Health Insurance Industry Issues and Legislation

An Orthopedic Surgeon and a patient are suing Sutter Health for numerous billing errors. The plaintiffs are seeking $519 million for alleged double billing without documentation and for overcharging patients recovering from surgeries and other services provided. The lawyer representing Sutter, which has previously paid large fines, said it is a non-profit with 'no profit motive' and 'last year gave hundreds of millions of dollars to local communities'.

All HHC Bill Reviews begin with a free prescreen to determine whether the potential savings on large hospital bills are significant enough to warrant a comprehensive review. If they are, highly experienced nurse coders scrutinize every line to identify duplicate charges, improper modifiers, inappropriate quantities, and any items that don't belong on the claim, both for high-dollar in-network and out-of-network bills. For out-of-network (OON) claims, we can also determine what other providers in the market charge (Usual and Customary - U & C) for the same service. Of course, we are here from day 1 to address any provider appeals at no extra charge.

Since the passage of the Affordable Care Act in 2010, the percentage of small employers offering at least one self-insurance option has grown and now stands at an all-time high. In contrast, the percentage of middle and large-sized companies offering a self-insurance option has dropped steadily and is at its lowest point in the last 12 years.

All parties at a recent congressional hearing agreed that the NSA has been largely successful in heading off most unexpected bills, but no one is totally happy with its implementation. However, no one is happy with its implementation. Some lawmakers said the implementation is 'flawed,' and it has not been properly executed. Providers complained that the deck is stacked against them, while payers testified that some providers are gaming the system.