Tag Archives: claims

Since I’ve already determined that I will need to get through more than one section a night to get to the end of this law in a reasonable time, I’ll attempt to get through at least the end of Section 1001 tonight.

There are three remaining sub-sections. The first, while long, can be summed up rather succinctly. Entitled “Bringing Down the Cost of Health Care” it requires that health insurance plans submit details of their plan premiums (or revenues) versus losses (or claims).

We should pause for just a moment to recognize that this terminology implies something specific. When you go to the doctor, your insurance company doesn’t think this is a good idea that could potentially save your life – they see it as a loss to their company – the same kind of loss that the grocery store entails when they have to throw away expired milk. Insurance companies would like nothing better than for you to pay premiums every day of your life and never, ever go to the doctor. Unlike car insurance, or fire insurance, where there is a strong chance that you can go your entire life without needing the payout, people are going to go to the doctor. But, we shan’t dwell too much on the fact that insurance is a stupid way to provide a product that everyone is going to need as some point. The best insurance companies can do is try to have more healthy people than sick (at least that they pay for).

Ok, so back to the Act. The insurance plans submit a report with the claims, the costs for improving health care quality, and non-health related costs (often referred to as administrative costs). Then, if the plan spends less than 85% (for large market plans, 80% for small market) of the premiums on health care claims, or quality improvement, they have to give money back to the people who paid the premiums. This started in 2011. In 2014, this payment is based on a three-year average of the ratio.

The second part for tonight requires that plans have an effective appeals process for denied claims, that complies with these regulations , which give some basic timeframes for appeals.

The last part (oh the progress!) says it is called “Patient Protections.” These protections state that you can pick any participating primary care provider that you want. Additionally, that emergency services, if offered, are covered without pre-authorization (because not everyone remembers to call the insurance company on the way to the hospital when they are dying), and covered at the same rate, regardless of whether the doctor or the emergency room is ‘in-network’ or not. The Act defines emergency medical conditions in terms of what is reasonable to a layperson, rather than an insurance administrator, and an emergency service to be an exam and stabilization. It allows you to choose to pick a pediatrician for the primary care provider of children. Finally, the protections ensure that you do not need a referral to see a gynecologist or obstetrician. If you see an OB/GYN, then the care he or she authorizes is as if the primary care physician had done so. It apparently doesn’t require that the plans offer these cover ages, just discusses what happens if they do.

So, we have come to the end of Section 1001. Hopefully the Supreme Court Justices can hold off on their decision until I’ve finished the whole thing, and then they can just read this blog instead of the Act itself. 😉