What Every Medical Practice Manager Should Know About Health Care Reform

August 6, 2012 Leave a comment

Below is what every Medical Practice Manager should know about health care reform.

The provisions listed below will have a direct impact on medical practice management and practice managers need to take the time to familiarize themselves with the new regulations.

Section 1001 Subsection 2712- Prohibition on Recissions
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved.

Section 1001 Subsection 2713 – Coverage of Preventive Health Care  

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for-evidence-based items or services that have in effect a rating of `A’ or `B’ in the current recommendations of the United States Preventive Services Task Force; immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Section 1001 Subsection 2714 – Extension of Dependent Coverage
A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age.

Section 1201 Subsection 2704 – Prohibition of Preexisting Conditions
A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.

Section 1421 – Tax Credit for Employee Health Insurance Expenses of Small Businesses
An eligible small employer, the small employer health insurance credit amount is 50 percent (35 percent in the case of a tax-exempt eligible small business).

Section. 3111 – Payment for Bone Density Tests
For dual-energy x-ray absorptiometry services (identified in 2006 by HCPCS codes 76075 and 76077 (and any succeeding codes)) furnished during 2010 and 2011, instead of the payment amount that would otherwise be determined under this section for such years, the payment amount shall be equal to 70 percent of the product.

Section 3134 – Misvalued Codes Under Physician Fee Schedule

For purposes of identifying potentially misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as 3 years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called `Harvard-valued codes’); and such other codes determined to be appropriate by the Secretary.

Section  4104 – Elimination of Co-Pay

Elimination of coinsurance (co-pay) on preventive services (ie. physical exams). Elimination of coinsurance (co-pays) in outpatient hospital settings.

Section  4108 – Incentives for Prevention of Chronic Diseases

Incentives for prevention of chronic diseases. A program described in this paragraph is a comprehensive, evidence-based, widely available, and easily accessible program, proposed by the State and approved by the Secretary, that is designed and uniquely suited to address the needs of Medicaid beneficiaries and has demonstrated success in helping individuals achieve one or more of the following: ceasing use of tobacco products, controlling or reducing their weight, lowering their cholesterol, lowering their blood pressure, avoiding the onset of diabetes or, in the case of a diabetic, improving the management of that condition.

Section 4204 – Immunizations
Funds received under a grant under this subsection shall be used to implement interventions that are recommended by the Task Force on Community Preventive Services (as established by the Secretary, acting through the Director of the Centers for Disease Control and Prevention) or other evidence-based interventions, including–providing immunization reminders or recalls for target populations of clients, patients, and consumers;educating targeted populations and health care providers concerning immunizations in combination with one or more other interventions; reducing out-of-pocket costs for families for vaccines and their administration; carrying out immunization-promoting strategies for participants or clients of public programs, including assessments of immunization status, referrals to health care providers, education, provision of on-site immunizations, or incentives for immunization; providing for home visits that promote immunization through education, assessments of need, referrals, provision of immunizations, or other services; providing reminders or recalls for immunization providers;conducting assessments of, and providing feedback to, immunization providers; any combination of one or more interventions described in this paragraph; or immunization information systems to allow all States to have electronic databases for immunization records.
Section 5202 –  Nursing Student Loan Repayment

The Secretary shall establish and carry out a pediatric specialty loan repayment program under which the eligible individual agrees to be employed full-time for a specified period (which shall not be less than 2 years) in providing pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care, including substance abuse prevention and treatment services.

Section 5301 – Financial Assistance for Students Going Into Primary Care
To provide need-based financial assistance in the form of traineeships and fellowships to medical students, interns, residents, practicing physicians, or other medical personnel, who are participants in any such program, and who plan to specialize or work in the practice of the fields of family medicine, general internal medicine, or general pediatrics training programs.

Section 5501 – Incentive Payments for Primary Care Physicians
Incentive payments for primary care physicians. In the case of primary care services furnished on or after January 1, 2011, and before January 1, 2016, by a primary care practitioner, in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service under this part.

Every Medical Practice Manager must take time to read and understand the above regulations. For more information, click HERE


ICD-10 Implementation To Cost Physicians and Hospitals Millions

July 31, 2012 1 comment

ICD-10 implementation is expected to happen now (after delays) in October 2014. The American Medical Association and Medical Group Management Associations state that implementation will cost a single  physician $27,000 – $29,000. This amount of money could potentially be detrimental to a physician ‘s (and even a hospitals) bottom line. Below is how much ICD-10 could potentially cost physicians (and hospitals). The calculations you will find below are based upon the number of physicians a facility has. Here is what some of our nation’s top hospitals might pay.


Cleveland Clinic                                                  –       $70,000,000   – $75,000,000

Duke Medical Center                                         –       $39,000,000    – $42,000,000

Emory University Hospital                              –       $27,000,0000  – $29,000,000

Johns Hopkins Hospital                                 –        $57,000,000     – $62,000,000

Massachusetts General Hospital                  –       $48,000,000 – $51,000,000

Mayo Clinic                                                         –        $99,000,000   – $107,000,000

Northwestern Memorial Hospital                 –        $48,000,000  – $51,000,000

NY Presbyterian Hospital                                –      $165,000,000  – $178,000,000

Ochsner Health System                                   –       $25,000,000    – $27,000,000

Texas Medical Center                                        –      $540,000,000  – $580,000,000

UCLA Medical Center                                        –       $52,000,000    -$56,000,000

Vanderbilt University Medical Center          –      $324,000,000  –  $348,000,0000

Timeline of Taxes and Penalties in the Affordable Care Act

July 20, 2012 Leave a comment

Below is a timeline and  listing of when the taxes and penalty provisions of the Affordable Care Act will be implemented.

Starting in 2009

(Sec. 9007) Establishes new requirements applicable to nonprofit hospitals. The requirements would include a periodic community needs assessment and certain limitations on charges.


(Sec. 9021) Provides an exclusion from gross income for the value of specified Indian tribal health benefits.


Starting in 2010

Imposes a ten percent tax on amounts paid for indoor tanning services in lieu of the tax on cosmetic surgery. Indoor tanning services are services that use an electronic product with one or more ultraviolet lamps to induce skin tanning. The tax would be effective for services on or after July 1, 2010.


Starting in 2011

(Sec. 9004) Increases the additional tax for HSA withdrawals prior to age 65 that are used for purposes other than qualified medical expenses from 10 percent to 20 percent. The additional tax for Archer MSA withdrawals not used for qualified medical expenses would increase from 15 percent to 20 percent


(Sec. 9008) Imposes an annual flat fee of $2.3 billion on the pharmaceutical manufacturing sector beginning in 2010. This non‐deductible fee would be allocated across the industry according to market share and would not apply to companies with sales of branded pharmaceuticals of $5 million or less.

(Sec. 10108) Requires employers that offer coverage and make a contribution to provide free choice vouchers to qualified employees for the purchase of qualified health plans through Exchanges. The free choice voucher must be equal to the contribution that the employer would have made to its own plan.

Employees qualify if their required contribution under the employer’s plan would be between 8 and 9.8 percent of their income. Excludes free choice vouchers from taxation and voucher recipients are not eligible for tax credits.


Starting in 2012

(Sec. 9006) Requires businesses that pay any amount greater than $600 during the year to corporate and non‐corporate providers of property and services to file an information report with each provider and with the IRS. Information reporting is already required on payments for services to non‐corporate providers.


(Sec. 9022) Establishes Simple Cafeteria Plans that ease participation restrictions so that small businesses can provide tax‐free benefits to their employees. Under this provision, self‐employed individuals are included as qualified employees. The provision also exempts employers who make contributions for employees under a simple cafeteria plan from pension plan nondiscrimination requirements applicable to highly compensated and key employees.

Starting in 2013

(Sec. 4375) Imposes a fee on each specified health insurance policies and self‐ insured health plans for each policy year ending after September 30, 2012, a fee equal to the product of $2 ($1 in the case of policy years ending during fiscal year 2013) multiplied by the average number of lives covered under the policy or plan. (Termination September 30, 2019).


(Sec. 9009) Imposes an annual flat fee of $2 billion on the medical device manufacturing sector beginning in 2010. This non‐deductible fee would be allocated across the industry according to market share and would not apply to companies with sales of medical devices in the U.S. of $5 million or less. The fee does not apply to any sale of a Class I product or any sale of a Class II product that is primarily sold to consumers at retail for not more than $100 per unit (under the FDA product classification system).


(Sec. 9012) Eliminates the deduction for the subsidy for employers who maintain prescription drug plans for their Medicare Part D eligible retirees.


(Sec. 9013) Increases the adjusted gross income threshold for claiming the itemized deduction for medical expenses from 7.5 percent to 10 percent. Individuals age 65 and older would be able to claim the itemized deduction for medical expenses at 7.5 percent of adjusted gross income through 2016.


(Sec. 9014) Limits the deductibility of executive compensation under Section 162(m) for insurance providers if at least 25 percent of the insurance provider’s gross premium income from health business is derived from health insurance plans that meet the minimum essential coverage requirements in the bill (“covered health insurance provider”). The deduction is limited to $500,000 per taxable year and applies to all officers, employees, directors, and other workers or service providers performing services for or on behalf of a covered health insurance provider.


(Sec. 10902) Indexes the $2,500 limit on contributions to a flexible spending arrangement by CPI‐U for years after December 31, 2011.


(Sec. 10906) Modifies the increased HI tax rate for single taxpayers with income in excess of $200,000 and couples filing jointly with incomes in excess of $250,000 from 0.5 percentage points to 0.9 percentage points.


Starting in 2014

(Sec. 36B) The premium assistance credit amount is calculated on sliding scale starting at two percent of income for those at or above 100 percent of poverty and phasing out to 9.8 percent of income for those at 400 percent of poverty. The reference premium is the second lowest cost silver plan available in the individual market in the rating area in which the taxpayer resides. The premium assistance credits do not take into account benefits mandated by States. Employees offered coverage by an employer under which the plan’s share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs or the premium exceeds 9.8 percent of the employee’s income are eligible for the premium assistance credit. This section also provides for reconciliation of the premium assistance credit amount at the end of the taxable year and for a study on the affordability of health insurance coverage by the Comptroller General.


(Sec. 125 (f)(3)) Plans provided through the exchange will not be an eligible benefit under an employer‐sponsored cafeteria plan, except in the case of qualified employers (i.e., small employers, and, after 2017, large employers in electing states) offering a choice of plans to their employees through the exchange.


(Sec. 1514) Requires large employers to report to the Secretary whether it offers to its full‐time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer‐sponsored plan, the length of any applicable waiting period, the lowest cost option in each of the enrollment categories under the plan, and the employer’s share of the total allowed costs of benefits provided under the plan. The employer must also report the number and names of full‐time employees receiving coverage.


(Sec. 9010) Imposes an annual flat fee of $6.7 billion on the health insurance sector beginning in 2010. This non‐deductible fee would be allocated across the industry according to market share and would not apply to companies whose net premiums written are $25 million or less and whose fees from administration of employer self‐insured plans are $5 million or less. The public option, as well coops and the national plan, will be subject to the insurance provider fee.


Starting in 2018

(Sec. 1401)  Reduces the revenue collected by the tax by 80 percent. This is achieved by: delaying the application of the tax until 2018, which gives the plans time to implement and realize the cost savings of reform; increasing the dollar thresholds to $10,200 for single coverage and $2 for family coverage ($11,850 and $30,950 for retirees and employees in high risk professions); excluding stand‐alone dental and vision plans from the tax; and permitting an employer to reduce the cost of the coverage when applying the tax if the employer’s age and gender demographics are not representative age and gender demographics of a national risk pool. Under the modified provision, the dollar thresholds are indexed to inflation and the dollar thresholds are automatically increased in 2018 if CBO is wrong in its forecast of the premium inflation rate between now and 2018.

Blue Cross Blue Shield Can Lose Tax Exemption Under Health Care Reform

July 20, 2012 Leave a comment

Blue Cross Blue Shield and other non-profit health insurance companies can lose their tax exemption if they do not spend 85% of their premiums on actual medical care (not profits or compensation for executives) thanks to Section 9016 of the Affordable Care Act. Here is the exact language of the provision:

(Sec. 9016) Requires Blue Cross or Blue Shield organizations or other nonprofit organizations that provide health insurance to reimburse at least 85% of the cost of clinical services provided to their enrollees to be eligible for special tax benefits currently provided to such organizations.

Humana to Pay $5.1 Million in Rebates for Violating Medical Loss Ratio

July 18, 2012 1 comment

Humana sent this blogger a personal letter today stating that it has violated the Medical Loss Ratio rule of the affordable care act. Under this rule, insurance companies are required to pay a rebate back to their policy holders if 80% of their premium dollars is not spent on medical care.

I live in Tennessee. Humana premiums totaled $30,623,077 and only spent $19,353,784 Million  (63.2%)  when it should have spent $24,498,461 (80%) on medical care. Humana used the extra money for “administrative costs” (i.e. profits for shareholders, executive compensation packages) and it thus missed the MLR by 16.8%. Humana is rebating 16.8% back to policy holders which totals $5,144,676 Million.

If you live In Tennessee and are a Humana policy holder, make sure you check your mailbox. If you wish to opine, please hit the Leave A Comment button.

The Physicians Prescription for Health Care Reform

July 17, 2012 Leave a comment

In the U.S. Congress, there are currently 21 physicians.  The physicians are  Senator John Barasso,
Rep. Dan Benishek,Rep. John Boustany, Rep. Paul Broun, Rep. Michael Burgess, Rep. Larry Buschon, Rep. Bill Cassidy, Rep. Donna Christensen, Senator Tom Coburn, Rep. Scott DesJarlais, Rep. John Fleming, Rep. Phil Gingrey, Rep. Paul Gosar, Rep. Andy Harris, Rep. Nan Hayworth, Rep. Joe Heck, Rep. Jim McDermott, Senator Rand Paul, Rep. Ron Paul, Rep.Tom Price, and Rep. Phil Roe. One of the physicians is an anesthesiologist, one is a dentist, one is an emergency medicine physician, four are family practitioners, one is a gastroenterologist, four are obstetricians / gynecologists, one is a psychiatrist, and four are surgeons (cardiovascular, thoracic, general, and orthopedic). Below is a listing of bills and provisions the physicians have introduced  that includes their prescription for health care reform.


Bills by Physician

John Barrasso    –  S. 244   (State Health Care Choice Act)
Michael Burgess – H.R. 896  (Medical Justice Act)
Bill Cassidy          – H.R. 3315  (Direct M.D. Care Act)
Tom Coburn        – S. 1031        (Medicaid Improvement and State Empowerment Act)
Phil Gingrey        – H.R. 5       (Protecting Access to Healthcare Act)
Paul Gosar           – H.R. 1150  (Competitive Health Insurance Reform Act)
Joe Heck               – H.R. 2472  (Health Care Professionals Protection Act)
Jim McDermott  – H.R. 1256   (Medicare Physician Payment Transparency Act)
Ron Paul              – H.R. 147     (Prescription Drug Affordability Act)
Tom Price            – H.R. 969     (Medical Practice Freedom Act)


Key Provisions


Medical Practice Management Provisions

Cap on non-economic damages to health care practitioners and hospitals (Source 2)
Speedy resolution of health insurance claims (Source 5)
Restoring Anti-Trust Laws to Health Insurance Companies (Source 5)
Prohibit health entities from reporting professional review against health care professionals (Source 6)
People may import pharmaceutical drugs into U.S. if is approved by Secretary of Health and Human Services (Source 8)
Physicians not required to participate in any health insurance plan as a condition of licensure (Source 9)
Tax incentive for maintaining health care coverage (Source 10)
Financial incentive for treatment compliance (Source 10)
Student Loan forgiveness for primary care providers (Source 10)
Federally supported student loans for medical students (Source 10)


Medicare and Medicaid Provisions
Establish pilot program for monthly fee based direct primary care medical home Medicare and Medicaid enrollees (Source 3)
Require analytic contractors to review Medicare Physician Fee Schedule (Source 7)
Refundable tax credit for low-income individuals (Source 10)
Enforcement of Medicare Secondary Payment Provisions (Source 10)


State Health Care Provisions
States can opt out of provisions of Patient Protection and Accountable Care Act   (Source 1)
State incentive fund for medical malpractice reform (Source 4)
Grant to create health care tribunal (Source 10)
Track banned medical providers across state lines (Source 10)



1. http://www.gpo.gov/fdsys/pkg/BILLS-112s244is/pdf/BILLS-112s244is.pdf

2. http://www.gpo.gov/fdsys/pkg/BILLS-112hr896ih/pdf/BILLS-112hr896ih.pdf

3. http://www.gpo.gov/fdsys/pkg/BILLS-112hr3315ih/pdf/BILLS-112hr3315ih.pdf

4. http://www.gpo.gov/fdsys/pkg/BILLS-112s1031is/pdf/BILLS-112s1031is.pdf

5. http://www.gpo.gov/fdsys/pkg/BILLS-112hr5eh/pdf/BILLS-112hr5eh.pdf

6. http://www.gpo.gov/fdsys/pkg/BILLS-112hr2472ih/pdf/BILLS-112hr2472ih.pdf

7. http://www.gpo.gov/fdsys/pkg/BILLS-112hr1256ih/pdf/BILLS-112hr1256ih.pdf

8. http://www.gpo.gov/fdsys/pkg/BILLS-112hr147ih/pdf/BILLS-112hr147ih.pdf

9. http://www.gpo.gov/fdsys/pkg/BILLS-112hr969ih/pdf/BILLS-112hr969ih.pdf

10. http://www.gpo.gov/fdsys/pkg/BILLS-112hr3000ih/pdf/BILLS-112hr3000ih.pdf

U.S. House Votes to Repeal Healthcare Reform 244-185

July 11, 2012 1 comment

The U.S. House today voted to repeal the Affordable Care Act 244-185.  Five Democrats voted FOR repeal and they are:
Dan Boren (D-OK 02), Larry Kissell (D-NC 08), Jim Matheson (D-UT 02), Mike McIntyre (D-NC 07), Mike Ross (D-AR 04). You can see how each member of the House voted by going here: http://clerk.house.gov/evs/2012/roll460.xml. The bill the House approved (H.R. 6079) can be read here: http://www.gpo.gov/fdsys/pkg/BILLS-112hr6079ih/pdf/BILLS-112hr6079ih.pdf.

Keywords:  health care insurance, health care, health plan, health policy, U.S. Congress, health care reform