August 2018 Volume 20 Issue 8
Providing Current Information on

Health Insurance Industry Issues and Legislation

New Jersey Outlaws Surprise Out-of-Network (OON) Medical Bills
Under a just passed law, providers in New Jersey are barred from billing patients
in excess of their deductible, copayment or coinsurance obligation for out-ofnetwork
services that are "inadvertent" or "emergent". Claims for OON services that
are "knowingly, voluntarily and specifically" selected are not protected under the
law. Self-funded Plans are addressed in the law with those covered by ERISA having
the ability to opt in. However, the status of non-ERISA covered plans under the law
is unclear. Importantly, providers can initiate arbitration proceedings against any
self-funded plan without qualification. Finally, apparent contradictions within the
law, potential conflicts with existing laws and federal preemption challenges may
impact implementation.
Out-of-Network Claims Are Not Going Away
Whether they are from inadvertent, emergent or from knowingly chosen providers,
costly OON claims are not going away. Neither are HHC Group's unceasing efforts
to ensure our clients pay only the appropriate amount for those claims. Our
bulldog negotiators work with providers to determine a reasonable charge and
get signed agreements on every deal. When necessary we access national and
regional networks to maximize potential savings. Finally, when neither negotiation
nor repricing gets the job done, we dig deeper to identify costly errors in the bills
themselves, so our clients can adjust their payments to the providers appropriately.
As long as there are OON claims, HHC Group will be here to assist payers in
minimizing their healthcare spend.
Attacking Musculoskeletal Claims
Between 1999 and 2016 health care insurance premiums increased 213%, more
than three times the overall inflation rate and unexpected medical bills became
the leading cause of bankruptcy in America. Musculoskeletal disorders account
for over half of all procedures and $213 billion in annual treatment, care and lost
wage costs, and are a major contributor to both the huge premium increases and
the bankruptcies. Some insurers are now starting to attack the musculoskeletal
disorder spending problem head on and are generating significant savings.
Strategies for Battling RX Price Increases
Paid charges for injectable drugs continued to skyrocket, hitting $584.5 million in
2017 and now account for 8.5% of total high-cost claims. The Affordable Care Act, RX
payment structure and incentives pharmacy benefit managers (PBM) receive are all part
of the problem. So, too, are decreased drug manufacturer competition and uncontrolled
increases in drug prices. Now, some insurers are finding ways to fight back and saving
big dollars.
Three Star Preferred Provider Program Additions
Rachelle M. Williams, MD PA
Houston, TX 77019

DuraMed LLC
Salt Lake City, UT 84115

Adjetry K. Lomo, M.D.
Houston, TX 77011

Henry Akinbobuyi , PT
Merrillville, TN

Medi MD
Ft. Lauderdale, FL 33328

Lake Cook Dental Center
Buffalo Grove, IL 60089
Dunwoody Labs
Dunwoody, GA 30338

Kimberly Johnson
Maceo, KY 52355

Jefferson County Lab
Louisville, KY 40202

Miranda Smith, M.D.
Boaz AL 35957

Family Medical Group
Saint Peters, MO 63376