical costs.Waivers are also available to states that can demonstrate meeting the MLR would destabilize their individual insurance market.Under the PPACA, beginning in 2011 the MLR standard is 85% for large group carriers and 80% for small group and individual carriers.Many carriers whose plans are not exempt from the MLR are finding that they are ill-equipped to manage the rebate process, as their systems and processes lack the flexibility necessary to adapt to the complex rebate regimen. They are also finding it necessary to implement higher value-add initiatives to off-set the increased costs of complying with multiple PPACA provisions, such as guaranteed issue and elimination of lifetime limits.In calculating its MLR, a carrier must aggregate data by state and market over a three-year period. Earned premium adjustments must be made for:• Assessments paid to, or subsidies received from, federal and state high risk pools• Premiums associated with group conversion charges• Experience rating refunds• Unearned premiumsIncurred claims must be adjusted for such things as:• Group conversion charges• Unpaid claims between the prior and current years’ unpaid claims reserves• Change in claims incurred by not reported (IBNR)• Other changes in reserves• Any experience rating refundsUnder the MLR formula, plan activities that improve healthcare quality can be counted with incurred claims. These activities include case management, care coordination, chronic disease management, accreditation fees directly related to quality of care activities, and quality reporting, as well as IT to support these activities. Other acceptable quality initiatives include those designed to prevent hospital readmissions, improve patient safety, reduce medical errors and promote wellness and health activities.Activities which are explicitly not considered activities that improve quality include fraud prevention, retrospective and concurrent utlilization review, as well as the costs of maintaining provider networks and provider credentialing.Thus, the actual formula for calculating the MLR is:Incurred Claims + Activities to Improve Quality divided byPremium Revenue – Taxes & FeesWhen it comes to rebates, calculations are no less complex:Premium paid by enrollee – Taxes & Fees multiplied byMLR Standard – Actual MLRThe challenge is not just determining the amount of the actual rebate. It is tracking the customer data required in the event a rebate must be issued and ensuring that payments are issued within the mandated timeframe (no later than August 1 following the end of the MLR reporting period).Strategic ObjectivesFor health plans, successful compliance requires adapting existing work processes and infrastructures in a way that enables the efficient processing of rebates. It must be done in a manner that does not interfere too significantly with current business operations, and that allows carriers to take advantage of new opportunities available in a post-PPACA environment.Carriers must focus on executing strategies that ensure they have the processes in place to streamline the rebate process and convert it from a cost center to a marketing opportunity. These should focus on:• Understanding the rules and evolving responsibilities governing MLR calculations and rebates and continuously monitoring for changes• Converting a fixed infrastructure investment into a predictable variable cost structure• Deploying integration pathways to ensure necessary data feeds and workflows• Deploying processes for interacting with members and employers to secure key data elements• Designing programs to leverage the rebate requirements as a means for up-selling to existing subscribers and re-engaging terminated onesFinally, any adaptations carriers make must be flexible enough to accommodate any future changes that may apply in the wake of legislative and legal challenges.HealthPlan ServicesHealthPlan Services (HPS) recognizes the challenges that carriers face in complying with the PPACA while replacing lost profits and capitalizing on emerging opportunities to strengthen revenues and market share. Partnering with HPS enables carriers to leverage the up-to-the-minute monitoring capabilities and understanding of both MLR policy changes and operational best practices provided by a trusted industry resource.HPS understands the many nuances of healthcare reform, and has leveraged that knowledge to create a suite of flexible rebate solutions that meet the unique needs of carriers confronted with the MLR rebate. Its full service offering is ideal for clients to whom HPS is already providing administrative services, while its stand-alone module offers a solution for carriers seeking only rebate processing support. Both feature multiple entry and exit points, including rebate refund and disbursement feeds.HPS’ rebate solutions are all about flexibility and compliance, offering multiple disbursement methods-paper check, ACH credit, credit card credit, pre-loaded debit card, credit on billing invoice-and electronic and paper statement options. HPS also provides a mechanism for gathering contribution rates for group plans, escheatment processingHPS understands the many nuances of healthcare reform, and has leveraged that knowledge to create a suite of flexible rebate solutions…

Factor Your Medical Receivables with Exclusive Programs for Healthcare Industry – Healthcare

Factoring is when a business sells its receivables for a service or product delivered to another business. Many people in the healthcare industry think that medical receivables can’t be factored because the “customer” is a person and not a business. But medical receivables can be factored because in most cases, your payment comes from Medicare, Medicaid, Blue Cross/Blue Shield, Aetna, etc. In other words, the payment is coming to you from a business, so the receivables CAN be factored.In the past, healthcare professionals could depend on efficient operations to keep
their cash flowing, but that often is not enough now. Increased costs and longer
times for insurance companies and Medicare to pay the bills are making it
impossible for them to keep their practices running smoothly.Most factoring companies do not factor medical receivables, but there are several
that specialize in this niche. They fully understand that accounts that are paid by
third party payors take more due diligence and more things have to be looked at
than with “regular” factoring. They know these receivables are filed and paid
differently by different states and then have elaborate payment methods and
computations. There are government and insurance regulations, delayed
reimbursements, HMOs, contractual allowances, multiple payors and many more
challenges that are only found in the healthcare industry. The factors who specialize
in your industry know all the lingo and terminology and will immediately understand
your needs.The healthcare businesses that will most easily be approved for factoring are: Acute
or Rehab or Specialty Hospitals, Physicians, Surgery or Imaging Centers, Dialysis or
Urgent Care or Rehab Centers, Ambulance companies, Medical Labs, DME/HME,
Osteopaths, Oral Surgeons, Pharmacies, Home Health Care and Workers Comp
Healthcare Providers and some Chiropractor groups.There are certain types of health related businesses that might be more difficult to
factor, mostly because the net collectable value from the private insurance
companies or government is too small each month for a factor to be interested.
These are small chiropractors, dentists, cosmetic surgeons and Lasik doctors (often
not covered by insurance) and some nursing homes because of credit problems.Medical receivable factoring companies all have different minimum monthly net
collectable amounts, so ask your broker for the one that will be able to help your
business. Some work with amounts as small as $35,000-$50,000, others have a
minimum of $200,000.Once your account is set up with the factor, you will receive up to 85% of the
invoices within hours of turning them in each week. When the bills are finally paid,
you will receive the rest of the amount owed, minus a small fee. The fee depends on
many things and will probably range somewhere between 2% and 6%.You will lose all the stress of not knowing when you will be paid for the work you
are doing. You’ll be able to pay all your vendors and staff on time, you’ll be able to
keep up with all your bills. You will even be able to hire more staff or buy more
equipment, because you’ll know you can accept more business.There have been instances when a medical business has been on the brink of
bankruptcy and decided to try factoring as a last ditch effort and it saved them.
They were able to turn everything around and are thriving now.Factoring should be considered as a tool for growth and management, not as a last
resort to save your business. Unless your practice has very expensive equipment or
diagnostic devices, your largest asset is its accounts receivables and these assets
can be used to keep your business running smoothly and growing.

Home Based Business – Healthcare Products Are Always in Demand – Healthcare

A home based business that caters to healthcare needs can achieve strong growth. The growth of personalized healthcare and round the clock medical services has not been impacted by recession.Healthcare offers high business potential as it can render wellness products and services to millions of people. It can provide financial security through a successful business model.Demand for Medical Services: The current healthcare system is under tremendous stress to meet the increasing demands for primary geriatric care. A high percentage of the baby boomer generation is expected to head to retirement this decade. The increasing preference for primary care at home among the elderly has further pushed up demand for medical services. It is said that more than 10 million people in developed nations are to become seniors by the year 2020.The medical expertise provided can vary from non medical for assisted living services. Non medical services provide assistance for comfortable stay at home for the seniors. An assisted living facility provides passage for shift in stay for those unable to live at homes. The profit margins with the above business opportunity are growing tremendously.Healthcare Products and Profits:Healthcare products of home based business can extend beyond vitamin supplements. Antiaging products, calorie drinks and cosmetics find strong appeal with the health conscious population. Natural health beverages with ayurvedic products that work against stress and general ailments are popular. Certain healthcare companies offer opportunities for executives and franchises to sell their product.Low cost home based business can be initiated by taking advantage of the opportunities offered by many such companies. Product information can be gained for a nominal amount through coaching centres and teleconferences.Business and Marketing Potentials:Neighbourhood networking can help identify the potential distributors for healthcare products and you can strategically join hands with them and earn regular commissions. Sales training and lead generation skills can be learnt though business training programs offered by product companies.An independent distributor program can be undertaken for wellness products which are developed by professionals. Enrolment as a dealer for new calorie drinks and herbal products can negate the difficulty of working in a saturated environment.Dealers can promote and place orders for their products from home though a provided back office URL. Consumers can place orders through the dealer’s website to earn reward points and bonuses with discounts. Marketing needs of a healthcare business can be attended through distribution of wellness information, press release and educational data.

DEA’s Role in Healthcare – Healthcare

What role does the Drug Enforcement Administration (DEA) have in patient healthcare? Is DEA involved with your physician’s medical practice or does DEA simply track prescription drugs? Why does DEA investigate and prosecute some doctors? What does DEA look for and how are they scrutinizing the professional activities of healthcare providers? Unfortunately, many physicians as well as patients do not understand DEA’s role in healthcare. Physicians know they receive a DEA registration number to prescribe controlled substances, but then what? DEA is responsible for enforcing the Controlled Substances Act which encompasses scheduled pharmaceuticals. DEA enforces and investigates a variety of medical business activities which are involved in the prescribing process.As a recently retired DEA Assistant Special Agent in Charge, I have first-hand experience investigating physicians and other healthcare personnel. As a DEA investigator, I would launch investigations into medical practitioners who prescribed controlled substances without a legitimate medical purpose and outside the usual course of professional practice. While prescribers understand the initial need to register with DEA for prescribing rights, there is a lack of training and information regarding best practice measures from a DEA regulatory standpoint. This leads to problems between physicians and DEA, but can also lead to problems between physicians and their patients when prescribing narcotics for pain.A fact few people know is there is a direct link between prescribing opiate pain-killers and heroin use. The explosion of the heroin abuse epidemic is a direct result of the abundance of prescriptions that have been written for opiates or “pain-killers” over the past two decades. Due to the stringent controls and the negative media attention placed on the abuse and diversion of opiate medications, practitioners have become reluctant to prescribe them, even when prescriptions may be warranted. This exemplifies a misunderstanding of DEA’s role and federal regulations. After talking with physicians throughout the country, I have determined there is a gross misunderstanding and overall lack of knowledge regarding what activities may trigger a DEA investigation. As a result, physicians may not prescribe legitimately justified opiates in fear of being investigated. Patients are thereafter turning to the alternative of heroin to manage their pain. As a result, the number of individuals with addictions is growing and people are dying.Physicians can protect themselves by taking the appropriate steps and measures during the course of patient treatment. Some physicians question DEA’s expertise in medical treatment. How do DEA investigators determine the best course of treatment if they are not doctors themselves? To ensure DEA does not impair medical treatment but also identifies illegitimate prescribing, medical experts are retained during investigations and often testify on behalf of the government. The medical experts review the treatment methods and patient charts to establish if the controlled substances were prescribed with a legitimate medical purpose.I am confident additional training in DEA Regulatory Policy can help physicians remain compliant and ultimately result in better care for their patients. DEA does not direct physicians how to practice medicine, but rather ensures prescribers are completing steps necessary to justify prescribing controlled substances. This is one of the primary roles DEA has in patient healthcare. DEA works to ensure medical practitioners are prescribing narcotics responsibly and in accordance with Federal regulations, for their safety and the safety and well-being of their patients.

Bill Clinton – Imperfect Healthcare Reform Better Than None – Healthcare

The current healthcare reform debate must bring up some bad memories for former President Bill Clinton. He, with the help of then-First Lady Hillary Clinton, tried to enact their own bill to reform the health insurance industry early in his first term. Their attempts failed to receive enough support from his party and failed; the Democrats then suffered a humiliating defeat in the 1994 mid-term elections. Yesterday, he visited the Senate to encourage the Democratic party to vote in favor of reform. His primary hope is that President Obama and congressional Democrats don’t repeat his mistakes; namely, a legislative process that continued to drag on.Clinton told the senators that it is imperative that the current combination of tens of millions of uninsured people and expensive health insurance plans must change as soon as possible. While he didn’t touch on specifics, such as the public option or the amendment that bans abortion coverage from subsidized health insurance, Clinton implored them to not let the perfect be the enemy of the good. From his experience, he came to believe that it would have been better if Democrats had passed some form of healthcare reform in the early 1990s–even if it wasn’t ideal–as opposed to allowing the problems to fester for the past decade-plus. Some are worried that it is far harder to modify a law once it’s in place, as opposed to amending it on the legislative floor. Their concerns are valid, but Clinton warned them of his own travails.So far, important Democrats have been following Clinton’s strategy on health insurance. Speaker of the House Nancy Pelosi had representatives working a rare Saturday night shift in order to get the bill passed, and included several compromises. Meanwhile, Senate Majority Leader Harry Reid has vowed to have passed a reform bill by Christmas. Ever since the inauguration, the Obama administration has pushed Congress to get a healthcare reform bill on his desk and signed by the end of this year, even to the detriment of other domestic priorities like the recession. Clinton claims that successful reform will actually help the economy, by decreasing the crushing cost of a health insurance plan for many Americans. Presumably, consumers could then use the money they save on premiums for spending, thereby increasing our GDP. However, Republicans are planning to debate the healthcare reform bill for as long as possible, for weeks months if necessary. It is somewhat suspicious that supporters want to move such important (and long) legislation through Congress so quickly. Some legislators have even failed to read the nearly 2,000-page bill–although maybe their aides have.Will Bill Clinton’s speech help get healthcare reform passed? He is a polarizing figure, but is greatly respected and admired among his own party. Negotiating the release of two North Korean hostages earlier this year proved that he still has political clout with the general public. His own attempt at reforming the health insurance industry gives him the ability to give helpful advice on the pitfalls; however, his baggage gives conservatives more ammunition in their fight against reform. In Clinton’s era, Republican groups and health insurance providers were successful in scuttling healthcare reform by claiming that it will negatively impact Americans’ existing health insurance plans –the famous “Harry and Louise” ads are a case in point. Back then, Clinton was also more adamant about enacting a single-payer health insurance plan, which allowed opponents to stoke the public’s fears of socialized medicine and governmental takeover. This time, such a comprehensive government-run program is a non-starter, but even the scaled-down public option (for the uninsured and those with pre-existing conditions) is untenable for many. They are again threatening the seats of conservative “Blue Dog” and moderate Democratic politicians. Both sides learned lessons from the last healthcare reform fight; the only thing that remains is who will win this time.

Digital Signage For Healthcare – Healthcare

Another one of those large industries that tends to be embracing the incorporation of interactive digital technology into the busy halls is the health care industry. One of the main reasons that digital signage for healthcare seems to be such an obvious solution is that the majority of people who walk into a hospital are stressed and/ or disoriented. Whether they are sick or injured themselves, visiting a loved one, or even just getting a routine checkup, there is plenty enough to worry about already.Digital signs can be used in a variety of ways to guide them, offering a smooth transition into the everyday life of the hospital environment and making it an easier process for everyone.This can be done through digital bulletin boards or an interactive display that gives instructions using touch-tone technology. Of course, there will always be patients who are in such a bad state they have no time or focus to concentrate on something even this simple, and they will blaze right past, but leading the rest of the patient population with interactive technology frees up more of the staff to focus on those patients who need immediate attention.Another great use of digital signs that works great in larger health care facilities are wayfinding displays. These are large interactive maps where visitors can quickly touch a finger to the destination they want to go and receive immediate directions.They can also see where all the most important locations are–such as restrooms, cafeteria, emergency room, waiting room, x-ray, and ICU. Hospitals are often quite bland and repetitive in design, and many people find they get lost in even the smallest facilities, especially under considerable stress.Of course, digital signage is not just beneficial to patients but helps the hospital staff in a variety of other ways as well. Everyone that works in the hospital is part of one huge team, and it takes effective management in order to keep that team functioning as one cohesive unit.This requires good communication, and this is where digital signage for healthcare comes in. Signs can be use to make announcements, give instructions, and send out health alerts. They can also be used in cafeterias to display cafeteria menus for everyone to see or provide entertainment when it is needed most.This is only the beginning, and if you think of the nature of health care technology, it should be obvious that digital signage will play an increasingly important role. How will this technology be used in the future to not only streamline processes but improve advanced methods of treatment?

How A Healthcare Advertising Agency Can Help Your Business Really Understand Your Audience – Healthcare

In the past, companies could afford to blanket consumers with information. There was little need for a healthcare advertising agency to spend much time targeting the most fruitful client bases. Radio and TV assured that everyone was virtually a captive audience for all promotions. With the arrival of the internet, everything changed. Now, every hospital marketing agency uses careful audience targeting – and if they don’t, they’re doing clients a disservice. For today’s healthcare advertising agency, identifying a target audience is just the beginning. The best promotional programs emerge after a much more in-depth process of research and investigation: the process of truly understanding the target demographic.A Good Hospital Marketing Agency Can Tell You Everything About The AudienceWhat does a neurologist do for lunch? How late does an average 45 year old with high cholesterol stay up at night? These questions might seem irrelevant until you consider their implications for medical promotions. In order to accurately target the neurologist, you need to know what media he encounters during the day. You need to know what websites he visits, and what medical journals he is most likely to read. The same thing is true for the 45 year old with high cholesterol. They will almost certainly have radically different schedules, and turn to totally disparate media in their downtime.Benefits Of In Depth ResearchSome might question whether or not it’s worthwhile to put this much time into research. There is still certainly the odd healthcare advertising agency resisting this new push for increased understanding of the audience, but even the holdouts show signs of embracing the facts. Thanks to increasingly specialized websites and publications, it is possible for a hospital marketing agency to provide a more targeted message than ever before. The limitation of that targeting is no longer the media, but rather the amount of research that can be performed. One can place an ad in a very specific, industry-only web sector, but not until that sector has been clearly identified as beneficial and receptive to these kind of products.Dollars And SenseThe increased spending on research is almost always less expensive than trying a particular broad campaign and hoping for good results. Focus groups can help even a small healthcare advertising firm understand the habits of a target audience at very little cost. The amount saved on otherwise wasted promotional efforts can be funneled into another campaign, perhaps targeted very directly at another promising sector.Every healthcare and hospital marketing agency faces the unique challenge of frequently appealing to two very different audiences. The same new medicine may be marketed to physicians and their patients, or hospital workers and in-home caregivers. With such a broad market to address, choosing the right audience and pinpointing the best ways to contact them become increasingly important. There is a big risk of wasteful spending unless highly targeted approaches are used for the two different sectors. When a health care marketing company can successfully isolate engagement opportunities, all funds can be used to their best advantage, helping health care companies maximize their return on investment.

The Difference Between Individual and Family Healthcare Plans – Healthcare

The costs of medical care in US are soaring with each passing day and in this scenario, it has become quite confusing to identify a perfect health insurance plan. However, if an individual has a clear idea of what kind of coverage his health insurance plan should provide him with as well as the budget that he can afford for the same, then the decision of choosing a good health insurance plan definitely becomes easier.The two most popular health insurance plans available are individual and family healthcare plans. Even though other health plans seem less costly, the fact remains that individual and family health insurance plans prove to be much more cost effective in the long run. However, before people choose any of the two plans, it is vital to understand the points of difference between the two.Individual healthcare plans, as the name suggests, provides medical care benefits to a single person and is best suited for people who do not have any family to support or provide medical care to. The plan comes with various options and price ranges depending on the type as well as level of coverage desired by an individual. The cost generally varies according to the individual’s preference of visiting a doctor as well as the medical care facilities of their own choosing or a pre-assigned set of doctors and medical care facilities.Family healthcare plans are generally selected by people who want a health cover for themselves as well as their families. Since the plan is designed to provide for the medical care of more than one person, it naturally comes with a higher price tag than individual plans. The cost of the plan can vary from one family to another according to the gender, ages as well as the eating and drinking habits of the family members.

Healthcare Nursing Jobs – Healthcare

Nursing is an immense area of opportunities for all those people who are willing to offer help to others. This field of work have got different sorts of responsibilities and working environments so as to fit as per one’s personality and pursuits. This field is panoptic from non- general nursing tasks to direct form of nursing services in different hospitals.Standard Healthcare nursing jobs are always comes in mind whenever any individual hear about the term nurse. Such jobs are generally situated in the healthcare centers and also feature various forms of skills which are for sure required. The Healthcare nursing jobs in the healthcare and hospital centers contain:• Staff nurse – These nurses are responsible for taking care of the patients on the floor. Actually, these patients suffer from psychiatric illnesses and cancer. Moreover, these nurses also take care of the newly born babies and mothers, surgical patients and emergency patients.• Surgical nurse – The surgical nurses organize patients for their respective surgeries, also help the doctors in the surgery process, and are responsible for taking proper care of the patients after surgery.• Nurse Supervisor – The nurse supervisor are there to supervise the staff nurses working on the floor. Moreover, they sometime handle the work of firing and hiring the nurses for the staff.• House supervisor nurses – The house supervisor nurses to handle the work of almost entire hospital and also aid in assisting the staff nurses if they require any help.The medical and healthcare industry is always demanding suitably skilled and experienced nurses to fill current and future vacancies. If you simply want a holiday with a secure source of income for a specific timeframe, get in contact with a well regarded and experienced healthcare recruitment agency today.