Health Care Coverage News

SPBA Comments to Transparency Coverage Rule

The Society of Professional Benefits Administrators has issued comments to CMS regarding the proposed transparency rule and some concerns SPBA has about how the rule will affect third-party administrators. Some of the issues raised in the comments include the cost of compliance. Some of the challenges raised by SPBA include: Physician pricing. SPBA suggests physicians provide dollar amounts for services in addition to procedure codes. Time delay in accessing networks. TPAs may be required to pay network access fees twice—once to create an estimate and the other when the claim is received. SPBA recommends to include a “safe harbor” rule for plans without direct access to negotiated in-network rates and allowed amounts or reference-based pricing in real time and should have 72 hours to complete estimates. Notice limitations. The current proposal needs to include language that lets the plan participant know there still could be surprise amounts due to complications, post procedure drug costs, etc. SPBA would also like to make it clear the plan cannot be sued if the estimate turns out to be less than the participant’s out-of-pocket costs. Cost burdens. Simply put, the costs estimated by CMS to comply with this rule are “woefully low”. Many plans don’t have the data or the funds required to build an online tool. Secondly, many plans will have to create a tool from scratch, which would unfairly benefit the large companies and plans. Read the full rules here. Source: Society of Professional Benefits Administrators

Self-Insurance Legislation Blocked in New Jersey

Self-Insurance came under attack in New Jersey recently when a bill designed to restrict the self-insurance marketplace in that state advanced in the legislature. The Governor, Phil Murphy, vetoed the bill which effectively blocked the legislation that would have eliminated stop-loss contracts. Read more about SIIA’s position on this kind of legislation. Source:

Pharmaceutical Companies Start 2020 with Drug Price Hikes

Some drug companies kicked off the new year with price hikes on their products an average of 6.3 percent. An analysis by RX Savings Solutions revealed the price hike which has increased as much as 10% for some drugs. January increases are common for pharmaceutical companies, and though prices are increasing, the average rates are less than in 2017. Pressure from the Trump Administration and consumer groups could be keeping price hikes from going even higher. Read more. Source:

Hospitals Sharing Data with Tech Giants

Hospitals control massive amounts of patient data and have been allowing  tech companies such as Amazon, Microsoft, and Google access to identifiable patient information for collaboration to develop research and products including cancer studies and artificial intelligence. HIPAA allows hospitals to send data to business partners related to health insurance, medical devices and other services as long as they notify patients, but doesn’t require permission. Read more about these collaborations. Source: Wall Street Journal

“Hotspotting” Study

Hotspotting is a health care model that helps people who face social barriers, and who use hospitals multiple times a year to gain access to programs to improve their lives (i.e. assistance with housing or substance abuse recovery), to reduce medical costs incurred in the ER. As this model becomes increasingly more popular, a study in the New England Journal of Medicine confirmed that while repeat hospitalizations did drop, the result was no better than a group of patients not part of a hotspotting program. While the results were disappointing, advocates say there is a place for these types of programs in social services. Read more about hotspotting. Source:

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