Anthem Sues Express Scripts for Over-Charging

Hospitals and providers aren’t the only suspected culprits in over-charging payers for services. Pharmacy benefit managers may also bear some of the responsibility for escalating claim costs.

According to the article, Anthem sued Express Scripts for $15 billion last year, claiming the company had charged too much for drugs and sought to terminate a 10-year contract.

http://www.stl.news/st-louis-based-express-scripts-to-lose-its-biggest-client/22727/

Struggling with high-dollar claims? We can help.

 

Three of the Biggest Issues in Healthcare

Three of the biggest issues in healthcare today:

1. Transparency.

2. Transparency.

3. Transparency.

For payers, the lack of transparency represents hidden charges, overcharges, duplicate charges, unnecessary procedures and upcoded procedures that often lead to high-dollar claims. Most rely on in-network discounts to offset the cost and believe that in-network claims can’t be negotiated and willingly pay without review. But that’s not always the case.

Check out this article on medical billing transparency:

http://www.latimes.com/business/lazarus/la-fi-lazarus-healthcare-billing-transparency-20160816-snap-story.html

 

Have high-dollar in-network claims? Give us a call. We can help.

EthiCare Advisors, Inc. Welcomes Back Erik Fuglestad

Succasunna, NJ – April 11, 2017 – EthiCare Advisors, Inc. (www.ethicareadvisors.com) announced today that  Erik Fuglestad has returned to the company to bolster their continued success in saving clients’ money through their proven medical cost containment efforts.  Erik returns with a wealth of industry experience acquired from his earlier time with EthiCare, with previous cost containment organizations and from management positions with two dialysis provider organizations.

Erik re-joins EthiCare Advisors as Managing Director & Chair of the Management Committee.  In this new role he will oversee the Dialysis Team as well as  manage several strategic accounts. In addition, Erik’s responsibilities as Chair of the Management Committee include coordinating Operations and Sales departments. In this position, he is charged with setting and executing short-term and long-term organizational goals. Erik comments “I’m excited to return to my roots at EthiCare Advisors and look forward to working together with the team to further develop their already proven services and cost saving efforts.”

Mark S. Hartmann, Jr., MS, EthiCare’s Managing Partner & CEO said, “We’re thrilled to have Erik return to the team.  His extensive knowledge of the dialysis industry and unique understanding of our clients’ needs will benefit the entire team. It’s exciting for all of us to welcome him back but it’s our clients that will receive the greatest benefit.”

Erik is a graduate of the University of Massachusetts, Dartmouth with a Bachelor’s degree in Political Science and a minor in Spanish.

Erik can be reached at erik@ethicareadvisors.com or by calling 888.838.4422 extension 706

About EthiCare Advisors, Inc.

Founded in 2002, EthiCare Advisors, Inc. is an innovative medical claims settlement and cost containment company that help payors save money by focusing on the claims that ruin loss ratios, namely, catastrophic claims over $100,000 and the ultra-expensive dialysis claims. EthiCare is an independent, owner-operated private corporation and is a three-time honoree of the Inc. 500|5000 award as one of the fastest growing privately held companies in America. Mark S. Hartmann, Jr., MS, Managing Partner & CEO at EthiCare Advisors can be reached at Mark@EthiCareAdvisors.com or 888.838.4422 extension 703. www.EthiCareAdvisors.com

HealthCare.gov May Pick Your Next Health Plan

If your current insurer has left the Affordable Care Act marketplace for 2017, the federal government may very well choose your next health plan. Unless you act by either opting out of the exchange or by selecting an alternate plan, the government will choose a health plan for you under a new policy to make sure consumers maintain coverage in 2017.

Consumers in discontinued plans may very well receive a welcome kit from a new company and a bill for the January 2017 premium. They may be surprised to learn that they have been placed in a new health plan offered by a different insurance company, with different doctors and benefits.

The Administration says the assignment of plans will protect consumers from coverage lapses and it notes that consumers are free to choose another plan if they don’t like the one chosen for them. Without coverage or an exemption, consumers can face a tax penalty of $695 or more.

Click here to read the entire article from the NY Times.

To download this blog entry to PDF: HealthCare.gov May Pick Your Next Health Plan

ACA Special Enrollment Customers Destabilizing the Program

An Analysis by health consultancy firm Avalere found that people that enroll in the Affordable Care Act (ACA) during special enrollment periods have higher health-care costs than those who sign up during the open-enrollment period. In addition, these people are costing insurers more because of a measurement used to calculate their predicted health benefit is lower than the actual costs they end up using.

The ACA is designed to lower financial risks for insurers covering higher-cost customers. According to Avalere, the financial risk measurement used indicates a lower risk for special enrollment customers, when in reality the financial risk is greater. This means insurers are getting less money than they should from the program while the customers are actually costing them more.

Under the ACA risk adjustment program, health plans with low risk scores give up some of their revenue to plans with high risk scores. However, the data suggests the risk scores may not accurately predict actual costs.

Avalere’s report also indicates that special enrollment customers spend just 3.6 months enrolled in the plan, compared to 7.8 months for open-enrollment customers. The shorter time span means that insures are collecting fewer premiums from the special enrollment customers to cover their higher healthcare costs than the open-enrollment customers.

The Avalere report comes less than a month before the start of the 2017 ACA open-enrollment period. For most people enrollment is only allowed during this period that runs November 1 to January 31. However, the ACA does allow for special enrollment periods to people with certain life events, such as marriage; change in household size or to people who lose healthcare coverage.

Click here to read the entire article on CNBC.

To download this blog entry to PDF:  ACA Special Enrollment Customers Destabilizing the Program

DOL Announces 2 Month Extension on Public Comments for Form 5500 Modernization Proposals

The US Department of Labor recently announced a two-month extension on the comment period related to the Form 5500 Modernization Proposals. A Notice of Proposed Revision of Annual Information Return/Reports was published in the Federal Register of July 21, 2016. The new deadline for the public to submit comments is December 5, 2016; the original deadline was October 4, 2016.

Form 5500 is the federal government’s primary source of information about the operation, funding, assets, and investments of pensions and other employee benefit plans. The proposed revisions are intended to improve and modernize the Form. Some believe the new requirements will be too burdensome, especially for small employers. See our previous blog entry on July 29th for more details on these concerns.

Click here to download the DOL Press Release.

To download this blog entry to PDF:  DOL Announces 2 Month Extension on Public Comments for Form 5500

EthiCare Advisors, Inc. Relocates Corporate Headquarters

Succasunna, NJ – September 9, 2016 – EthiCare Advisors, Inc. is pleased to announce that it has moved its corporate headquarters to a larger space in nearby Succasunna, New Jersey. Succasunna, established around 1740, is an unincorporated community located within Roxbury Township in Morris County. The name Succasunna comes from the Lenni-Lenape Native American word for “land of black stones,” which refers to the iron-ore rich soil deposits found in the area.

The new address is:
EthiCare Advisors, Inc.
22 Route 10 West, Suite 201
Succasunna, New Jersey 07876

The phone number (888) 838-4422 and the fax number (866) 662-4121 will remain the same.

“Team EthiCare is very excited about the move to the new office space,” said Managing Partner & CEO, Mark S. Hartmann, Jr., MS. “This new, larger space will help ensure that EthiCare will have adequate room to deliver world-class service and achieve our long-term strategic goals.”

To learn about EthiCare and its services, please visit www.EthiCareAdvisors.com or contact the Managing Partner & CEO, Mark S. Hartmann, Jr., MS, at 888-838-4422 extension 703.

About EthiCare Advisors, Inc.

Founded in 2002, EthiCare Advisors, Inc. is an innovative medical claims settlement, cost containment and consulting services company that helps medical claim payers save money, by focusing on the claims that ruin loss ratios, namely, catastrophic claims over $100,000 and the ultra-expensive dialysis claims. EthiCare is an independent, owner-operated private corporation and is a three time honoree of the Inc. 500|5000 award as one of the fastest growing privately held companies in America. Mark S. Hartmann, Jr., MS, Managing Partner & CEO at EthiCare Advisors can be reached at Mark@EthiCareAdvisors.com or 888-838-4422 extension 703. Visit the website at www.EthiCareAdvisors.com.

 

To download to PDF:  Press Release – EthiCare Advisors, Inc. Relocates Corporate Headquarters

EthiCare Advisors, Inc. Launches HIPAA Compliance Solutions on the 20th Anniversary of HIPAA Becoming Law

Budd Lake, NJ – August 19, 2016 – EthiCare Advisors, Inc. is pleased to announce a valuable new service for our clients, HIPAA Compliance Solutions. This new service is being launched on the 20th anniversary of HIPAA being signed into law by President Bill Clinton on August 21, 1996.

HIPAA Compliance Solutions was created to help our clients abide by the strict guidelines set out in the law regarding the privacy and security of protected health information. Having the proper measurers in place to meet the requirements of HIPAA will help our clients protect their businesses and to be prepared if they ever face a federal compliance audit. Mark S. Hartmann, Jr., MS, EthiCare’s Managing Partner & CEO said, “Our clients were instrumental in the creation of this service, many stressed the need for assistance with HIPAA compliance. We think we have the solutions to help.”

The major components to good HIPAA compliance include the performance of regular Security Risk Assessments, updated and customized Policies & Procedures and systematic Employee Training. EthiCare will offer these and other compliance related services such as IT Security, Software Compliance and Breach Investigation.

To learn more about our new offering please contact Mark S. Hartmann, Jr., MS, directly at 888-838-4422 extension 703 or visit our HIPAA Compliance webpage.

About EthiCare Advisors, Inc.

Founded in 2002, EthiCare Advisors, Inc. is an innovative medical claims settlement, cost containment and consulting services company that helps medical claim payers save money, by focusing on the claims that ruin loss ratios, namely, catastrophic claims over $100,000 and the ultra-expensive dialysis claims. EthiCare is an independent, owner-operated private corporation and is a three time honoree of the Inc. 500|5000 award as one of the fastest growing privately held companies in America. Mark S. Hartmann, Jr., MS, Managing Partner & CEO at EthiCare Advisors can be reached at Mark@EthiCareAdvisors.com or 888-838-4422 extension 703. Visit our website at www.EthiCareAdvisors.com.

To Download to PDF:  Press Release – EthiCare Launches HIPAA Compliance Solutions – August 2016

DaVita Releases 2nd Quarter 2016 Results

DaVita HealthCare Partners Inc. announced financial results for the 2nd quarter ended, June 30, 2016. Reported net income attributable to DaVita Healthcare Partners Inc. for the quarter was $53.4 million, down $117.1 million (-69%) from the end of the 2nd quarter of 2015.

The current quarter net income includes certain items that DaVita does not believe are indicative of ordinary results, including a goodwill impairment charge ($176 million), a gain on the partial sale of Tandigm ($40.3 million), a loss on the sale of HCP Arizona ($10.5 million) and related income tax ($10.4 million). When adjusted for these items net income was $210.0 million for the quarter. The adjusted net income for the 2nd quarter 2015 was $211.2 million, essentially flat year over year.

Adjusted operating income for the 3 months ended June 30, 2016 was $475.3 million, a 1.9% decrease when compared to adjusted operating income of $484.6 million for the same time period last year.

Net Revenues for the 2nd quarter 2016 were $3,717.7, a $283.1 million (8.2%) increase over the quarter ended, June 30, 2015. Net operating revenues for US Dialysis and Related Lab Services grew 5.1% to $2,264 million in the 2nd quarter 2016, from $2,154 million in the 2nd quarter of 2015.

DaVita projects adjusted consolidated operating income for the full year 2016 to be in the range of $1.785 billion to $1.875 billion. This projection is lower than the previous guidance of $1.800 billion to $1.950 billion.

Click here to view DaVita’s complete 2nd quarter 2016 financial results.

To Download to PDF:  DaVita 2nd Quarter 2016 Results

 

For more information on EthiCare’s Dialysis Claims Settlement, please call Mark S. Hartmann, Jr., MS at (888) 838-4422 extension 703 or e-mail him at Mark@EthiCareAdvisors.com.