Small Business Health Insurance - The Best Policy Is A Great Agent

I have been a health insurance broker for over a decade and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. Unfortunately, insurance companies are driven by profits, not people (albeit they need people to make profits). If the insurance company can find a legal reason not to pay a claim, chances are they will find it, and you the consumer will suffer. However, what most people fail to realize is that there are very few "loopholes" in an insurance policy that give the insurance company an unfair advantage over the consumer. In fact, insurance companies go to great lengths to detail the limitations of their coverage by giving the policy holders 10-days (a 10-day free look period) to review their policy. Unfortunately, most people put their insurance cards in their wallet and place their policy in a drawer or filing cabinet during their 10-day free look and it usually isn't until they receive a "denial" letter from the insurance company that they take their policy out to really read through it.

The majority of people, who buy their own health insurance, rely heavily on the insurance agent selling the policy to explain the plan's coverage and benefits. This being the case, many individuals who purchase their own health insurance plan can tell you very little about their plan, other than, what they pay in premiums and how much they have to pay to satisfy their deductible.

For many consumers, purchasing a health insurance policy on their own can be an enormous undertaking. Purchasing a health insurance policy is not like buying a car, in that, the buyer knows that the engine and transmission are standard, and that power windows are optional. A health insurance plan is much more ambiguous, and it is often very difficult for the consumer to determine what type of coverage is standard and what other benefits are optional. In my opinion, this is the primary reason that most policy holders don't realize that they do not have coverage for a specific medical treatment until they receive a large bill from the hospital stating that "benefits were denied."

Sure, we all complain about insurance companies, but we do know that they serve a "necessary evil." And, even though purchasing health insurance may be a frustrating, daunting and time consuming task, there are certain things that you can do as a consumer to ensure that you are purchasing the type of health insurance coverage you really need at a fair price.

Dealing with small business owners and the self-employed market, I have come to the realization that it is extremely difficult for people to distinguish between the type of health insurance coverage that they "want" and the benefits they really "need." Recently, I have read various comments on different Blogs advocating health plans that offer 100% coverage (no deductible and no-coinsurance) and, although I agree that those types of plans have a great "curb appeal," I can tell you from personal experience that these plans are not for everyone. Do 100% health plans offer the policy holder greater peace of mind? Probably. But is a 100% health insurance plan something that most consumers really need? Probably not! In my professional opinion, when you purchase a health insurance plan, you must achieve a balance between four important variables; wants, needs, risk and price. Just like you would do if you were purchasing options for a new car, you have to weigh all these variables before you spend your money. If you are healthy, take no medications and rarely go to the doctor, do you really need a 100% plan with a $5 co-payment for prescription drugs if it costs you $300 dollars more a month?

Is it worth $200 more a month to have a $250 deductible and a $20 brand name/$10 generic Rx co-pay versus an 80/20 plan with a $2,500 deductible that also offers a $20 brand name/$10generic co-pay after you pay a once a year $100 Rx deductible? Wouldn't the 80/20 plan still offer you adequate coverage? Don't you think it would be better to put that extra $200 ($2,400 per year) in your bank account, just in case you may have to pay your $2,500 deductible or buy a $12 Amoxicillin prescription? Isn't it wiser to keep your hard-earned money rather than pay higher premiums to an insurance company?

Yes, there are many ways you can keep more of the money that you would normally give to an insurance company in the form of higher monthly premiums. For example, the federal government encourages consumers to purchase H.S.A. (Health Savings Account) qualified H.D.H.P.'s (High Deductible Health Plans) so they have more control over how their health care dollars are spent. Consumers who purchase an HSA Qualified H.D.H.P. can put extra money aside each year in an interest bearing account so they can use that money to pay for out-of-pocket medical expenses. Even procedures that are not normally covered by insurance companies, like Lasik eye surgery, orthodontics, and alternative medicines become 100% tax deductible. If there are no claims that year the money that was deposited into the tax deferred H.S.A can be rolled over to the next year earning an even higher rate of interest. If there are no significant claims for several years (as is often the case) the insured ends up building a sizeable account that enjoys similar tax benefits as a traditional I.R.A. Most H.S.A. administrators now offer thousands of no load mutual funds to transfer your H.S.A. funds into so you can potentially earn an even higher rate of interest.

In my experience, I believe that individuals who purchase their health plan based on wants rather than needs feel the most defrauded or "ripped-off" by their insurance company and/or insurance agent. In fact, I hear almost identical comments from almost every business owner that I speak to. Comments, such as, "I have to run my business, I don't have time to be sick! "I think I have gone to the doctor 2 times in the last 5 years" and "My insurance company keeps raising my rates and I don't even use my insurance!" As a business owner myself, I can understand their frustration. So, is there a simple formula that everyone can follow to make health insurance buying easier? Yes! Become an INFORMED consumer.

Every time I contact a prospective client or call one of my client referrals, I ask a handful of specific questions that directly relate to the policy that particular individual currently has in their filing cabinet or dresser drawer. You know the policy that they bought to protect them from having to file bankruptcy due to medical debt. That policy they purchased to cover that $500,000 life-saving organ transplant or those 40 chemotherapy treatments that they may have to undergo if they are diagnosed with cancer.

So what do you think happens almost 100% of the time when I ask these individuals "BASIC" questions about their health insurance policy? They do not know the answers! The following is a list of 10 questions that I frequently ask a prospective health insurance client. Let's see how many YOU can answer without looking at your policy.

1. What Insurance Company are you insured with and what is the name of your health insurance plan? (e.g. Blue Cross Blue Shield-"Basic Blue")

2. What is your calendar year deductible and would you have to pay a separate deductible for each family member if everyone in your family became ill at the same time? (e.g. The majority of health plans have a per person yearly deductible, for example, $250, $500, $1,000, or $2,500. However, some plans will only require you to pay a 2 person maximum deductible each year, even if everyone in your family needed extensive medical care.)

3. What is your coinsurance percentage and what dollar amount (stop loss) it is based on? (e.g. A good plan with 80/20 coverage means you pay 20% of some dollar amount. This dollar amount is also known as a stop loss and can vary based on the type of policy you purchase. Stop losses can be as little as $5,000 or $10,000 or as much as $20,000 or there are some policies on the market that have NO stop loss dollar amount.)

4. What is your maximum out of pocket expense per year? (e.g. All deductibles plus all coinsurance percentages plus all applicable access fees or other fees)

5. What is the Lifetime maximum benefit the insurance company will pay if you become seriously ill and does your plan have any "per illness" maximums or caps? (e.g. Some plans may have a $5 million lifetime maximum, but may have a maximum benefit cap of $100,000 per illness. This means that you would have to develop many separate and unrelated life-threatening illnesses costing $100,000 or less to qualify for $5 million of lifetime coverage.)

6. Is your plan a schedule plan, in that it only pays a certain amount for a specific list of procedures? (e.g., Mega Life & Health & Midwest National Life, endorsed by the National Association of the Self-Employed, N.A.S.E. is known for endorsing schedule plans) 7. Does your plan have doctor co-pays and are you limited to a certain number of doctor co-pay visits per year? (e.g. Many plans have a limit of how many times you go to the doctor per year for a co-pay and, quite often the limit is 2-4 visits.)

8. Does your plan offer prescription drug coverage and if it does, do you pay a co-pay for your prescriptions or do you have to meet a separate drug deductible before you receive any benefits and/or do you just have a discount prescription card only? (e.g. Some plans offer you prescription benefits right away, other plans require that you pay a separate drug deductible before you can receive prescription medication for a co-pay. Today, many plans offer no co-pay options and only provide you with a discount prescription card that gives you a 10-20% discount on all prescription medications).

9. Does your plan have any reduction in benefits for organ transplants and if so, what is the maximum your plan will pay if you need an organ transplant? (e.g. Some plans only pay a $100,000 maximum benefit for organ transplants for a procedure that actually costs $350-$500K and this $100,000 maximum may also include reimbursement for expensive anti-rejection medications that must be taken after a transplant. If this is the case, you will often have to pay for all anti-rejection medications out of pocket).

10. Do you have to pay a separate deductible or "access fee" for each hospital admission or for each emergency room visit? (e.g. Some plans, like the Assurant Health's "CoreMed" plan have a separate $750 hospital admission fee that you pay for the first 3 days you are in the hospital. This fee is in addition to your plan deductible. Also, many plans have benefit "caps" or "access fees" for out-patient services, such as, physical therapy, speech therapy, chemotherapy, radiation therapy, etc. Benefit "caps" could be as little as $500 for each out-patient treatment, leaving you a bill for the remaining balance. Access fees are additional fees that you pay per treatment. For example, for each outpatient chemotherapy treatment, you may be required to pay a $250 "access fee" per treatment. So for 40 chemotherapy treatments, you would have to pay 40 x $250 = $10,000. Again, these fees would be charged in addition to your plan deductible).

Now that you've read through the list of questions that I ask a prospective health insurance client, ask yourself how many questions you were able to answer. If you couldn't answer all ten questions don't be discouraged. That doesn't mean that you are not a smart consumer. It may just mean that you dealt with a "bad" insurance agent. So how could you tell if you dealt with a "bad" insurance agent? Because a "great" insurance agent would have taken the time to help you really understand your insurance benefits. A "great" agent spends time asking YOU questions so s/he can understand your insurance needs. A "great" agent recommends health plans based on all four variables; wants, needs, risk and price. A "great" agent gives you enough information to weigh all of your options so you can make an informed purchasing decision. And lastly, a "great" agent looks out for YOUR best interest and NOT the best interest of the insurance company.

So how do you know if you have a "great" agent? Easy, if you were able to answer all 10 questions without looking at your health insurance policy, you have a "great" agent. If you were able to answer the majority of questions, you may have a "good" agent. However, if you were only able to answer a few questions, chances are you have a "bad" agent. Insurance agents are no different than any other professional. There are some insurance agents that really care about the clients they work with, and there are other agents that avoid answering questions and duck client phone calls when a message is left about unpaid claims or skyrocketing health insurance rates.

Remember, your health insurance purchase is just as important as purchasing a house or a car, if not more important. So don't be afraid to ask your insurance agent a lot of questions to make sure that you understand what your health plan does and does not cover. If you don't feel comfortable with the type of coverage that your agent suggests or if you think the price is too high, ask your agent if s/he can select a comparable plan so you can make a side by side comparison before you purchase. And, most importantly, read all of the "fine print" in your health plan brochure and when you receive your policy, take the time to read through your policy during your 10-day free look period.

If you can't understand something, or aren't quite sure what the asterisk (*) next to the benefit description really means in terms of your coverage, call your agent or contact the insurance company to ask for further clarification.

Furthermore, take the time to perform your own due diligence. For example, if you research MEGA Life and Health or the Midwest National Life insurance company, endorsed by the National Association for the Self Employed (NASE), you will find that there have been 14 class action lawsuits brought against these companies since 1995. So ask yourself, "Is this a company that I would trust to pay my health insurance claims?

Additionally, find out if your agent is a "captive" agent or an insurance "broker." "Captive" agents can only offer ONE insurance company's products." Independent" agents or insurance "brokers" can offer you a variety of different insurance plans from many different insurance companies. A "captive" agent may recommend a health plan that doesn't exactly meet your needs because that is the only plan s/he can sell. An "independent" agent or insurance "broker" can usually offer you a variety of different insurance products from many quality carriers and can often customize a plan to meet your specific insurance needs and budget.

Over the years, I have developed strong, trusting relationships with my clients because of my insurance expertise and the level of personal service that I provide. This is one of the primary reasons that I do not recommend buying health insurance on the Internet. In my opinion, there are too many variables that Internet insurance buyers do not often take into consideration. I am a firm believer that a health insurance purchase requires the level of expertise and personal attention that only an insurance professional can provide. And, since it does not cost a penny more to purchase your health insurance through an agent or broker, my advice would be to use Ebay and Amazon for your less important purchases and to use a knowledgeable, ethical and reputable independent agent or broker for one of the most important purchases you will ever make....your health insurance policy.

Lastly, if you have any concerns about an insurance company, contact your state's Department of Insurance BEFORE you buy your policy. Your state's Department of Insurance can tell you if the insurance company is registered in your state and can also tell you if there have been any complaints against that company that have been filed by policy holders. If you suspect that your agent is trying to sell you a fraudulent insurance policy, (e.g. you have to become a member of a union to qualify for coverage) or isn't being honest with you, your state's Department of Insurance can also check to see if your agent is licensed and whether or not there has ever been any disciplinary action previously taken against that agent.

In closing, I hope I have given you enough information so you can become an INFORMED insurance consumer. However, I remain convinced that the following words of wisdom still go along way: "If it sounds too good to be true, it probably is!" and "If you only buy on price, you get what you pay for!"

©2007 Small Business Insurance Services, Inc. http://www.smallbusinessinsuranceservices.com

C. Steven Tucker, is the President of Small Business Insurance Services, Inc. and has been a Licensed Mult-State Insurance Broker serving the small business and self-employed market for over a decade. Mr. Tucker believes an informed insurance consumer makes the best health insurance purchasing decisions. Mr. Tucker has written several articles that focus on small business health insurance, which can be read on a number of web sites.

Mr. Tucker's blog can be read at http://www.smallbusinessinsuranceservices.vox.com

If you have general questions regarding health insurance, or you are in the market to purchase a health insurance plan, you can contact Mr. Tucker through his web site at http://www.smallbusinessinsuranceservices.com,

via Email at smallbusinssvcs@aol.com or by plone, toll-free at 1-866-SBIS123 (724-7123)

Low Cost Health Insurance Options Are Overlooked

Let's stick with the concept that something is better than nothing. Low cost health insurance alternatives are the only solution to millions of people right now. If you're uninsured you either don't have a job, don't have enough money to pay for an expensive plan or you don't have good enough health for a standard plan. Which category are you in?

This article is dedicated to a couple of overlooked health care options that millions of uninsured Americans can afford yet they don't have. Spreading awareness about these options is vital in helping improve our health care crisis.

The negative affects of not having health insurance are very straight forward. You end up with medical collections that ruin your credit and tax payers cover your bill. This is one of the reasons health care costs keep going up as the insured are now under more strain to help compensate for all the uninsured. Finding a low cost health insurance alternative that actually is within your financial budget can save you from adding to this problem.

There are two plans cheaper than short term health insurance that stick out and remain ready and waiting for you to jump on. The great thing about these plans is you don't have to worry about being turned down. Anyone under 64yrs of age can enroll. If you've already checked for a short term plan and can't afford the premium then this is your solution. One of these two low cost health insurance options will be within your reach.

Your first option is a form of supplemental health care. A fixed indemnity plan pays you a fixed amount of cash when qualified medical services are needed. The coverage is very broad and for many individuals a fixed indemnity plan is all they will ever need. Only a major, life changing health condition would be enough to outweigh the protection of these plans. A fixed indemnity plan is one of the most valuable dollar for dollar health care options available today.

The plan provides network discounts like an HMO, so you save money on your medical needs. Most insurers give you a card that you use like a credit card when you need a medical service. Fixed indemnity plans are low cost health insurance plans simply because you pay the monthly premium and don't have to worry about a deductible or co-insurance costs. There is a set cash amount credited you for each service you receive. For example, a visit to your doctor would bring you a $50 credit. If you needed a name brand drug prescribed while you're there, you would receive a $25 credit for the prescription.

The plan also covers allergy shots and immunizations, outpatient medical events, surgery, anesthesia, ground and air ambulance, emergency room or urgent care and inpatient hospital confinement. The primary insured on the plan also receives a built in life insurance policy to cover final expenses. If you're stuck in the hospital, you'll receive $2,000 a day for illnesses and $4,000 a day for injuries. As you can see, there is plenty of value in these plans, but how much do they cost you might wonder?

The cost of your premium for a fixed indemnity plan is based strictly on your age, but can also be affected by where you live. Pre-existing conditions are not covered under these plans so you're not penalized for any health conditions including smoking. In most cases, the premiums are slightly higher than short term premiums...usually between $20-$50, depending on the deductible and co-insurance you might choose for a short term plan. As stated though, you avoid the cost of deductibles and co-insurance with a fixed indemnity plan.

For a base example, a 35 yr old male would pay $120 a month. This same male with an equal aged spouse and one child would run a monthly premium of $330, a slight discount for family pricing. By way of comparison, you could easily pay $330 just for yourself without factoring in the rest of your family or deductibles and co-insurance using a traditional health insurance plan.

We highly recommend Assurant Health's "Health Access" fixed indemnity plan. It's a very mainstreamed, popular choice used by many large scale companies like Wells Fargo for their employees. This is a tremendously underused health care plan that millions of uninsured people need to start considering as soon as possible.

The other option is a simple health discount plan. This is by far the cheapest route and for good reason. Health discount plans are not insurance, so technically it really isn't low cost health insurance. Regardless, it remains at tremendous value when utilized.

You receive discounts on services you select that cover your entire family. There are three choices you can choose to receive discounts for and we will again use Assurant's Discount Plan for this example. You can pick any combination or all of the discount options to customize your plan.

The first option is the medical discount plan which saves you up to 40% on physician and hospital services, prescriptions, dental and eye care. This option costs $20 a month. The dental and vision plan provides discounts on a broader range of services including eyeglasses and vitamins for $10 a month. There is also a prescription discount plan for $8 a month that covers additional drug, hearing and nutritional care.

Combining all three plans together provides substantial discounts for your family for about $38 a month. This is as cheap as health care plans get. The sad fact is that there a countless uninsured families who could easily afford the $38 a month for a discount plan like this and they go without. If you can afford to combine both of these low cost health insurance options together we strongly suggest you do.

Having a fixed indemnity plan with a health discount plan on top of it makes sense. You'll maximize your protection and still be paying far less than you would with any standard health insurance plan. It all comes down to understanding your health care options and being proactive.

You'll need to check to see if your state will allow you to enroll in either their "Health Access" fixed indemnity plan or the Health Discount Plan as coverage isn't available in every state.

These plans need to be utilized on a much greater level if America's health care problem is going to start improving. Now that you've read this page, spread awareness!

Thank you for reading our article. We welcome you to visit our web site for more information.
Our Brand Statement; "You are the best source for deciding the right health care plan for yourself and your family. Insurance agents don't know your budget or your family's health history. Insurance is a game of risk. Who better to judge and balance your personal risk than you?"

For more information on applying for the plans in this article, visit us at http://my-cheap-health-insurance.com and use our web site as your guide. It will make you aware of the affects your health status has on your insurance costs. We seek to educate and inform by spreading health care awareness and also provide all the resources you need to make it easy finding the best coverage available in your area.

A Model for Advancing Policy in Cultural Competency and Health Disparity

As The US emerges from a long recession, managing the growing cost of healthcare remains an ongoing concern. The Affordable Health Act will eventually assure the availability of healthcare insurance coverage to over 30 million more Americans. This landmark legislation will improve access to a previously uninsured or underinsured group of Americans.




Health and Healthcare disparities is broadly defined as worse baseline states of health and relatively worse clinical outcomes associated with certain diseases in certain population groups. The affected groups may be distinguished by race, ethnicity, culture, gender, religion and age. The costs to treat the diseases which result from Health and Healthcare disparities represent one of the recognized areas of unnecessary and arguably avoidable healthcare delivery costs. Specifically, in certain instances both prevention and more cost efficient management of chronic disease states can significantly reduce healthcare costs. A chronic disease is defined as a long lasting or recurrent medical condition.
Some common examples include diabetes, hypertension, asthma and cardiovascular disease. Unfortunately, our current healthcare system may be better equipped to manage intermittent and episodic disease occurrences and not the demands of chronic medical conditions In a study published by Weidman et al from The Urban Institute,the authors estimated that in 2009, disparities among African Americans, Hispanics, and non-Hispanic whites will cost the health care system $23.9 billion dollars. Medicare alone will spend an extra $15.6 billion while private insurers will incur $5.1 billion in additional costs due to elevated rates of chronic illness among these groups of Americans. Over the 10-year period from 2009 through 2018, the authors estimated that the total cost of these disparities to be approximately $337 billion, including $220 billion for Medicare.
In the same study, the authors estimated the total healthcare costs secondary to racial and ethnic health disparities in chronic disease treatment (diabetes, hypertension, stroke, renal disease, poor general health) in African Americans and Latino Americans residing in the Commonwealth of Pennsylvania to be $700 million. The Urban Institute. A study entitled The Economic Burden of Health inequalities in the United States by LaVeist et almeasured the economic burden of health disparities in the US using three measures: (1) direct medical costs of health inequalities (2) Indirect costs of health inequalities (3) Costs of premature death Their findings revealed:

The combined costs of health inequalities and premature death in the US among African Americans, Hispanics and Asian Americans were $1.24 trillion
Eliminating health disparities for minorities would have reduced direct medical expenditures by $229.4 billion for the years 2003-2006
Between 2003 and 2006, 30.6% of direct medical expenditures for African Americans, Asians, and Hispanics were excess costs due to health inequalities.

Cultural competence (CC) refers to an ability to interact effectively with people of different cultures. CC comprises four components: (a) Awareness of one's own cultural worldview, (b) Attitude towards cultural differences, (c) Knowledge of different cultural practices and worldviews, and (d) cross-cultural skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures. CC has been increasingly recognized as an important, overlooked and underappreciated factor in delivering healthcare to an increasingly diverse America. US census estimations project that by 2050, over 50% of Americans will be non-white. Over 50% of children will be nonwhite by 2025. It seems intuitive to that the interface between patient, healthcare system and healthcare provider is a critical point in the delivery of healthcare. To this end, The Office of Minority Health in the Department of Health and Human Services has issued mandates and recommendations to inform, guide and facilitate the creation of cultural and language appropriate services. (CLAS Culturally and Linguistically Appropriate Services). Implementation of these guidelines within systems and agencies and among individuals can enhance CC and ultimately improve clinical outcomes.. The Center for Health Improvement and Economic Development was one of several parties which advocated for statewide guidelines regarding the cultural competency CME (continuing medical education) requirements for initial licensure and relicensing of physicians in the Commonwealth of Pennsylvania. To accomplish this goal, we set forth to educate and inform the various stakeholders regarding the intrinsic value of CC as a critical determinant of improving healthcare outcomes and a direct result of a utilitarian argument of social justice in the United States. The Center also recognized the importance of making a compelling business case in the current economic climate Partnering with the Gateway Medical Society, the Pennsylvania State Legislative Black Caucus (PSLBC) under the leadership of State Representative Ronald G. Waters and the Center for Health Improvement and Economic Development-a townhall format meeting was organized and planned in Pittsburgh. Local legislators including State Representatives Jake Wheatley, Tom Preston and Daniel Frankel were in attendance.
The townhall program: Working To Eliminate Healthcare Disparities in the Commonwealth of Pennsylvania was held in Pittsburgh. Attendees and participants included state policy makers, legislators, healthcare providers, healthcare administrators, social activists, business leaders and members of the general public. Robust debate occurred throughout the day and the exchange between audience members, legislators, policy makers and thought leaders underscored the recognized importance of the critical issue of Health Disparity and Cultural Competency. It is important to recognize the backdrop of the day's events. The meeting took place two days after the initial steps of The Affordable Care Act were initiated with critical new consumer protections in the Patient's Bill of Rights, including no pre-existing diseases for children, outlawing rescission and creating a path to allow adult children to remain on their parent's insurance until age 26. The enthusiasm of the day culminated with a pledge from State Representative Ronald G Waters to support a resolution on CC to be submitted to the National Black Caucus of State Legislators- ultimately a path to introducing the legislation to all states and ultimately to the Congressional Black Caucus. The meeting emphasized the necessity and the benefit of identifying stakeholders, recognizing mutual agendas and seeking consensus in the path to generating support for public policy. Addressing CC in the healthcare environment through requirements for healthcare provider continuing education is one small step. Certainly, this requirement should be considered for other healthcare professionals, administrators and ancillary staff members. Greater awareness of the emerging diversity of America and understanding how to manage that diversity will significantly enhance the delivery of healthcare. The Pennsylvania State Legislative Black Caucus, The Center for Health Improvement and Economic Development and The Gateway Medical Society call upon other groups to join in our collaborative model to reduce Health Disparity and enhance healthcare delivery in The Commonwealth of Pennsylvania and beyond.
The Legislative Black Caucus of Pennsylvania The PLBC was organized by House Majority Leader K. Leroy Irvis during the 1973-74 legislative session. K. Leroy Irvis saw the need for the caucus because he felt that legislators representing minority districts needed to speak with a united voice regarding the issues and concerns of their constituents. State Representative Ronald G. Waters was first elected to the House of Representatives in a special election in May 1999. He is chairman of the Health and Human Services Subcommittee on Health and serves on the Children and Youth, Health and Human Services, Judiciary, Liquor Control and Professional Licensure committees. He is also a member of the Philadelphia and the Southeast Pennsylvania delegations. Waters is also the chairman of the Pennsylvania Legislative Black Caucus, and chairman of Region 2 (which includes Pennsylvania and New York) of the National Black Caucus of State Legislators. About the Authors: Lee Kirksey MD is co-founder of The Center for Health Improvement and Economic Development, a public policy think tank. The organization is focused on the impact of social determinants on community health utilizing public private partnerships. His current research efforts include cultural competency and it impact on health disparities within surgery. He is author of The Wellness Revolution: Eliminating Disparities and Promoting Prevention...For All. Dr Kirksey is an Assistant Professor of Surgery in the University of Pennsylvania School of Medicine. Michele Jones, MSW, MHA serves as Manager of Partnership Development and Community Relations at Fox Cancer Center in Philadelphia. Having over 15 years management experience in health disparities, health education, public relations and development, Ms. Jones oversees prevention practices and partnership development. Through the years, she has worked in similar capacities at companies covering San Diego, New York as well as Pennsylvania. Through her work, she has become known as an innovator in the areas of health access, prevention and education, acquiring City Citations and Awards for both Community Outreach and Health Education. Jones is the founder of Jones Health Care Management Solutions and is currently a second-year Bioethics Student attending the University of Pennsylvania, School of Medicine.
The Gateway Medical Society The Gateway Medical Society is a component of the National Medical Association. The National Medical Association objectives are to promote the science and art of medicine and the betterment of public health. Organized in 1895, the NMA Limits memberships to physicians licensed to practice medicine in any state or territory of the United States and the District of Columbia. Election of Membership may be obtained through Constituent Associations, through affiliation with societies consisting organized women physicians, Haitian physicians, and other minority physicians. The Gateway Medical Society is therefore a component society of its constituent association the Keystone State Medical Society of Pennsylvania.
LaVeist TA, Gaskin DJ, Richard P, The Economic Burden of Health In equality in the US. Joint Center for political and Economic Studies.. Accessed Oct 10, 2010
National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, OMH, 2001







Lee Kirksey MD is a board certified vascular surgeon. He is founder of The Center for Health Improvement and Economic Development. Dr Kirksey is a clinical assistant professor of surgery at The University of Pennsylvania School of Medicine. His special interests include Cultural Competency, Health Disparity and the role of social determinants in community health http://blog.leekirkseymd.com/.
Dr Kirksey is author of The Wellness Revolution: Promoting Prevention and Eliminating Disparities...For All.

Health Care Fraud - The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.



Why does health care fraud appear to get the 'lions-share' of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with 'sleight-of-hand' precision?
Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.
1. Astronomical Cost Estimates
What better way to report on fraud then to tout fraud cost estimates, e.g.
- "Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system... It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today... We pay these costs as taxpayers and through higher health insurance premiums... We must be proactive in combating health care fraud and abuse... We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud." [Senator Ted Kaufman (D-DE), 10/28/09 press release]
- The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year - or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.
- The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.
Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don't know and what we know that is not so. [The Cato Journal, 3/22/02]
2. Health Care Standards
The laws & rules governing health care - vary from state to state and from payor to payor - are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.
Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers' services, many insurers instruct providers to report codes based on what the insurer's computer editing programs recognize - not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid - in some cases codes that do not accurately reflect the provider's service.
Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage - especially if it is Medicare that denotes non-covered services as not medically necessary.
3. Proactively addressing the health care fraud problem
The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.
They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.
4. Exorcise health care fraud with the creation of new laws
The government's reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws - presuming new laws will result in more fraud detected, investigated and prosecuted - without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.
With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.
In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments' capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.
Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.
What's one person's fraud (insurer alleging medically unnecessary services) is another person's savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.
If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:
- DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.
- REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn't paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient...
- REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.
- PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.
- PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.
5. Insurers are victims of health care fraud
Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.
It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?
Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.
6. Increased investigations and prosecutions of health care fraud
Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.
With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.
Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.
Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.
Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.
Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.
Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters - steal up to a certain amount, stop and change jurisdictions?
In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud - on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!
Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.







Daniel J. Osborne, M.S., is a renowed expert on health care fraud issues and recognized authority on health care compliance. He can be contacted at Provider Fraud Consultants, Inc., dba Chiropractic Compliance Consultants, Inc., 18065 238th Street, Tonganoxie, Kansas 66086, 913-369-9000, http://www.cccpfc.com

Cheap Health Insurance , Is It For You?

Cheap health insurance is still available, it has not gone the way of the nickel soda or the 10 cent candy bar. As the cost of medical treatment continues to rise, finding cheap health insurance is becoming increasingly difficult. Cheap health insurance is an option for not having any health insurance at all. Choosing cheap health insurance is not something bad, but people have to understand they must go about it the right way.

Cost

Health insurance costs are rising all the time. The costs vary, so do plenty of research before choosing one or another. Many agents will work very hard to get you an affordable health insurance plan for your family at a cost you can live with. The rising cost of health care has made it so that even those with very limited budgets simply have to get some form of health insurance or they run the risk of encountering a large medical bill that can put their financial future in jeopardy. One good tactic to lower your monthly cost is to simply choose a plan with a higher deductible. A good scenario might cost you a couple hundred dollars but a bad scenario could ruin you financially and devastate your family. Check what they cover, deductibles, whether there are maximum payouts under any one category, whether they are for a family or individual health insurance, and of course the cost of the benefits which can vary a great deal. The cost of health insurance can vary greatly depending on the amount of coverage you need, if you were take all the options available in private health insurance then the premium would be astronomical and something which very few people can afford to do. Always check the policy because it might include things which you don't need, for instance if you are a single man and a policy includes costs for pregnancy then this obviously won't be needed. If you are considering the lowest cost health insurance then look into purchasing a policy that only covers major illnesses.

Part of the problem is the rising cost of medical care due to uninsured patients. Because of that, hospitals charge inflated rates to cover their own costs. Most low cost health insurance schemes provide for all basic medical and health related expenses, the difference lies in the type and extent of coverage that each of them provides. Low cost health insurance is for people whose annual income falls below a certain range. Health insurance costs depend on the health insurance rate and the range of coverage. Check the monthly cost and amount of deductibles charged and the extent of cost that they cover. There are several ways you can obtain affordable, low cost health insurance.

Search

The costs vary, so do plenty of research before choosing one or another. The best place to start your search for cheap health insurance providers is undoubtedly the internet. However, don't be tempted to simply perform a search for 'cheap health insurance' as there is a high probability that almost all health insurance providers have this statement somewhere in their site's text. See how cheap term life insurance really be by researching and comparing quote on-line from these top life insurance providers. Generally, health care can be exclusive, therefore if you are searching for a health insurance plan for your family unit, you have to look for plans that are both reasonably priced, and that would offer health coverage you require. Instead, take your time and do your research. With any Commendable Cheap-Health-Insurance plan, you need to read the Cheap-Health-Insurance terms of service of the Cheap-Health-Insurance account and search for any extra Cheap-Health-Insurance fees. As when looking at any health insurance policy, you ought to search for coverage that has a maximum payout of at least $1 million.

Conclusion

As the cost of medical treatment continues to rise, finding cheap health insurance is becoming increasingly difficult. The key to finding cheap Health insurance is knowing every option that is available, a process that can take a long time for an individual to complete. The key with health insurance and especially cheap health insurance is you need to know where health insurance is.

Jim Swank has been in the health care field for a number of years. His particular area of expertise is Health and Nutrition. This information was written by Jim Swank. His web site is [http://www.healthandbizguru.com]

Don't Fall Victim To A Health Insurance Scam - 10 "Red Flags" You Should Look For

In today's fast paced world, business owners don't often have the time to thoroughly check out the companies they rely on to provide goods and services. In many cases, a determination of product/service quality can be made at the time goods are delivered or services are rendered. If goods or services do not meet expectations, there is often an immediate remedy available. For example, poor quality goods can be shipped back to the supplier and/or payment for services can be withheld until services are satisfactorily rendered.

Unfortunately, business owners do not always purchase items that are tangible items, in the sense that they can immediately determine the quality of the goods and/or services at the time of purchase. One example of such a purchase is health insurance. Since health insurance is not usually used immediately after purchase, the quality of care or the legitimacy of the policy may not even come into play until the business owner, or a family member, actually needs to have medical treatment. This is one of the primary reasons that many companies, often appearing legitimate, can get away with selling bogus health insurance coverage to unsuspecting business owners.

In most cases, fraudulent health insurance policies are sold to business owners by telemarketers or "agents" through bogus Associations and Unions. In that, the buyer must join a professional and/or trade association or become a union member to qualify for health insurance. In fact, in a study published by the U.S. General Accountability Office (GAO) in 2004, the GAO found that association schemes ranked at the top of the marketing methods followed by bogus health insurers. According to the report, "Employers and Individuals Are Vulnerable to Unauthorized or Bogus Entities Selling Coverage, between 2000 and 2002, the U.S. Department of Labor and state insurance regulators identified 144 unauthorized entities selling health insurance unlawfully. These entities defrauded 15,000 employers and more than 200,000 policyholders out of $252 million."

However, it is important to mention that many individual and group health insurance products are endorsed by reputable Associations, such as the ARRP and the American Bar Association and, many reputable Unions, such as the AFLCIO and the Teamsters. These organizations have long been recognized for bringing a common class of professionals or citizens together for other purposes that have very little to do with health insurance. Membership commonly includes a wide range of other benefits in addition to discounted health insurance. Typically, the organizations have a governing organization, a constitution and bylaws, a set of officers, voting rights, regular membership meetings and a professional code of conduct.

Unfortunately, most individuals do not find out that they were making hefty monthly payments or premiums to fraudulent Associations or Unions until they have a severe condition that requires medical treatment. Usually, it isn't until after they receive treatment that they receive notice from their medical provider that the claim that was submitted to the insurance company was denied and that all the medical charges that were incurred are now their responsibility.

Often, the scheme starts when business owners are contacted by telephone or approached by someone who claims to represent a certain, official sounding, Association or Union. The business owner is then informed that if s/he becomes a member of the Association or joins the Union, s/he could qualify for a low cost group or individual health insurance plan. Typically the Association or Union is promoted to represent self-employed individuals and small business owners. The low cost health insurance is usually presented as one of the many "perks" that the business owner can qualify for, in addition to many other "member" benefits, like discounts on other services, such as dental, eyeglasses, office supplies, hotels, rental cars, etc.

In many instances, these bogus companies involve licensed health insurance agents to sell their fraudulent health insurance products. Sometimes the "agents" know the products are fraudulent, other times, the "agent" also falls prey to the scheme. Often, the schemes prey upon consumers who have been previously declined insurance coverage or suffer from a pre-existing condition. Since these consumers have very limited options to purchase private health insurance coverage, the benefits of an Association or Union membership that offers health insurance coverage for a "membership fee" or "union due" is enticing. To the unsuspecting consumer that has a pre-existing medical condition or is paying high premiums for coverage, the "membership fee" or "union due" is a small price to pay for what they believe will be a quality health plan that provides "guaranteed" coverage with no "pre-existing condition exclusions" and no "waiting periods."

In many circumstances, the print materials that are left with the consumer are very well designed, however, the majority of the time, the language in the "health plan brochure," if there is one, is very unclear. The literature may name the entity that is authorized to act as the health plan administrator of the plan, but neglect to name the actual insurance company that is providing the health insurance coverage. Unfortunately, it is often difficult for the consumer to separate the illegitimate companies selling official sounding health plans from the legitimate ones. Typically fraudulent health plans have many commonalities.

Here are 10 "Red Flags" that may indicate health insurance fraud:

1. The "agent" is not a licensed insurance agent but an "enrollment" or "membership" coordinator.

2. The term "discount plan" is written in the product literature, but the term health plan, health insurance or policy is frequently used by the plan promoter. Discount plans often provide nothing more than a discount for medical services, such as prescription medications, eyeglasses, dental, etc. These plans are not designed to offer major medical health insurance coverage.

3. The official sounding "Association or Union" is one that you have never heard of before.

4. The plan is referred to as an ERISA plan. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that allows employers to set up employee benefit plans for employees and their dependents. ERISA plans are not subject to state regulation and are not regulated by the state insurance commissioner. ERISA plans are normally not sold as health insurance, but are instead, established by employers, unions or groups acting on behalf of employers. Therefore, unsuspecting buyers believe these plans actually offer health insurance coverage, when if fact, they do not.

5. The buyer is told that the "membership fee or union dues" includes the health insurance premium, but there is no mention of the word "premium" in any of the plan literature.

6. The plan offers "guaranteed" insurance coverage with no exclusions for "pre-existing conditions" and no "waiting periods."

7. The plan is significantly cheaper in price than other health insurance plans.

8. The term "reinsured" is used in regards to the plan. Reinsurance is something insurance companies buy to protect themselves against their own risks. It is insurance for insurance companies. Licensed insurers rarely have their agents mention any of their reinsurance arrangements during a sales presentation.

9. If the Association or Union is comprised of members from all walks of life and/or requires its members to state that they belong to a certain trade, class or group of professionals that they have no affiliation with, for example, the Association or Union is said to be comprised of "Food and Beverage" workers, but "Florists" and "Machinists" are allowed to enroll as members.

10. If the Association or Union is said to have a special arrangement with a health insurance company, a plan administrator or another third party that has designed the plan using a legal "loophole" that allows members to purchase health insurance at a discounted rate or to purchase a individual or group health insurance policy.

So how can you protect yourself from falling victim to a fraudulent insurance scam? Make sure you contact your state's department of Insurance to determine if the health insurance company and the third-party administrator are licensed to do business in your state and make sure that the "agent" selling the plan is a "licensed health insurance agent." Additionally, make sure that the health insurance company has been approved to sell the particular policy that is being offered. Since it may be difficult to tell if fraud is involved, always put off buying your insurance policy until you have had the opportunity to perform your own due diligence.

©2007 Small Business Insurance Services, Inc. http://www.smallbusinessinsuranceservices.com

C. Steven Tucker, is the President of Small Business Insurance Services, Inc. and has been a Licensed Mult-State Insurance Broker serving the small business and self-employed market for over a decade. Mr. Tucker believes an informed insurance consumer makes the best health insurance purchasing decisions. Mr. Tucker has written several articles that focus on small business health insurance, which can be read on a number of web sites. Mr. Tucker's blog can be read at http://www.smallbusinessinsuranceservices.vox.com. If you have general questions regarding health insurance, or you are in the market to purchase a health insurance plan, you can contact Mr. Tucker through his web site at http://www.smallbusinessinsuranceservices.com, via Email at smallbusinssvcs@aol.com or by plone, toll-free at 1-866-SBIS123 (724-7123)

Hiring a Home Health Care Employee

 Providing the primary care for an elder loved one can be difficult. When you cannot deliver all the elder care yourself and support from friends, family, and community organizations is not enough, it may be useful to hire a home health care worker. He or she can offer care from a few hours a week to 24 hours a day, and can provide many other helpful services. Types of in-home health care services include:

General Health Management like administration of medication or other medical treatments
Personal care such as bathing, oral hygiene, dressing, and shaving
Nutrition help like preparing meals, assisting eating, and grocery shopping
Homemaking services including laundry, dishwashing, and light housework
Companionship for example reading to the senior or taking them on walks

Recruiting and Interviewing Applicants

There are many avenues for hiring a home health care employee. Generally, home health care workers can be hired directly or through an agency. Home health care agencies often have a staff that includes social workers and nurses that will manage your care. However hiring an independent home health care worker is generally more cost effective, it will also give you more control over the type of care you receive. 

Senior home care workers should be carefully screened for proper training, qualifications, and temperament. Fully discuss the needs of the elder care recipient during an interview with a prospective home health care employee.  There should be a written copy the job description and the type of experience you are looking for.

References

Have applicants fill out an employment form that includes the following information:

Full name
Address
Phone number
Date of birth
Social Security number
Educational background
Work history 
Before hiring, you should ask to see the senior home care worker's licenses and certificates, if applicable, and personal identification including their social security card, driver's license, or photo ID. 

References should be checked out thoroughly.  Prospective employees should provide the employer with names, dates of employment, and phone numbers of previous employers and how to contact them.  It is best to talk directly to previous employers, rather than just to accept letters of recommendations. Also ask the applicant to provide or sign off on conducting a criminal background check 

Special Points to Consider

Make sure the person you are considering hiring knows how to carry out the tasks the elder care recipient requires, such as transferring the senior to and from a wheelchair or bed.  Training may be available, but make sure the worker completes the training successfully before hiring him or her.

No one should be hired on a seven-day-a-week basis.  Even the most dedicated employee will soon burn out.  All employees need some time to take care of their personal needs.  No worker should be on call 24-hours a day.  If the elder care recipient needs frequent supervision or care during the night, a family member or second home health care worker should be able to help out or fill in.

Live-in assistance may seem to be more convenient and economic than hourly or per-day employees but there can be drawbacks.  Food and lodging costs must be calculated into the total cost of care, and it could be difficult to dismiss someone without immediate housing alternatives.  If you decide to utilize a live-in arrangement, the employee should have his own living quarters, free time, and ample sleep.

Job Expectations and Considerations

Before hiring a senior home health care worker, you should go over the tasks you expect them to perform and other issues, such as promptness, benefits, pay scale, holidays, vacations, absences, and notification time needed for either employer or employee before employment is terminated. If you work and are heavily dependent on the home health care worker, emphasize the importance of being informed as soon as possible if he or she is going to be late or absent so that you can make alternative arrangements. Be clear about notification needed for time off, or what to do in the case the home health care worker experiences a personal emergency that requires them to abruptly leave work.  It is important to have a backup list of friends, family, other home care workers, or a home health care agency you can call on.

Be clear about issues concerning salary, payment schedule, and reimbursement or petty cash funds for out of pocket expenses.  

You should spend the day with the home health care worker on his first day to make sure you are both in agreement over how to carry out daily tasks.  It would also be helpful to supply the home health care worker with a list of information on the elder care recipient such as: special diets, likes, dislikes, mobility problems, health issues, danger signs to monitor, possible behavior problems and accompanying coping strategies, medication schedule, therapeutic exercises, eye glasses, dentures, and any prosthetics. 

You should also provide the following information to your home health care worker: your contact information, emergency contacts, security precautions and access to keys, clothing, and locations of washing/cleaning supplies, medical supplies, light bulbs, flashlights, fuse box, and other important household items.

Transportation

Another big consideration in hiring a senior home care worker is how he or she is going to get to work.  If they do not have a reliable car or access to public transit, then you might want to consider hiring someone to drive him or her, which might be more economical than using taxis.  Inform your insurance company if the home health care worker is going to drive your car when caring for the senior.  Your insurance company will perform the necessary driving background checks.  If the home health care worker is using his or her car to drive the elder care recipient, then discuss use of her or his car, and conduct a driving background check.

Insurance and Payroll

Check with an insurance company about the proper coverage for a worker in your home.

Make sure all the proper taxes are being drawn from the employee's check by contacting the Internal Revenue Service, state treasury department, social security, and the labor department.  If you do not want to deal with the complexities of the payroll withholdings yourself, than you can hire a payroll company for a fee.

Even if your home health care worker is working as a contractor, you are still obligated to report the earnings to the IRS.  Talk to your accountant or financial adviser about making sure you are following IRS rules.

Ensuring Security

You should protect your private papers and valuables in a locked file cabinet, safe deposit box, or safe. If you are unable to pick up your mail on a daily basis, have someone you trust do it, or have it sent to a post box. You should check the phone bill for unusual items or unauthorized calls. You should put a block on your phone for 900 numbers, collect calls, and long-distance calls.

Keep checkbooks and credit cards locked up. Review credit card and bank statements on a monthly basis, and periodically request credit reports from credit reporting agencies.  Lock up valuable possessions or keep an inventory of items accessible to people working in the house.

You can help to prevent elder abuse to your loved one by: 

Make sure the home health care worker thoroughly understands his or her responsibilities, the elder care recipient's medical problems and limitations, and how to cope with stressful situations.
Do not overburden the home health care worker.
Encourage openness over potential problems.
The following are possible signs of elder abuse or neglect: 

Personality changes
Crying, whimpering, or refusing to talk
Sloppy appearance
Poor personal hygiene
Disorganized or dirty living conditions
Signs of inappropriate sedation, such as confusion, or excessive sleeping
Mysterious bruises, pressure sores, fractures, or burns
Weight loss
If you suspect abuse, act immediately.  Do not wait until the situation turns tragic.  Investigate the situation by talking to the elder care recipient in a safe situation, or install monitoring equipment. Examples of abusive behavior include yelling, threatening, or over controlling behavior that could involve isolating the senior from others. If the situation is serious, you should replace the home health care worker as quickly as possible. If you fear the elder care recipient is in danger, he or she should be separated from the home health care worker as soon as possible.  Place the elder care recipient with a trusted relative or in a respite care facility. Make sure your loved one is safe before confronting the home health care worker, especially if there is concern about retaliation.

Report the situation to Adult Protective Services after ensuring the safety of the elder care recipient.  The police should be contacted in the case of serious neglect, such as sexual abuse, physical injury, or misuse of funds.

Supervising a Home Health Care Worker

The most important thing to remember after hiring a home health care worker is to keep the lines of communication open.  You should explain the job responsibilities clearly, and your responsibilities to the home health care worker. Do not forget that the home health care worker is there for the elder care recipient and not the rest of the family.  For live-in arrangements, the maximum amount of privacy should be set up for the home health care worker's living quarters. Meetings should be set up on a regular basis to assure that problems are nipped in the bud.  If conflicts cannot be resolved after repeated attempts, than it is best to terminate the employee.  In such a case, you may have to either place the elder care recipient in a nursing home temporarily or hire a home health care worker through an agency.  Reserve funds should be kept on hand in the case of such an emergency.  

General Eligibility Requirements for Home Care Benefits

Hiring a home health care worker directly is usually less expensive than hiring through a home health care agency; but if the elder care recipient is eligible and you wish to use assistance from Medicare, you must hire someone through a certified home health care agency.  For the senior patient to be eligible, three or more services must be ordered by a physician. Other factors or eligibility are the required need for skilled nursing assistance, or one of the following therapies: physical, speech or occupational. The elder care recipient's medical needs will determine asset and income requirements.

Hiring Home Health Care Workers through Home Health Care Agencies versus Independently

Different health professionals can assess the elder care recipient's needs.  A nurse or social worker can help with design and coordination of a home care plan.  Your care manager, doctor, or discharge planner can help with services being covered by Medicare.  They generally help make the arrangements with a home care agency.

You should ask the home health care agency how they supervise their employees, and what kind of training their employees receive. Find out the procedures for when an employee does not show up.  Also ask about the fee schedule and what it covers, there may be a sliding fee schedule. Furthermore, find out if they have a policy for minimum or maximum hours. Ask the agency if there are any limitations on the types of tasks performed.

Especially if you have to pay for the care services yourself, find out if there are any hidden costs such as transportation.  If all the costs for hiring a care worker through an agency become too much, you may want to consider hiring directly. 

Hiring independent home health care workers is not only more economical than using an agency, but it also allows more direct control over the elder care.

The Caring Space
http://www.TheCaringSpace.com

David Crumrine at the Caring Space
We are an organization that connects caregivers and care seekers, providing an easy and affordable resource for families seeking care for friends/loved ones and caregivers seeking employment.

Health Care Reform Wayback - A Brief History of Health Care Reform in the USA

Is Health Care Reform New?

As somebody who is very interested in the progress of health care reform as a taxpayer, private consumer of health insurance and services, and as a professional, I have been trying to follow the current health reform debates. I am getting a little frustrated with the lack of progress on either side of the aisle, and also by some of the knee jerk reactions by politicians and their groupies.. You would think that the current administration, and its political adversaries, had just invented health reform or the cries of outrage that sound against it.

I decided to do my best to outline some of the highlights of the health reform attempts, failures, and progress in the past 100 years or so. I am not a professional historian, by any means, so some may feel as if I left out important things or took them out of context. I am trying to be balanced, but take all the blame if I neglected something you feel is important.

Teddy Roosevelt In the 1910's

Teddy Roosevelt ran on a very progressive platform in the early part of the last century. His campaign promises for 1912 included protection for workers safety on the job women's right to vote, and a national health care program. He was president of the United States, by the way, from 1901 - 1909. But he lost the election of 1912 to Woodrow Wilson. It is interesting to note that this Roosevelt was a Republic. Wilson was the Democrat. Never assume that American party politics are set in stone.

Early Models of Current Health Insurance and Cries of Socialism

In 1929, Baylor Hospital in Dallas, Texas came up with a pre-paid program for a large areal teacher's union. This is considered one of the earliest models of health insurance. Now here's the irony. A few years later, an Oklahoma doctor formed a farmer's association with a pre-paid plan. Members of the association would pay into the plan, and then get services covered. The American Medical Association called this doctor's plan socialism!

Despite this, pre-paid hospital and doctor plans continued to grow in popularity around the US. However, they usually left out the unemployed and elderly.

The New Deal in the 1930's

Another Roosevelt, FDR, also wanted to implement national health reform. He wanted to include it as part of social security legislation. That did not work out, but even Truman wanted to set up a national fund. for health care. He figured everybody could pay in, like we do for social security, and then it could make sure that people's most severe health needs were met. All of this was left out of the New Deal, and the AMA continued to criticize it as socialism.

Post World War II

By the end of the second world war, it became a lot more obvious that there was a big gap between health care costs and what mos people could afford. Congress did pass a bill to build a lot more hospitals. They also required hospitals to provide charity care. They had a clause to forbid discrimination on race, religion, etc. But they did allow separate but equal care, which did not always turn out to provide equal care to everybody.

In the 1950's, labor unions began adding health benefits to their collective bargaining agreements. This really formed the basis for the group health insurance many people enjoy at work today. So group health plans became more popular, and in 1954, Congress voted to make this benefits tax-exempt.

The 1960's

JFK fought hard for national health care, but again he was met with cries of socialism. But Medicare and Medicaid, regarded as American institutions now, did emerge despite this. Medicare is the US national health plan for seniors and disabled people. Medicaid is the national health plan for very poor people.

Despite the fact that millions of Americans had heath insurance coverage for the first time, in the 1960's, health care spending and costs were beginning to rise.

The 1970's - Nixon and Carter

President Nixon, a Republican, worked for health reform. He proposed a bill that would require employers to provide minimum health insurance coverage. Under his administration, money was allocated for the development of HMOs and managed care to contain costs.

Carter ran for president, and national health care was a large part of his campaign platform. Even though he won, the severe recession put these plans on hold.

The 1980's and COBRA

COBRA is the national law that requires some employers to extend group health benefits to terminated employees for several months.

The 1990's and The Clintons

Probably the most famous previous attempt to dramatically reform health care was under President Clinton. Hillary Clinton, then first lady, spear headed this work. You will probably not be surprised to learn that political critics of the pan delighted in calling it socialism. Experts contend that the plan failed because of partisan politics on both sides. The drug and insurance companies, and the American Medical Association (AMA) also spent a lot of time and money getting the Health Security Act defeated.

CHIPS - I cannot leave the 1990's without mentioning CHIPS. This is the state and federal children's health insurance program which covers millions of children from lower and moderate income families.

21st Century Health Reform

I have to credit George Bush, a Republican, with passing the Medicare Prescription plan in 2003. This is also known as Medicare Part D, and it helps fund prescription insurance for Medicare beneficiaries.

Obama ran on a platform that included health reform. It seems like it is as tough to pass now as it was during the time of Teddy Roosevelt, FDR, Truman, and Bill Clinton. Politicians are still making deals behind closed doors, and of course, people are still shouting socialism.

But some things have changed. The AMA now supports health reform. Many businesses are concerned about spiking costs of covering employees, and representatives have admitted they would like to see some reform that would help them. Even insurance companies have said they will cooperate.

Hopefully, we can see some progress. I have no idea what will (or should) happen next.

What Next?

Read more about health care reform in the US.

Also stop by for individual health insurance quotes.

Health Insurance For Solo Entrepreneurs

One of the most important benefits employed people enjoy is health insurance coverage. It is also the single most costly expense for self-employed entrepreneurs. So what can you do to reduce ever increasing costs of health care coverage? Here are a few tips.

1. If a medical bill seems excessive, try negotiating

Your doctor or the office manager who handles billing will probably be flexible, provided you make a valid case. When one woman in Texas was charged $900 for surgery and "consultation," she explained that she had visited the hospital just once, for surgery; her bill was promptly cut by $370.

2.. Contact a medical bill "auditor"

Several services have a medical bill "auditing" system that evaluates your medical bills to determine if errors occurred in the billing process. Considering that 97 percent of hospital medical bills contain errors, it's no wonder why out-of-pocket medical expenses are on the rise for consumers. Because the typical hospital bill is extremely complicated, often containing several hundred line-item charges, there is ample opportunity for computer mistakes and accidental human error. Do a Google search for medical bill auditors to find companies offering this service.

3. You may get a tax break on your medical bills

Keep all your medical bills together and add them up at tax time. If they exceed 7.5 percent of your adjusted gross income, you may deduct the excess. Please note that these items also may be included in the total: the cost of eye glasses, contact lenses, physical therapy, x-rays, hearing aids, psychiatric care, insurance and transportation to the hospital or doctor's office (at 30 cents a mile). There are phase-outs in some cases based on adjusted gross income. Check with your professional tax adviser.

4. Deduct 100% of your healthcare costs from your taxes

The IRS allows all self-employed to deduct 100% of health care costs from their taxes by using Section 105 of the Internal Revenue Code. To receive this deduction, you must do the following:

a) Hire your spouse as an employee of your business.

b) Have your spouse receive health insurance in his or her name, and include the family on the policy.

c) Pay your spouse a salary that will cover the costs of the insurance.

d) Talk to your tax professional about planning for Section 105 on your taxes.

We all know your spouse is active in your business. Now, you can equally recognize their contribution he or she makes - and get Uncle Sam to give you a tax break.

5. Help for families with kids -- CHIP

All states have established new programs that help lower income families with children to pay for health insurance for their kids. Financed partly by the federal government, the Children's Health Insurance Programs (CHIP) operate either as an expansion of the state's Medicaid program or a subsidy for basic private health insurance. Eligible families may be able to access coverage for their children at greatly reduced premiums which will vary depending upon family income. Contact your state Department of Health or Insurance for more information.

6. Shop around

Hospital costs vary widely, especially between urban and rural facilities. If your doctor has admitting privileges at more than one hospital, find out if you can be admitted to the one that's less expensive. Keep in mind that hospitals operated by non-profit foundations are usually less expensive than investor-owned, for profit hospitals. To find out how much your local hospitals charge, ask your doctor. Many states have Health Services Cost Review Commissions, which compile such data.

7. Check for free clinics in your community

You and your entire family can save hundreds of dollars by taking advantage of the many free screenings, immunizations, and other health clinics offered by your local community or a town near you. Numerous community hospitals and social services can provide blood pressure checks, shots for your children, free contraceptives and/or advice, and other preventative health care at little to no cost.

8. Get a second opinion out of town

Believe it or not, your chance of undergoing an expensive surgery or preventative procedure may depend solely on where you happen to live. Statistics show that the frequency in which certain medical procedures are performed varies widely from location to location. For example, residents of New Haven, Conn., are twice as likely to undergo a coronary bypass operation as residents of Boston, Mass. What's the reason for this discrepancy? One Dartmouth Medical School expert, John E. Wennberg, M.D., M.H.P., explains that certain operations are simply more fashionable in some parts of the United States than others. So, if you plan to get a second opinion prior to surgery, consider going to a specialist in another city. In addition, try to find out what the surgery rates for your procedure are in different cities. HealthAllies.com also offers this service online. To get the names of second-opinion doctors in your region, call the U.S. government's toll-free second-opinion hotline at 1-800-638-6833.

9. Don't pay double for a second opinion

As you make arrangements for a second opinion, ask your doctor to send copies of your medical records, x-rays, and lab tests to the second-opinion doctor. These tests don't need duplication; your second doctor will have the information he or she needs - and you don't pay double.

10. Emotional stability

Your mental health is equally important as your physical health. Do you have blue days once in awhile, or struggle with gray winters? St. John's Wort, an over-the-counter herbal supplement, has been proven to increase positive moods. Before rushing to your family physician for medication to make you feel better, try supplements with a combination of expressing your feelings with friends and a healthy lifestyle. Mood stabilizers are some of the most costly medications on the market today. However, you should be aware of the signs of stress or even depression. Give yourself a simple screening test:

Do you have feelings of sadness and/or irritability?
Has there been a loss of interest in pleasure activities you once enjoyed?
Have there been changes in your weight or appetite?
Have you noticed changes in your sleeping pattern?
Are you feeling guilty?
Do you have the inability to concentrate, remember things or make decisions?
Are you fatigued or have a loss of energy?
Do you experience restlessness or decreased activity noticed by others?
Do you have feelings of hopelessness or worthlessness?
Do you have thoughts of suicide or death?

If you answer "yes" to any of these questions, consider consulting your family physician. If they recommend mental health treatment, it is more cost-effective to have your family physician prescribe mood stabilizers instead of seeing a psychiatrist. However, follow your doctor's instructions on counseling and referrals to mental health professionals.

11. Order your prescription drugs by phone, web or mail

There are many discount prescription drug benefits available for a modest cost. Communicating for Agriculture and the Self-Employed offers a free prescription card through PCS. This program saves its members up to 40 percent at over 55,000 pharmacies nationwide. On average, CA members save $9.39 per prescription order. You can enroll free on SelfEmployedCountry.org.

12. Ask your doctor to prescribe generic drugs

Medicine marketed under its scientific name is usually 50 percent cheaper and just as effective as brand-name versions. In addition, look for generic drugs in the medicine you purchase over the counter. For example, 100 generic aspirin may cost $1.79; the same ingredients packaged under a well-known brand name can cost more than $5 for 100 tablets. Consider, also, just how important the new easy-to-swallow products are to your comfort. The lesser price of some medicines may be comparably easier to swallow when thinking about your budget.

13. Get enrolled in a group plan

For self employed people including those involved in small businesses, individual health insurance can be extremely costly - sometimes as much as 30 percent of your take home pay. By joining associations like National Association for the Self Employed (www.nase.org), you have the opportunity to enroll in a group insurance plan with unique built-in cost controls.

14. Choose a higher deductible

Often for the healthy family, the number of visits to the doctor totals less than $250 a year, a normally low deductible rate. This low deduction rate, however, can end up costing you more in the form of higher premiums. If your family has enjoyed good health for a number of years, you may want to switch to a higher deductible of $500 or $1000. You'll notice greatly reduced premiums.

15. Pay premiums annually

You avoid the service fee and may also receive a discount from your insurance carrier. Check with your insurance agent about how much money you can save if you pay your premium one time during the year.

16. Make sure there's a ceiling for out-of-pocket expenses for catastrophic illnesses

About half of individual policyholders lack this important provision, according to insurance experts, who recommend a major medical policy with a stop-loss clause limiting policyholder payout to $2,000 or $3,000.

17. Get educated about your health

Invest in your health by becoming information-rich. Read publications about health care. Pay special attention to free wellness publications like Inside Mayo Clinic at MayoClinic.org or have on hand a book on medical self-care, like The AAFP Family Health and Medical Guide and The Merck Manual of Diagnosis and Therapy. A wealth of information is also available on the Internet.

18. Take advantage of free health advice

For free information booklets from the U.S. government about nearly every health care topic you can imagine, simply write to the Consumer Information Center in Pueblo, Colorado. The government offers several dozen booklets on topics ranging from nutrition, medical problems, mental health, to drugs, exercise and weight control. To receive a catalog explaining these booklets, write to:

Consumer Information Center

PO Box 100

Pueblo, CO 81009

http://www.pueblo.gsa.gov (you can download booklets from this site)

Once again the U.S. Government comes through by providing a number of toll free health care information phone services. Topics are numerous, including hearing aids, cancer information, Alzheimer's disease, drugs and pregnancy issues. For information on the health topics and phone numbers, call the National Health Information Center at 1-800-336-4797.

19. Brush up on first-aid skills and become CPR certified.

Proper treatment of various accidents may reduce the number of visits to the doctor, and can save lives in an emergency. It's important to always keep an updated medical kit in your home or office.

Here are the basics for your first-aid kit:

bandage supplies, including a roll of 3 inch wide gauze, individually packaged 4 inch sterile gauze pads, a roll of 1 inch bandage tape, butterfly bandage tape, and scissors
elastic bandages
cotton swabs
sterile dressings or towels
pain reliever (acetaminophen or ibuprofen)
anti-inflammatory medicine (ibuprofen)
ipecac syrup (for use on advice of medical professional to induce vomiting)
tweezers
hydrogen peroxide
skin creams, including hydrocortisone cream, calamine lotion and antibiotic creams
an antihistamine (diphenhydramine for allergic reactions)
flashlight
eye patch
arm sling
tongue depressors (to be used as a finger splint)
ice pack
re-hydration fluids (such as Pedialyte or Infalyte)

20. Take a lifestyle approach to wellness - every day

Take charge of your health by making simple changes in your lifestyle. By following these seven basic rules of good health, you'll improve your chances of living a long, healthy, active life.

Get eight hours of sleep per night.
Eat breakfast every morning.
Cut down on snacks between meals.
Keep within 10 pounds of your recommended weight range. If you're unsure what your weight range should be check with your doctor.
Exercise aerobically for at least 30 minutes three times per week.
Don't smoke.
Don't drink more than two alcoholic beverages per day.
Take recommended dosages of vitamins and supplements.

Copyright 2004, Monikah Ogando, Ogando Associates, Inc.

Monikah Ogando is a highly skilled facilitator and charismatic speaker. She continues to inspire her audience through her expertise in Business Development, leadership effectiveness, individual accountability and the values that guide excellence. She practices what she speaks: an entrepreneur, Monikah leads her own two companies, business coaching firm http://www.ogandoassociates.com and Exodus House Media.

Group Insurance Health Care and the HIPAA Privacy Rule

HIPAA stands for Health Insurance Portability and Accountability Act. When I hear people talking about HIPAA, they are usually not talking about the original Act. They are talking about the Privacy Rule that was issued as a result of the HIPAA in the form of a Notice of Health Information Practices.

The United States Department of Health & Human Services official Summary of the HIPAA Privacy Rule is 25 pages long, and that is just a summary of the key elements. So as you can imagine, it covers a lot of ground. What I would like to offer you here is a summary of the basics of the Privacy Rule.

When it was enacted in 1996, the Privacy Rule established guidelines for the protection of individuals's health information. The guidelines are written such that they make sure that an individual's health records are protected while at the same time allowing needed information to be released in the course of providing health care and protecting the public's health and well being. In other words, not just anyone can see a person's health records. But, if you want someone such as a health provider to see your records, you can sign a release giving them access to your records.

So just what is your health information and where does it come from? Your health information is held or transmitted by health plans, health care clearinghouses, and health care providers. These are called covered entities in the wording of the rule.

These guidelines also apply to what are called business associates of any health plans, health care clearinghouses, and health care providers. Business associates are those entities that offer legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.

So, what does a typical Privacy Notice include?

The type of information collected by your health plan.
A description of what your health record/information includes.
A summary of your health information rights.
The responsibilities of the group health plan.


Let's look at these one at a time:

Information Collected by Your Health Plan:

The group healthcare plan collects the following types of information in order to provide benefits:

Information that you provide to the plan to enroll in the plan, including personal information such as your address, telephone number, date of birth, and Social Security number.

Plan contributions and account balance information.

The fact that you are or have been enrolled in the plans.

Health-related information received from any of your physicians or other healthcare providers.

Information regarding your health status, including diagnosis and claims payment information.

Changes in plan enrollment (e.g., adding a participant or dropping a participant, adding or dropping a benefit.)

Payment of plan benefits.

Claims adjudication.

Case or medical management.

Other information about you that is necessary for us to provide you with health benefits.

Understanding Your Health Record/Information:

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment.

Means of communication among the many health professionals who contribute to your care.

Legal document describing the care you received.

Means by which you or a third-party payer can verify that services billed were actually provided.

Tool in educating health professionals.

Source of data for medical research.

Source of information for public health officials charged with improving the health of the nation.

Source of data for facility planning and marketing.

Tool with which the plan sponsor can assess and continually work to improve the benefits offered by the group healthcare plan. Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy.

Better understand who, what, when, where, and why others may access your health information.

Make more informed decisions when authorizing disclosure to others.

Your Health Information Rights:

Although your health record is the physical property of the plan, the healthcare practitioner, or the facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on otherwise permitted uses and disclosures of your information for treatment, payment, and healthcare operations purposes and disclosures to family members for care purposes.

Obtain a paper copy of this notice of information practices upon request, even if you agreed to receive the notice electronically.

Inspect and obtain a copy of your health records by making a written request to the plan privacy officer.

Amend your health record by making a written request to the plan privacy officer that includes a reason to support the request.

Obtain an accounting of disclosures of your health information made during the previous six years by making a written request to the plan privacy officer.

Request communications of your health information by alternative means or at alternative locations.

Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Group Health Plan Responsibilities:

The group healthcare plan is required to:

Maintain the privacy of your health information.

Provide you with this notice as to the planâEUR(TM)s legal duties and privacy practices with respect to information that is collected and maintained about you.

Abide by the terms of this notice.

Notify you if the plan is unable to agree to a requested restriction.

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. The plan will restrict access to personal information about you only to those individuals who need to know that information to manage the plan and its benefits. The plan will maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal information. Under the privacy standards, individuals with access to plan information are required to:

Safeguard and secure the confidential personal financial information and health information as required by law. The plan will only use or disclose your confidential health information without your authorization for purposes of treatment, payment, or healthcare operations. The plan will only disclose your confidential health information to the plan sponsor for plan administration purposes.

Limit the collection, disclosure, and use of participant's healthcare information to the minimum necessary to administer the plan.

Permit only trained, authorized individuals to have access to confidential information.

Other items that may be addressed include:

Communication with family. Under the plan provisions, the company may disclose to an employee's family member, guardian, or any other person you identify, health information relevant to that person's involvement in your obtaining healthcare benefits or payment related to your healthcare benefits.

Notification. The plan may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, general condition, plan benefits, or plan enrollment.

Business associates. There are some services provided to the plan through business associates. Examples include accountants, attorneys, actuaries, medical consultants, and financial consultants, as well as those who provide managed care, quality assurance, claims processing, claims auditing, claims monitoring, rehabilitation, and copy services. When these services are contracted, it may be necessary to disclose your health information to our business associates in order for them to perform the job we have asked them to do. To protect employee's health information, however, the company will require the business associate to appropriately safeguard this information.

Benefit coordination. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with plan benefit coordination.

Workers compensation. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Law enforcement. The plan may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Sale of business. If the plan sponsor's business is being sold, then medical information may be disclosed. The plan reserves the right to change its practices and to make the new provisions effective for all protected health information it maintains. Should the company's information practices change, it will mail a revised notice to the address supplied by each employee.

The plan will not use or disclose employee's health information without their authorization, except as described in this notice.

In Summary:

As an employee, you should be aware of your rights and feel confident that your employer is abiding by the guidelines of the Privacy Rule.

As an employer offering group insurance health care benefits, you should make your employees aware of their rights and should give them an avenue to obtain more information or to report a problem.

When you get your health insurance coverage through a broker that specializes in employee benefits, they should provide you with all of the necessary information and Privacy Notice to make sure you comply with the HIPAA guidelines.

Corinne Mitchell has worked in the insurance industry for 10+ years and currently works with the Group Insurance Benefits Specialists at http://www.nicoins.com

Read her blog http://www.groupinsurancebenefitsspecialists.com/ for more tips.

Make sure you get expert advice and find the right coverage for you and your employees.