The federal government is currently challenging hospitals regarding excessive and inappropriate use of implantable cardiac devices (ICDs)... the same excessive and inappropriate use MedBen has been catching for years.
According to Modern Healthcare, hundreds of hospitals have settled with the Department of Justice as part of a multiyear, nationwide investigation into the suspected overuse of implantable cardioverter defibrillators, or ICDs. Settlement figures have not been made public, but individual SEC filings suggest the cumulative amount could total in the billions of dollars.
Under Medicare rules, ICDs cannot be implanted within 40 days of a heart attack or 90 days of bypass surgery or angioplasty. But upwards of 40% are implanted contrary to clinical practice guidelines, as they may not be medically necessary.
MedBen follows similar standards as Medicare, which reflect industry standards for appropriate placement of the cardiac devices. Additionally, MedBen has been performing clinical reviews on ICDs for its clients since 2007 – three years before the Office of the Inspector General started its review. During that time, we discovered and denied 63 inappropriate ICD device placements, saving almost $2.5 million for clients.
“This is a standard part of our clinical review process,” said Kurt Harden, President and COO of MedBen. “Coding software and standard claim payment reviews don’t catch these unnecessary charges. Only a detailed clinical review by cardiologists can root out unnecessary ICD placements.”
At $40,000 or more per unit, ICDs are among the most expensive devices to treat abnormal heart rate – and the devices need to be replaced every 5 years for the life of the patient. But in certain cases, a less expensive pacemaker, or even medication, may be sufficient to treat the condition.
Harden added that MedBen's comprehensive review process doesn't stop with ICD devices. "We employ a team of over 125 expert physician reviewers and a one-of-a-kind system that routes and reviews the claims quickly for clients. The savings are significant and our physicians step in to help the client and the member," he said.
Clients with questions regarding MedBen’s cardiovascular review procedures are welcome to contact Kurt Harden at 888-633-2364.
Today's the day when providers begin using the new ICD-10 medical coding system. The rollout comes after multiple deadline extensions -- but all along, MedBen has been preparing for the changeover and is ready to handle the new codes.
The new system increases the number of descriptive codes from ICD-9's 14,000 to 68,000. Such a substantial expansion has produced some, shall we say, interesting additions. From CIO:
"Some of the diagnostic codes can be archaic or absurd. Code Z63.1, for example, describes 'Problems in relationship with in-laws,' and code V97.33XD covers patients who were 'sucked into a jet engine.'"
Because doctors and hospitals only formally begin using the new codes today, MedBen won't begin receiving claims containing them for several days. But when we do, we're confident that our system components will able to accept and process ICD-10 codes without interruption to our day-to-day processes.
MedBen conducted internal system testing of the ICD-10 modifications as early as 2014. And throughout this year, we've conducted connectivity tests with an external vendor to ensure the accuracy of our work. All told, we've been fully compliant for the better part of 2015.
As claims with the new codes start coming in, there will undoubtedly be a "learning curve" as medical facilities get comfortable with the new codes. But with the advanced preparation, MedBen is confident that clients will see no increase in claims turnaround times. And we'll be ready to assist providers whenever necessary.
MedBen clients with questions regarding the ICD-10 coding system may contact MedBen Director of Data Processing and Technical Compliance Wayne Millard at email@example.com.
From 2008 through 2014, average U.S. prices for the most widely used brand-name drugs jumped 128%, according to prescription benefit manager Express Scripts. Not surprisingly, part of that increase is due to expensive new drugs that can cost as much as $100,000 or more for a year or course of treatment.
As you can see, there are a lot of factors at play in driving drug costs up... and it underscores the need for a pharmacy plan that helps to keep those costs more manageable.
MedBen offers a transparent, full pass-through Rx model -- 100% of discounts and paid pharmacy rebates go directly into the client's health plan -- that results in better savings. In addition, we offer superior discount rates, including generic discounts that are among the best in the industry.
MedBen supports its pharmacy program with strong, useful reports and recommendations that drive groups toward good plan design decisions. We'll work closely with your group to design a pharmacy plan that best meets member needs, with no hidden fees – instead, you get the maximum savings possible.
To learn more about MedBen pharmacy plans, contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
The drumbeat to repeal the Affordable Care Act's "Cadillac tax" is growing louder... and now includes a presidential candidate.
BenefitsPro reports that Independent Senator Bernie Sanders (Vt.) has joined seven Democrats in sponsoring a repeal measure. They join other Senate members who have supported bipartisan legislation to drop the measure, which will impose a 40% excise tax on individual health plans worth more than $10,200 and family plans worth more than $27,500.
An increasing number of Congressional Democrats have split from President Obama over the tax, due in part to pressure from labor unions over concern that the tax would affect benefit-rich union health plans. The White House, in turn, has criticized repeal efforts because they offer no replacement funding for the estimated $87 billion the tax would generate.
Sanders, a leading candidate for the Democratic Party's presidential nomination, has said the shortfall could be offset by creating a new tax on rich people.
The Cadillac tax is currently set to take effect in 2018.
Good news for those of you who got a flu shot in 2014 but still got sick: the U.S. Centers for Disease Control and Prevention reports that this year's vaccine should be more successful in helping you battle the bug.
Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, said that he expects the 2015-16 flu vaccine to 50-60% effective, in line with most years. This means that if you get a flu shot, your chances of getting the flu are reduced by as much as 60%.
According to HealthDay, last year's flu season was particularly severe because the predominant strain was an influenza A called H3N2. The vaccine didn't include that strain, and as such, was only 13% effective against it.
The vaccine for the 2015-16 season contains the H3N2 strain, Frieden said.
The CDC recommends that everyone 6 months of age and older get a flu shot every year. If you get a flu shot from someplace other than your family doctor's office, it’s a good idea to let him or her know during your next wellness exam. And if you have a fear of needles, talk to your doctor about using a nasal spray flu vaccine instead.
As you know, the Affordable Care Act (ACA) and its supporting regulations require that all employers offering health benefits to their employees report on certain health coverage information. Health coverage data collected during 2015 must be aggregated and reported to employees no later than January 31, 2016 on IRS Form 1095 and reported to the IRS no later than February/March 2016 (depending on filing requirements) on IRS form 1094. Applicable Large Employers (those with 50 or more employees) must report using the IRS’ C-series forms and small employers offering coverage (those with fewer than 50 employees) must report using the IRS’ B-series forms.
To assist our clients who are Applicable Large Employers (ALE) with this important task, MedBen has contracted with an outside vendor to provide ACA-related services, including 6055/6056 reporting, through proprietary on-line applications. After spending the summer vetting multiple companies, we chose one that we found to be among the most knowledgeable and best priced vendors in this market. In doing so, we can offer several service options to help ALEs create and distribute Form 1095-C to employees and prepare and file Form 1094-C with the IRS.
In addition, MedBen will be able to assist our clients who are small employers by preparing related IRS Forms (1095-B – employee notice and 1094-B – IRS transmittal) for a nominal fee.
We understand that this subject is confusing and that there is a lot of information you still need. That said, we wanted to provide clients with information about a company that is among the top vendors in the area of ACA data management and reporting. Over the next few weeks, our clients will be getting that information through various means, including educational seminars and webinars on the subject.
We also know that January still seems a long way off, but please do not wait to consider purchasing these services. Clients who wish to purchase these services through MedBen, please let us know immediately. If you are planning to create these forms yourself or you’re working with another vendor, we would appreciate knowing that too. Either way, it is important that you start planning now.
MedBen clients with questions regarding the data reporting services available, please contact your Group Service Representative or Caroline Fraker, Vice President of Compliance & Chief Privacy Officer, at email@example.com.
"Members of Congress from both parties [...] are calling for changes in the Affordable Care Act to prevent premium increases that are expected to affect workers at many small and midsize companies next year," The New York Times reports:
"At issue is a provision of the health care law that expands the definition of a 'small employer' to include companies with 51 to 100 employees, subjecting them to stringent insurance regulation starting on Jan. 1. States have historically defined small employers as those with 50 or fewer employees.
"Because many organizations with 51 to 100 employees will be reclassified as small employers, they will have to offer a package of “essential health benefits” specified by the health law — in some cases more generous than what they now offer. Insurers will no longer be allowed to set premiums for such groups based on their claims history, industry or size — factors now commonly considered.
"Legislation to let states keep the current definition of 'small employer' has won support from 229 House members, including 43 Democrats. The legislation has been endorsed by 43 senators, including 10 Democrats.”
MedBen clients who have questions regarding employer shared responsibility penalties under the ACA are welcome to contact Vice President of Compliance Caroline Fraker at firstname.lastname@example.org.
Back in the day -- like, four years ago -- there seemed to be a growing consensus that Congress would overturn the provision of the Affordable Care Act that required a doctor's prescription to purchase over-the-counter drugs (OTCs) with FSA or HSA funds. Ultimately, various bills went nowhere, and the matter was dropped... until now.
Business Insurance reports that the House Ways and Means Committee yesterday approved a new bill that would once again allow health care plan members with an FSA, HSA or HSA to use their tax-free contributions to pay for OTCs. The legislation was introduced by Reps. Lynn Jenkins, R-Kan., and Ron Johnson, R-Wis.
This legislation “will help so many families across the country,” said Rep. Erik Paulsen, R-Minn., referring to the restoration of the tax break. But Rep. Xavier Becerra, D-Calif. countered that restoring the tax break would only be “fair if everyone is treated the same,” including individuals not covered by tax-free accounts.
Unlike earlier attempts to overturn the provision, both houses of Congress now have Republican majorities, making passage of the legislation more likely... though, of course, President Obama can still veto the bill if it does get that far. And the 2013 elimination of the "use-it-or-lose-it" rule for FSAs makes the matter somewhat less pressing, as fewer members need to use up leftover account dollars at the end of the plan year.
Older adults at high risk of heart disease could benefit from a daily aspirin, according to the U.S. Preventive Services Task Force.
In a newly-released draft report, the medical organization recommends that men and women between the ages of 50 and 69 take a low-dose (about 81 milligrams) aspirin every day if they have a 10% or greater risk of having a heart attack or stroke during the next 10 years. The aspirin regimen may also help those who have a higher risk for developing colon cancer.
The task force added that the benefits of aspirin are strongest in people 50 to 59, but that people 60 to 69 “can also benefit” after consulting their doctors.
It should be noted that taking a daily aspirin is not without risks of its own, such as bleeding in the stomach and brain -- and carries greater risks still for people with ulcers or kidney or liver problems. Therefore, the guidelines recommend that potential candidates seek a medical opinion before beginning an aspirin regimen.
Lowering your blood pressure to a healthier level can have a huge impact on your well-being, NPR reports:
"Cutting blood pressure below the currently recommended target can significantly reduce the rate of heart attacks, strokes, heart failure and deaths, federal health officials reported [on September 11].
"The findings come from the largest study ever conducted to examine whether reducing systolic blood pressure — the top number patients get when examined — below the currently recommended goal would be beneficial.
"The study was halted early when an analysis indicated the benefits were clear, officials said. 'This is landmark study,' says Dr. Gary Gibbons, director of the National Heart, Lung and Blood Institute, which sponsored the study. 'We think that this study will clearly have an impact on patient care for those with hypertension.'"
Subjects in the study who got their systolic blood pressure down to 120 or lower reduced heart attacks, strokes and heart failure by almost a third and the risk of death by almost a quarter. This was a notable improvement compared to a second group in the study with a target systolic of 140.
“A survey of 60 leading health care vendors conducted by Aon, a major human resources consulting firm, shows that the cost of prescription drugs is on pace to increase by 10 percent in the next year, up from the estimated 6.3 increase over the past year. The cost of specialty pharmacy drugs is rising even faster — 22.7 percent in the coming year versus the estimated 18.2 percent rise over the past 12 months.
“'There is a robust pipeline of specialty drugs, which is contributing to the dramatic spike we see in cost trend,' said John Malley, head of Aon Health’s Innovation Pharmacy Team. 'Oncology drugs have been filling the pipeline and will be the largest category of specialty drug approvals in the near future. Specialty drugs for cholesterol may also have a significant impact, given that the market has not had this type of drug for such a prevalent disease state before.'”
The rising trend in prescription drug costs -- in particular, specialty drug costs -- reflects the growing importance medications play in many of our everyday lives. It also highlights the usefulness of a strong pharmacy plan to help keep those costs down.
In 2014, MedBen clients saw their pharmacy plan spending rise just an average of 0.5%. We provide multiple Rx solutions to help businesses keep drug costs in check, such as returning to clients that which is rightfully theirs. Rather than withholding part of a pharmacy rebate, we give 100% of the rebate back to the client.
Additionally, MedBen helps clients balance plan member needs with cost considerations. In the case of specialty drugs, we employ strategies to ensure that employers don't get stuck paying for high-cost medications when less expensive alternatives are available.
To learn more about the MedBen Advantage for pharmacy plans, we invite you to contact Vice President of Sales & Marketing Brian Fargus at email@example.com.
A new study suggests that diabetes continues to be a national problem -- and reinforces the need for a greater emphasis on personal wellness.
According to a paper published in JAMA, 12.4% of U.S. adults had diabetes from 2011 to 2012. Most of these diabetics are type 2, which typically results from poor diet, obesity and lack of exercise. Another 37% of Americans were considered "pre-diabetic" -- their elevated blood sugar level puts them at greater risk for developing the disease.
From the "half glass full" perspective, these findings can be viewed as positives, because while the proportion of diabetics hasn't gone down, it hasn't increased, either. In fact, the percentage of people diagnosed with diabetes remained steady from 2008 to 2012.
Still, the reality remains that many individuals have health issues that could be reduced or avoided altogether. And in the case of type 2 diabetes, there are measures employers can take to promote better habits in the workplace, such as offering healthier vending machine fare and paying a portion of local gym memberships.
Another effective method to reduce the percentage of diabetics is through one-on-one nurse coaching, like that offered through MedBen WellLiving. An RN Health Consultant contacts program members at high risk of type 2 diabetes to offer customized counseling. Those who choose to use the service get individualized, confidential disease monitoring on a scheduled basis.
Specialty care is just one of the ways MedBen WellLiving helps to reduce the risk of critical diseases. To learn more about how a focused wellness strategy can benefit your business, visit MedBen.com or contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
Last week, the U.S. Department of Health & Human Services (HHS) proposed new Affordable Care Act regulations designed to eliminate discrimination toward transgender people in the area of health care benefits, including certain gender transition services.
“Individuals cannot be denied health care or health coverage based on their sex, including their gender identity,” said a fact sheet released by the HHS. “Explicit categorical exclusions in coverage for all health-care services related to gender transition are facially discriminatory.”
The new rules would apply to insurers that participate in the state and federal marketplaces, as well as health care providers that get federal financial assistance. While the rules don't explicitly require insurers to cover gender transition surgery or related treatment, those that deny medically necessary services related to gender transition by a man who identifies as a woman (or vice versa) could face questions, said Jocelyn Samuels, head of the HHS Office for Civil Rights.
“It is basically a requirement that insurers use nondiscriminatory criteria,” Samuels told reporters.
It is important to note that currently, these new rules do not apply to employers who self-fund their health care benefits. Of course, that could change in the future.
HHS is seeking feedback and public comment on the proposed rule by no later than November 6, 2015. You can submit comments, identified by RIN 0945-AA02, electronically through regulations.gov, or by mail to the HHS Office for Civil Rights.
MedBen clients with questions regarding this rule are welcome to contact Vice President of Compliance Caroline Fraker at email@example.com.
The staff of MedBen would like to wish you and your family a safe and relaxing Labor Day!
MedBen will be closed on Monday, September 7 and will reopen at 8:00 a.m. the following day. But even when we’re out of the office, MedBen Access stays open around the clock.
Benefits and Claims Information: Plan members can use MedBen Access to check the status of a health claim, review benefit coverages, and more. To visit, simply visit MedBen.com and click on the “MedBen Access” link.
Rx Resources: This useful feature, available through MedBen Access to plan members who use PDMI as their pharmacy benefits manager, allows individuals to review personal prescription detail and benefit coverage, and compare lower cost alternatives. Click a plan member name under “My Rx Claims” on the MedBen Access sidebar to open.
FSA/HRA Online System: MedBen FSA and HRA members can use this site to review claim submissions, check payments issued, see total deposits posted to date and get answers to a variety of questions. In MedBen Access, select the “FSA/HRA Online Inquiry” option under the “My Plan” section on the sidebar. Alternately, you may log in directly to the site (using a separate User ID and PIN) by going to MedBen.com, clicking on the “Plan Members (Insureds)” button and selecting “FSA-HRA Account Information” from the “Online Services” drop-down menu.
One more reminder: MedBen.com also offers a variety of resources, including links to additional online services, downloadable forms and network directories. Separate areas are available for employers, insureds and providers – just select the appropriate button to enter!
Prostate cancer is one of the most common cancers among men. Fortunately, it is seldom fatal – in fact, more than two million adult males can today call themselves survivors of the disease.
While there is no known cause of prostate cancer, researchers do know that it begins when some cells in the prostate become mutated, changing the DNA. The cancer usually grows slowly and may not cause any harm, though in rare cases it spreads at a much quicker pace.
Detecting prostate cancer can be difficult, as symptoms may develop only as the disease becomes more aggressive. There are many symptoms and signs related to this cancer, but some of the most common include trouble urinating, pelvic discomfort, and bone pain.
Prostate cancer testing is no longer recommended as a standard measure for men 50 and over. Instead, the American Cancer Society (ACS) encourages men to discuss options with their family doctor, who can then help them make an educated decision about testing based on family history, lifestyle and symptoms.
The ACS also offers these suggestions to help men protect themselves from the disease: Eat at least 2½ cups of a wide variety of vegetables and fruits every day, keep physically active, and stay at a healthy weight.
What does sub-Saharan trade with the United States have to do with health care reform? Both were modified as part of the Trade Preferences Extension Act of 2015 (TPEA), passed into law earlier this year.
As part of this trade bill, Congress passed several tax provisions, including the increase in penalties applicable to employer plan sponsors’ Affordable Care Act reporting requirements. In particular, the TPEA increased penalties for an employer’s failure to file or furnish “information returns and payee statements.” This includes W-2 and 1099 forms as well as the newly required 1095-B and 1095-C forms first due this coming January, 2016.
Where prior to the passage of the TPEA the penalty for failing to file an information return was $100 for each return with respect to which a failure occurs, now the penalty is $250 per failure – more than twice the original penalty. Maximum annual penalties for non-willful failures to file increase to $3,000,000, double the original $1,500,000 penalty. (See Internal Revenue Code Section 6721.) Below is a listing of the penalty increases mandated by the TPEA that affect employer informational returns:
There are additional penalties that apply to other delinquencies, including penalties for intentional disregard, that have been increased along with the above.
These penalties are particularly worrisome given the complicated nature of next year’s 1095 series reporting requirements. That means that if you miss an employee’s 1095 form, there will be both a penalty for failing to deliver it to the employee as well as a penalty for failing to file it with the IRS. The good news? The IRS has indicated that they do not intend to impose these penalties on employers who file the ACA reporting forms (1094/1095 series) in a timely manner, if the employer completes the forms in good faith.
MedBen is currently negotiating with vendors to assist you in completing these forms. We will let you know when we select one that we feel will provide you with quality service for a reasonable price. In the meantime, MedBen clients who have any questions may contact Vice President of Compliance Caroline Fraker at firstname.lastname@example.org.
The state of health care costs in 2015, summed up in two new surveys (per Business Insurance):
"Large employers are projecting health care costs before implementing plan design changes to increase an average of 6% in 2016, according to a National Business Group on Health survey published earlier this month.
"And according to an Arthur J. Gallagher & Co. survey of smaller employers, most of which have less than 1,000 employees, released Friday, 44% reported premium rate hikes of 6% or more in 2014. Twenty-three percent saw rates in the double digits, the survey showed."
Surveys like this, coupled with other recent reports, portend larger health care spending increases in the coming years following nearly a decade of slow growth -- and emphasize the need for sound benefits management solutions like those offered by MedBen. Because unlike national trends, on average, our clients actually saw lower costs in 2014 than in the prior year.
A closer look at MedBen’s municipality and hospital employers, two of the company’s biggest blocks of business, reveals that municipal claims costs increased just 2.5% in 2014, while hospital costs decreased by 1%. Likewise, our clients' pharmacy plan spending only rose an average of 0.5% in 2014, compared to 13% nationwide.
As to how we help businesses keep their costs down... well, we invite you to visit our website and learn about The MedBen Advantage. Or contact our Vice President of Sales & Marketing Brian Fargus at email@example.com.
Dental benefits are sometimes an afterthought for employers when developing a group health care plan. But as a recent USA Today article makes clear, such coverage offers a valuable advantage -- financial as well as health-wise.
According to the article, "an analysis of the most recent federal data by the American Dental Association shows dental ER visits doubled from 1.1 million in 2000 to 2.2 million in 2012, or one visit every 15 seconds." Most of those patients lack adequate dental coverage.
People with dental problems typically visit ERs when the pain from a toothache becomes overwhelming. Unfortunately, the most help they can provide are painkillers and antibiotics -- short-term fixes at best. Even so, the cost is more than three times as much as a routine dental appointment, averaging $749 a visit.
MedBen Dental helps employers reduce the potential risk of unnecessary ER visits. Much like an annual wellness exam from the family doctor, regular dental exams enable a dentist to monitor the condition of the teeth and gums over time, making it easier to detect subtle changes before a condition escalates to the point where far more costly care is required.
For employers, offering MedBen Dental also serves as an inexpensive incentive for potential employees to join your company, especially when offered as part of a larger health care package.
Dental coverage is relatively inexpensive, but it pays huge dividends. To learn more about how it can benefit your employees and your bottom line, contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.
Turns out there's quite a number of "benefit-rich plans" out there -- that is, if you define "benefit-rich" by the Obama Administration's criteria of which employers are likely to take a financial hit when the so-called "Cadillac tax" rolls out in 2018.
Forbes.com reports that, based on research by the Kaiser Family Foundation, 26% of employers could initially be affected by the regulation if they don't scale down their benefit structures. That number could rise to 30% of employers in 2023, and jump up to 42% by 2028 "if their plans remain unchanged and health benefit costs increase at expected rates."
Under the Affordable Care Act, employers will pay a 40% tax on costs of health plans that are above $10,200 per individual and $27,500 for family coverage.
The KFF brief also notes that employers are already taking measures to sidestep the tax, such as raising copays and deductibles, reducing covered services and narrowing provider networks. "For the most part these changes will result in employees paying for a greater share of their healthcare out-of-pocket," wrote Kaiser vice presidents Gary Claxton and Larry Levitt.
As we posted on the MedBen Blog earlier this month, the IRS has requested feedback on a recent Notice pertaining to the Cadillac tax. Here's how to share your thoughts by the October 1, 2015 deadline:
As always, MedBen clients with questions about any aspect of the ACA are welcome to contact Vice President of Compliance Caroline Fraker at email@example.com.
Employee awareness is critical to the success of a company wellness program, yet many employees apparently aren't getting the message... which is why MedBen WellLiving takes an "all in" approach to worksite wellness.
About 7 out of 10 employers offer some type of wellness program, a Society for Human Resource Management (SHRM) study recently found. But when a separate survey by communications firm Brodeur Partners asked employees if their company had such a program in place, only about one-third of respondents said they did.
Why the disparity? Brodeur Partners CEO Andrea Coville has two theories: One, employers have a wellness program but they haven’t fully communicated its existence to their workers; or two, the plan is so weak employees don't consider it to be a wellness program.
MedBen WellLiving wellness programs put participant awareness front and center, working with clients to ensure that employer and employer alike benefit from it. We start by using an "opt-out" approach, meaning that all employees and their dependents on the health plan are considered participants in the wellness program unless they indicate otherwise.
Of course, automatic enrollment doesn't ensure actual participation. So WellLiving helps clients build further awareness through program handouts, posters and a monthly WellCare newsletter. Incentives are introduced and promoted to encourage buy-in. And when a plan member is determined to be at risk for developing a chronic condition, an RN Health Consultant reaches out to provide individualized counseling.
Having a wellness program is a good start, but real success only comes when employees are fully engaged -- and MedBen WellLiving can help your business achieve that goal. To learn more, contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.