“Ignorance is bliss” may be true in most cases; but it is a misnomer when it comes to health literacy.  A study conducted by Kaiser Permanente and published recently in the Journal of the American Medical Association found that patients with congestive heart failure and low health literacy are three times more likely to die in a given year than patients with better health literacy skills.

For instance, patients, with high deductible health plans, might be avoiding even basic preventive care like annual checkup, etc., simply because they do not know that preventive care does not attract any out of the pocket expenses as it is covered by the plan. It might also be because these patients have not  understood the benefits of their plan and hence avoid visiting the hospital.

Increasingly, stakeholders across the health care system have recognized the important link between health literacy and health status, and are advocating the necessity of  ‘clear communication’ to provide consumer health and benefits information that :

• Is easy to access, understand, and act upon
• Promotes consumer’s engagement in their own health
• Results in better health outcomes

So what are the health plans doing to improve health literacy of the consumers?

Some common strategies that could be employed by various health plans to promote health literacy are:

• Assessment of an organization to see if infrastructure exists to provide clear, easy to use information
• Awareness sessions for the personnel who are involved in either written or spoken communication to promote health literacy
• Adopt a target reading level for all communications, within and outside the organization
• Standardize the jargons and acronyms used across organizations. This would require a joint effort from multiple organizations

In our next blog post we will examine how improved health literacy among Americans will impact the health of the patients and reduce the overall cost of health care.

Healthcare fraud is an intentional deception or misrepresentation made by a person or an entity s, knowing that the misrepresentation could result in a payment to which the person or entity is not entitled. As healthcare fraud is seamless, it tends to blend making detection a challenge.

Fraud detection and prevention tools are no longer a “nice to have” but a critical element for sustaining the business. The damages incurred due to health care fraud has increased exponentially over the past few years. To reap the advantages of health care reform it is essential to strengthen fraud, waste and abuse protocols with strong processes, tools and services.

The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in tens of billions of dollars each year. As per the numbers provided by the Federal Bureau of Investigation[Ref], fraud, waste, and abuse account for 3 to 10 percent of the total health care expenditure. These losses lead to a causal system where increased health care costs are met by a surge in cost of coverage. The disproportionate surge of coverage as against income burdens the end customer.

The comprehensive solution to this issue is a two-pronged approach. Many organizations are not adequately staffed to review the high volume of claim activity that requires validation.

There is a need to provide aid in designing processes and services for claim validation, tracking, and recovery services to interpret the data output from their traditional tools, such as rule engine, scoring models. This would help in dealing with the volumes of claims that require validation leading to potential recovery of losses.

HCL offers an experienced professional claim validation and recovery management team that is capable of auditing high claim volumes. This team can either compliment a health plan’s current staffing or act as a completely outsourced unit for the plan.  If health plans do not have appropriate fraud detection tools in place, HCL along with its partner vendors can offer tools that aid in the identification and detection of FWA claims and links.

Find out more about our FWA solutions in our next blog…

ICD-10 Compliance date in healthcare industry is swiftly approaching and the ICD-10 steering committees of healthcare organizations are now rushing for the management of various tasks associated with ICD-10. The major areas of concern for the ICD-10 program managers include ensuring transactional neutrality with their trading partners and meeting timely compliance. It is absolutely essential that healthcare organizations assess the readiness of their partners and perform a round of testing with their partners transacting new ICD-10 code sets.

CMS set forth the key to success for ICD-10 compliance is to consider ICD-10 as a business initiative and not a code set update and compliance with ICD-10 simply means the ability to accept and send transactions.

ICD-10 noncompliance of trading partners would result in operational challenges necessitating them to make adjustments for reconciliation of billing codes. Also, the providers or clearing houses might face revenue shortfalls due to inability to process new ICD-10 codes.

Healthcare organizations today are looking for solutions to facilitate assessment of trading partners and track their ICD-10 readiness and perform end-to-end ICD-10 Testing with their partners.

Tracking partners for ICD-10 readiness calls for a solution or framework that can help them in the identification of problematic partners and drive better risk awareness among business partners. Also, healthcare organizations need to quickly start automating the tracking and testing process so that staff effort on monotonous everyday jobs can be reduced and better resolution of ICD-10-related issues can be achieved. Proper communication, coordination, transparency and multiple rounds of testing among the trading partners are critical to achieve compliance and mitigate compliance risks.

We all have been hearing about the issues, challenges, and bottlenecks in the US healthcare industry and the many approaches /solutions that have been discussed and designed to tackle them.

 

In order to initiate a reality check, I am outlining a few pointers  published online…

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• The congressional budget estimated that this legislation would cost around $900 billion with reduction in fiscal deficit of around $120 billion over a period of 10 years.
• It is also estimated that the act will reduce the number of uninsured by 32 million in 2019.
• This legislation will also result in 24 million people obtaining coverage through the newly created state health insurance exchanges or HIE.
• Approximately 16 million more people would be able to enrol in Medicaid and CHIP.
• Savings from Medicare/Medicaid, fees, taxes, etc. will offset the cost
• The act would also penalise insurance company for abuses, malpractices, etc.
• The legislation has already provided tax credits to small business health plans, allowed states to cover more people under Medicaid, ensured tough actions on health care fraud, expanded the coverage to retirees, and the coverage for pre-existing conditions.
• Insurance companies with excessive or unjustified premiums may not be able to participate in health insurance exchanges in 2014.
• The act also extends the coverage to young adults who are dependants or live with their parents and do not have dependants.

 

 

 

Interestingly these pointers have given rise to some more   questions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• What are the execution/implementation strategies, which will play a crucial role in making this a historical act?
• How will the immense cost burden impact insurance premiums?
•  How willing are  the providers, payers, states, businesses, and members to adopt these guidelines?
• How to provide  the enormous training efforts that will be required to operate and adopt these legislatures?
• What about the information security/safety, quality check, and many more measures?

 

 

 

These questions require further examination…

With U.S President Obama getting re-elected for the second term, healthcare in the nation has been witnessing changes leading to increased access to affordable care.

The Patient Protection and Affordable Care Act became law on March 23, 2010, beginning a series of important, sweeping reforms to the healthcare system that will expand coverage, control health care costs and improve the healthcare delivery system. While the act’s provisions will continue to be implemented through 2016, its reforms are already benefiting millions of Americans in important ways.

One of the foremost important objectives of PPACA was to increase access to affordable healthcare. Let’s have a  look at what has happened with the help of some numbers and facts below:

• 2.5 million young adults gained health insurance.
  This is an example of the coverage gains for millions of people the Affordable Care Act is projected to provide. The Affordable Care Act allows young adults to stay on their parents’ insurance plans until age 26.
• More than 40,000 Americans with pre-existing medical conditions gained affordable coverage through the federally administered Pre-Existing Condition Insurance Plan.
  Those with pre-existing conditions, such as cancer or chronic disease, can access insurance to meet their health needs through the plan.
• The Department of Health and Human Services awarded more than $14 million in 2011 alone to school-based health centers across the country, increasing the number of children served by 50 percent.
  The Affordable Care Act provides a total of $200 million for school-based health centers, which provide primary care, dental health, mental health, substance-abuse counselling, and health and nutrition counselling.
• Across the country, 350 new community health centers were built and nearly 19,000 new jobs were created in 2011 alone to provide critical healthcare to the 50 million Americans living in medically underserved areas. 
  The Affordable Care Act provides a total of $11 billion to support and expand community health centers nationwide.
• Consumers are enjoying greater protection from unreasonable private-insurance premium hikes.
  The Affordable Care Act helped 42 states, the District of Columbia and five U.S. territories strengthen their rate-review laws, bringing greater transparency and accountability to private insurance rate increases. For example, Connecticut rejected a 20% rate hike by insurers, and Oregon halved the rate increase by one of its largest insurers, saving money for more than 60,000 people, and the Department of Health and Human Services recently deemed increases in five states “unreasonable.”

Taking the above facts in to consideration, I am pretty sure that the ‘Increased access to affordable care’ objective is on the perfect path to success. What do you think?

Next time, we will take a closer look at ‘Making Care More Affordable’!

The health insurance environment has gone through significant changes over the past few years and continues to evolve at a rapid pace. There is an industry-wide focus on ways to manage the rising cost of care, improving quality and achieving improved health outcomes. By 2014, millions of newly insured individuals will be joining the system and health plans will be under more pressure than ever before to improve the quality of services and deliver greater transparency to members, providers and other stakeholders.  Lack of a focused strategy that differentiates health plans in terms of enhanced customer service interactions and dedicated retention programs can significantly impact business growth.

Current statistics indicate no major improvement in member experience in the health insurance industry over the last five years. To make matters worse, member expectations continue to rise, with demand for fast, consistent and accurate information as well as the ability to communicate across different channels such as mobile, web, email, kiosks etc. All these call upon payers to collaborate better with members and become more proactive about improving member satisfaction.

Many health plans are yet to adopt innovative member engagement and technology strategies to determine how they are interacting with the members. These strategies focus on superior customer service and advanced, real-time member data profiling providing a 360-degree view of the health plan member interactions. Adopting such a model is a transformational change for payers and will require new technology investments, cultural and behavioral change and greater understanding of member preferences. These investments will play a big role in improving member enrollments, reducing costs and promoting overall member wellness.