Overdose cluster in Georgia linked to mystery pill- CNN

At least a dozen people have been hospitalized over 48 hours in central and south Georgia after swallowing an unidentified street drug, according to state and hospital officials. Four deaths have been linked to the overdose cluster, but officials are still waiting on autopsy results to determine the exact cause of death.

“What is uncommon is to see so many (overdoses) come in in such a short time frame,” said Dr. Christopher Hendry, chief medical officer of Navicent Health, one of three hospitals in Georgia that is known to have received the patients.

Some patients have described taking a yellow pill they thought was the prescription painkillerPercocet, Hendry said, but the overdose symptoms were “much more severe in onset.” He is concerned the drug could be a compound of much more powerful opioids, which could prove difficult for doctors to reverse.

“There’s a compound in the South that’s recently popped up — 10,000 times more powerful than morphine — where the normal doses of Narcan are not effective,” Hendry said of the medication that is typically used to reverse opioid overdoses.

The patients, mostly brought in by ambulance, appeared sleepy, had slurred speech and had difficulty breathing, Hendry said. These symptoms led doctors to suspect an opioid overdose, but toxicology results won’t be back for at least a couple of days. Until then, Hendry said, “this is an evolving event.”

In addition to Navicent Health in Macon, Georgia, patients have been sent to nearby Coliseum Health and Houston Healthcare.

Other street drugs — such as the opioid concoction known as “grey death” — have recently been linked to overdoses in Georgia and other parts of the South.

There were about 1,300 overdose deaths in Georgia in 2015, according to the US Centers for Disease Control and Prevention.

Sheriff David Davis of Bibb County said investigators have been following leads, but there are no suspects at this time.

Although it is common for dealers to sell real prescription drugs on the street, Davis suspects that “someone has developed this particular pill … and is passing it off as a prescription medicine.”

“The individuals that are involved in the drug trade, this may be their newest product,” he said, urging people to come forward with more information or turn themselves in.

“We need to know who’s putting this poison in the community right now.”

Source: Google Play Newsstand

Posted in Industry Updates, Opioid Epidemic

8 Colorado hospitals trying alternatives to opioids in emergency rooms | FOX31 Denver

The Colorado Hospital Association (CHA) has launched an opioid safety pilot in eight hospital and three freestanding emergency departments, with the goal of reducing the administration of opioids in emergency departments.

Pilot hospitals and emergency departments will use the new American College of Emergency Physicians 2017 Opioid Prescribing and Treatment Guidelines. The guidelines recommend the use of alternatives to opioids as a first-line treatment for pain, rather than opioids.

According to the CHA, the pilot program is necessary to gather data, establish best practices and determine the efficacy of using alternatives for the management of acute pain.

The CHA is citing the fact that Colorado has the 12th highest rate of misuse and abuse of prescription opioids across all 50 states as one of the reasons for the pilot program.

According to CHA, the initiative will be one of the largest opioid research efforts in the United States.

Pilot hospitals include:

  • Swedish Medical Center in Englewood
  • Boulder Community Health and Boulder Community Medical Center Emergency Room in Boulder
  • Gunnison Valley Health in Gunnison
  • Medical Center of the Rockies in Loveland
  • UCHealth-Greeley Emergency & Surgery Center in Greeley
  • Poudre Valley Hospital & UCHealth Emergency Room – Harmony in Fort Collins
  • Sedgwick County Health Center in Julesburg
  • Sky Ridge Medical Center in Lone Tree
  • Yampa Valley Medical Center in Steamboat Springs

Source: 8 Colorado hospitals trying alternatives to opioids in emergency rooms | FOX31 Denver

Posted in Industry Updates, Opioid Epidemic

Gov. Greg Abbott pushes back announcement on Texas special session | The Texas Tribune

Gov. Greg Abbott‘s announcement on whether he will call a special session is not expected to happen before next week.

On Monday, Abbott said he would share his verdict “later this week.” On Friday, his office said he would not make the announcement Friday or over the weekend.

Abbott is facing pressure to bring lawmakers back to Austin to deal with unresolved debates over property taxes and a “bathroom bill” that would regulate which restroom transgender Texans can use. Lt. Gov. Dan Patrick has been pushing for a special session to address those issues.

Asked Wednesday morning about a special session, Abbott said he was waiting for the budget to be certified and wanted to go through more bills on his desk. Comptroller Glenn Hegar announced Thursday evening he had certified the budget.

Source: Gov. Greg Abbott pushes back announcement on Texas special session | The Texas Tribune

Posted in Government Regulations, Industry Updates

Major Insurance Company’s Payment Decision Angers ER Doctors – NBC News

It hurts when you take a deep breath. Is it a heart attack? A blood clot in the lung? An infection?

Emergency room doctors are questioning letters than have gone out to some Anthem Blue Cross/Blue Shield members in three states that threaten a crackdown on reimbursements.

“Save the ER for emergencies — or cover the cost,” reads a letter sent last month to Blue Cross and Blue Shield of Georgia members.

“Going to the emergency room (ER) or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations,” it reads.

“But starting July 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency. That way, we can all help make sure the ER’s available for people who really are having emergencies.”

Similar letters have gone out to members of plans owned by Anthem, Inc. in Missouri and Kentucky.

Anthem, Inc. said it’s trying to steer patients to proper care. “What we are really trying to do is make sure that people are seeing their doctors first,” said Joyzelle Davis, communications director for Anthem, Inc.

She said patients are inappropriately showing up to emergency departments with itchy eyes and other non-emergency symptoms.

Dr. Becky Parker, president of the American College of Emergency Physicians (ACEP), said it’s about money.

“The insurance company is not on the same plane. They are not here to take care of people. They are here to make money. It’s clear that the insurance companies are looking to make money. It is about the dollar. It is not about high quality care,” Parker said.

“Our concern is that the insurance industry is trying to push this nationally.”

The 2010 Affordable Care Act lays down strict rules for covering emergency room visits. ACEP said the insurance industry is taking advantage of the Trump administration’s disregard for the ACA to push the boundaries.

“Health plans have a long history of not paying for emergency care,” Parker said.

“For years, they have denied claims based on final diagnoses instead of symptoms. Emergency physicians successfully fought back against these policies, which are now part of federal law. Now, as health care reforms are being debated again, insurance companies are trying to reintroduce this practice.”

Davis denies this. “It is reinforcing language that has been in the contract that has not necessarily been enforced before,” she said. She said policies still apply what is known as the “prudent layperson” standard.

Anthem defines it in the letter:

“Emergency” or “Emergency Medical Condition” means a medical or behavioral health condition of recent onset and sufficient severity, including but not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that not getting immediate medical care could result in: (a) placing the patient’s health or the health of another person in serious danger or, for a pregnant woman, placing the woman’s health or the health of her unborn child in serious danger; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. Such conditions include but are not limited to, chest pain, stroke, poisoning, serious breathing problems, unconsciousness, severe burns or cuts, uncontrolled bleeding, or seizures and such other acute conditions as may be determined to be Emergencies by us.

But Parker said the letters and the new policies have a chilling effect on patients and could leave some with bills in the thousands of tens of thousands of dollars.

“The ‘prudent layperson’ standard requires that insurance coverage is based on a patient’s symptoms, not their final diagnosis,” ACEP said.

“If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance.”

Blue Cross and Blue Shield may potentially deny a claim from someone who shows up with chest pain, ACEP said. Davis said a sharp pain with a deep breath could be a symptom of the common cold, and is not an emergency.

Parker said it’s not reasonable to expect a patient to know the difference. “I don’t know and you don’t know if that is a heart attack, a blood clot, or a collapsed lung unless I see you in the emergency room,” she said.

The last thing a doctor wants is for a potentially dying patient to hesitate, worried about a bill.

“It’s really dangerous for our patients,” Parker said.

“I had a woman the other day who was in her early 40s who came in for having a stroke,” added Parker, an emergency physician at West Suburban hospital in Oak Park, Illinois.

“She had had severe dizziness, vertigo symptoms.”

The patient had waited until office hours to come in because the co-pay on her health insurance plan to see a primary physician was $50 but it was $250 for an ER visit. The patient missed an important early window for treating her stroke, Parker said. “She told me, ‘I can’t believe I risked my life for $200.'”

Dr. Howard Forman, an expert in health policy and medical imaging at Yale, said both sides are right.

“To me, this is a problem of the system,” Forman said. “This is not about bad actors.”

Doctors want to work 9 to 5 and patients have few other choices outside of those hours, he said.

“There are a lot of people who go to emergency rooms for things that are not true emergencies,” Forman said.

Many may simply go because they are anxious. “That incurs a significant cost to the healthcare system,” he added.

“I don’t believe insurance companies hold down costs so they can make more profit,” Forman said. Many insurance companies simply manage programs for employers who are self-insured, meaning they pay their employee health costs themselves.

That said, Forman added, ACEP has a point.

“It is really difficult to know in advance which patient is really having an emergency,” he said. “Doctors aren’t even great at predicting which patients have something terrible.”

And you cannot blame patients for using ERs. “The emergency room has become the multi-specialty clinic of the 21st century,” Forman said. “You can go to the emergency room with blood in your stool, which for most people is not an emergency, and four hours later not only be diagnosed with colon cancer but you could have already met with the oncologist,” he added.

“We provide a level of service in the ER now that is extraordinary.”

And that drives up costs. What the insurance companies say they want to do is direct people to less expensive and more appropriate options.

“If a member can’t get an appointment with their primary care doctor, most non-emergent medical conditions can be easily treated at retail clinics, urgent care clinics or 24/7 telehealth services such as LiveHealth Online,” the Anthem letter advises.

Source: Major Insurance Company’s Payment Decision Angers ER Doctors – NBC News

Posted in ER Billing, Industry Updates

Risk of Zika epidemic in Texas is almost zero, except for these three

The good news: Across most of Texas, there is almost no chance of a Zika epidemic, even if there is a documented case of mosquitoes transmitting the disease from one Texan to another at the height of mosquito season.The bad news: If two separate cases were to be diagnosed in the Rio Grande Valley or in Travis or Harris counties – the Austin and Houston areas – there would be greater than a 50 percent chance that an epidemic breaks out.These conclusions come from recent computer modeling done by University of Texas researchers who have combined demographic data, international travel patterns, mosquito habitat and population and the typical rates of Zika detection into a risk-assessment program.

Source: Risk of Zika epidemic in Texas is almost zero, except for these three

Posted in Industry Updates, Zika Virus in U.S.

Blue Cross in Alabama says it won’t quit paying for some ER visits | AL.com

Starting in July, Blue Cross Blue Shield of Georgia will stop covering emergency room visits that the health insurance provider deems unnecessary.

Don’t expect Alabama to follow suit, however.

The Georgia Blue Cross policy is an effort to keep people from using emergency rooms as their source of primary care. Instead of a costly trip to the ER, the insurance provider is encouraging customers to use urgent care clinics, retail health clinics and BC/BS’ LiveHealth app or online site, all cheaper alternatives than a trip to the hospital.

“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” BC/BS spokesperson Debbie Diamond told the Atlanta Journal Constitution. “Health care is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”

If a person goes to an ER for something other than what a “prudent layperson” would deem as a serious danger, BC/BS in Georgia said it won’t cover the cost. There are exceptions – the rule won’t apply to children 13 and younger; members who don’t have urgent care clinics within 15 miles; or ER visits made on Sundays or major holidays.

 

While Georgia is moving ahead with efforts to reduce unnecessary ER visits, Alabama BC/BS has no plans to implement a similar policy, according to spokesperson Koko Mackin.

“Blue Cross and Blue Shield of Alabama is not ending coverage of ER visits,” Mackin told AL.com “We remain committed to providing our members access to the right medical care in the right setting at the right time, whether that is in the doctor’s office, an urgent care clinic or the emergency room.

“We will continue to cover our members’ emergency rooms visits according to their benefit plan,” she added.

According to the National Center for Health Statistics, Americans made some 130 million visits to the ER last year, 37 million of which were for injuries and 12 million of which resulted in a hospital admission. Alabama reported 440 emergency room visits per every 1,000 residents; Georgia had 430 ER visits per 1,000 residents in 2015, the most recent data available.

Recent government data showed more than 10 percent of all ER visits were non-urgent in nature.

Source: Blue Cross in Alabama says it won’t quit paying for some ER visits | AL.com

Posted in ER Billing, Government Regulations, Industry Updates

Blue Cross Blue Shield Wants People in Georgia to Self-Diagnose Before Heading to the Emergency Room

BLUE CROSS BLUE SHIELD is quietly telling its individual market patients in Georgia that it will stop reimbursing some emergency room visits.

The revelation comes from the Atlanta Journal-Constitution, which reports that Georgians are getting letters warning them that the insurer will no longer cover emergency room visits unless it determines them to have been necessary.

This raises the worry from some public health advocates that patients will be afraid to go to the emergency room out of the fear that their treatment will not be reimbursed by their insurer. Laura Harker, a policy analyst who studies Georgia’s health care system at the Georgia Budget & Policy Institute, explained some of the possible outcomes to The Intercept.

“Patients do not always know if they are having a true emergency or not. This policy could make some patients more likely to put off care that they need,” Harker said. “Many hospitals in rural Georgia are already struggling financially, and this policy could further hurt their bottom line. If BCBS decides that a visit does not count as an emergency, the hospital would most likely not get paid at all. Many patients wouldn’t be able to afford the full cost of an ER visit or they could end up with medical debt.”

Debbie Diamond, a spokesperson for Blue Cross Blue Shield of Georgia, did not provide a copy of the letters being sent to patients to The Intercept. She did, however, offer a defense of the policy.

“Please know that this policy is not intended to keep our members away from the emergency room if that is where they need to be treated. We worked with four board-certified emergency medicine doctors employed by Anthem, our parent company, to develop a list of nonemergency conditions that would be better treated by a patient’s primary care doctor than in an emergency room,” she wrote in an email. “The list includes conditions such as suture removals, athlete’s foot, common cold symptoms and seasonal allergies including itchy eyes.”

“If a member choses to receive care for these common ailments in the ER when a more appropriate setting is available, their claim will be reviewed by an Anthem medical director using the prudent layperson standard before a determination is made,” she continued. “In reviewing the claim, the medical director considers the member’s presenting symptoms that may have appeared to be an emergency even if the diagnosis turned out to be a nonemergency ailment.”

The Medical Association of Georgia, the top lobbying group for physicians in the state, expressed concerns about the shift.

“What Blue Cross is asking patients do is determine without a clinical background whether their certain situation is truly an emergency, which is a lot to ask of a patient when they’re obviously presenting themselves to the emergency room because they do have concerns,” Executive Director Donald Palmisano told The Intercept.

As the AJC reports, BCBS is the only insurer in the health insurance marketplace in 96 of Georgia’s 159 counties. Particularly in rural Georgia, it has a monopoly over patients. As the Washington Post noted in 2014, southwest Georgia is “one of the most expensive places in the nation to buy health insurance.”

One way to weaken that monopoly would be for Georgia to expand Medicaid. Its Republican governor and GOP-dominated legislature have blocked the expansion, and national BCBS funded Republican Governors Association ads attacking unsuccessful Democratic candidate gubernatorial Jason Carter, who campaigned on expanding Medicaid during the 2014 cycle.

By not expanding Medicaid, Georgia puts more of the onus for covering the cost of caring for patients on the hospitals themselves. Hospitals respond by charging people who can pay — namely, insurance companies — more.

The unnecessary use of emergency departments for ailments that would be better treated at an urgent care center is indeed a real issue, said Palmisano and Harker. But the solution, they said, is better education and preventative and comprehensive care, rather than warning patients their trip to the ER may or may not be covered.

“I’m happy to say that I’m glad that I do not have Blue Cross Blue Shield as my health insurance company with this kind of restriction,” Palmisano said.

Source: Blue Cross Blue Shield Wants People in Georgia to Self-Diagnose Before Heading to the Emergency Room

Posted in ER Billing, Government Regulations, Industry Updates

A big health insurer is planning to punish patients for ‘unnecessary’ ER visits

Anthem is the nation’s second-largest health insurer, with thousands of medical professionals on its payroll. Yet its Blue Cross and Blue Shield of Georgia subsidiary has just informed its members that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their claim won’t be paid.

It’s a new wrinkle in the age-old problem of how to keep patients from showing up at the ER for just anything. But medical experts say the Georgia insurer is playing with fire. By requiring patients to self-diagnose at the risk of being stuck with a big bill, it may discourage even those with genuine emergencies from seeking necessary care. And it’s asking them to take on a task that often confounds even experienced doctors and nurses.

“Patients don’t come with a sticker on their forehead saying what the diagnosis is,” said Renee Hsia of the Institute for Health Policy Studies at UC San Francisco, who has studied the difficulty of making snap diagnoses at the ER. “We as physicians can’t always distinguish necessary from unnecessary visits.”

Blue Cross Blue Shield of Georgia, the only insurer offering individual insurance plans in 96 of the state’s 159 counties, sent letters to its enrollees in late May stating that it would refuse to cover non-emergency ER visits starting July 1. It defined inappropriate visits as any but those that “a prudent layperson, possessing an average knowledge of medicine and health,” would believe needed immediate treatment. It hoped to encourage patients with non-emergency conditions to seek help instead at an urgent care clinic or a doctor’s office.

The policy of Blue Cross Blue Shield of Georgia, however, could allow the insurer to decide for itself after a claim is submitted whether the patient actually acted prudently.

A spokesperson for Anthem didn’t respond to my query about the new policy. A spokeswoman for the Georgia insurer, Debbie Diamond, told us its goal was to control costs by steering patients away from expensive ER services and toward doctor offices or urgent care clinics when those are more appropriate settings for treatment. “People who have a cold or use the ER as their primary physician — that’s got to stop,” she said. “This really is a question of getting healthcare more affordable.”

She said the policy wouldn’t apply when the patient is 14 or younger, an urgent care clinic isn’t located within 15 miles, or the visit occurs on a Sunday or holiday. She said it’s aimed at manifestly minor ailments — “If you had cold symptoms; if you have a sore throat. Symptoms of potentially more serious conditions, such as chest pains, could be seen at the ER even if they turn out to be indigestion.”

But doctors argued that many symptoms on the list, which included headaches, earaches and bronchitis, could be indicators of genuinely serious conditions. Bronchitis, for example, often can’t be distinguished from pneumonia without a chest x-ray. Headaches could be symptoms of meningitis, encephalitis or hemorrhage.

Gov. Christine Gregoire quashed the plan in 2012, on the day it was to begin. Washington later instituted a program encouraging hospitals to develop systems to weed out unnecessary visits more effectively, in part through patient education and by identifying frequent visitors or patients presenting at the ER chiefly to obtain drugs.

Hsia’s research, published last year in the Journal of the American Medical Assn., found that ER doctors and triage nurses often were unable to distinguish urgent from non-urgent visits without examining the patient. Six of the 10 top reasons for unnecessary visits, including back, abdominal and chest pain and sore throats and headaches, were also among the top 10 symptoms of real emergencies. Many visits that were later deemed unnecessary “arrived by ambulance … had procedures performed, and were admitted to the hospital, including critical care units,” her group’s study found.

“Everyone in insurance, everyone in emergency medicine has stories to tell about wildly inappropriate emergency room presentations,” observed David Anderson, an insurance expert at Duke University. “The problem is that the decision to go to the emergency room is fraught with uncertainty. Most people know that something is wrong and they don’t know if it is really, really wrong or mildly wrong. … Retrospective claims review with denials is too blunt of a tool to deal with a scenario with explicit uncertainty and information gaps.”

Nor is it clear how much money could be saved by really cracking down. “The caricature is of a patient blindly visiting the ER [for no reason], but that’s relatively uncommon,” said Ari Friedman, a physician who collaborated on Hsia’s research. Policies aimed at cutting down on inappropriate visits are all based on judgments made after final diagnoses, which obviously aren’t available to patients before they decide to go to the ER.

ER services come to only 2% to 6% of total U.S. healthcare spending, Friedman said, “and most of that is spending on sick patients, not healthy ones.”

Hsia called the Blue Cross Blue Shield of Georgia rule a “well-intentioned policy with dangerous consequences for patients.” Studies have shown that efforts to use financial incentives to reduce healthcare usage often lead patients to cut down on necessary as well as unnecessary care. That was the finding of a classic Rand Corp. study in the 1970s, which found that patients subjected to co-pays did indeed use fewer healthcare services than those who got the services for free — but that they “reduced the use of both highly effective and less effective services in roughly equal proportions.”

Diamond said that Blue Cross Blue Shield of Georgia patients have access to telehealth services via smartphones and other connected gadgets, which will allow them to get a basic judgment about the seriousness of their symptoms remotely. But it’s questionable whether that’s an adequate substitute for an ER visit in all cases. Not all patients will have access to smartphones or connectivity, for one thing. For another, when even trained triage nurses can’t flawlessly judge the urgency of a patient’s condition when meeting face-to-face, a phone consultation may not be very reliable.

As Hsia said, the impetus underlying the Georgia policy is understandable in economic terms. But this Anthem subsidiary and its cousins in New York, Missouri and Kentucky have chosen a crude and counterproductive way to cut costs by putting the onus on patients to know just how serious their condition may be, at risk of what could be hundreds of dollars or more in unpaid claims. If this is the healthcare world of the future, it’s a perilous and costly place.

Source: A big health insurer is planning to punish patients for ‘unnecessary’ ER visits – LA Times

Posted in ER Billing, Government Regulations, Industry Updates

Amarillo’s Four Price pushes 10 health care bills through Legislature

State Rep. Four Price is pleased with how Texas’ 85th Legislative Session has gone in terms of health care for the state’s residents.

Ten health care- related bills authored or sponsored by the Amarillo Republican have made their way to Gov. Greg Abbott’s desk, with the possibility of more before the session concludes Monday.

“I haven’t seen a session as productive with regards to behavioral and mental health as this one, so it’s an exciting time for sure,” said Price, chairman of the House Committee on Public Health.

Price’s House Bill 2425, also known as the CARE (Caregiver Advice, Record, Enable) Act, requires hospitals to let patients designate a caretaker to receive home care medical instructions upon the patient’s discharge.

Abbott is expected to sign the bill after it passed the House and Senate earlier this week. Similar laws have passed in 35 states over the last three years, as well as Washington D.C., Puerto Rico and the U.S. Virgin Islands.

The Texas AARP lobbied for a similar bill in the 2015 legislative session, but it failed without support from the Texas Hospital Association.

The THA supported this session’s CARE Act, chief business development officer Lance Lunsford said, because it contained softer language that would keep many hospitals from altering their current practices.

“We worked with them over the last several years to get on the same page about what the bill should address, and as things went along, I think we met in the middle on what it needed to look like,” Lunsford said.

Price also pushed two bills aimed at loosening restrictions for medical support via video conference, HB 2697 and HB 1697.

HB 2697 would ease restrictions on practicing “telemedicine,” or administering medical advice and offering prescriptions through video.

The bill would primarily benefit residents of rural counties, who would otherwise need to take off work to drive into cities for medical treatment, and mental health patients whose behaviors can be monitored through screens.

HB 1697 would found a pediatric telecommunications resource program. Both bills have been sent to Abbott’s desk.

“This is changing the paradigm on telemedicine delivery and coverage of that for health providers across Texas,” Price said. “In my opinion, these are the biggest advancements in health care this session.”

Amarillo’s strong medical options draw patients from all over the Texas Panhandle, and rural clinics have had difficulty staying open in recent years.

Thirteen hospitals in sparsely populated areas across Texas have closed since 2010, by far the most of any state, per the North Carolina Rural Health Research Program.

In Lipscomb County, where Underwood Law Firm shareholder Gavin Gadberry grew up, the Teare Memorial Clinic is the only health facility open five days a week (dentist Richard Sheppard spends Wednesdays, Thursdays and Saturdays in Booker).

Gadberry, who practices health care law and has been THA’s general counsel for 20 years, said the problem will be compounded as rural residents age and young adults move into cities at higher rates than before.

“Rural Texas and health care, if it’s not at a crisis, it’s approaching a crisis. I believe Chairman Price is very familiar with that, and he’s trying to help,” Gadberry said.

“It’s going to be a problem if we don’t address it in the next few years.”

Price also sponsored Senate Bill 932 by Sen. Charles Schwertner, R-Georgetown, which would have allowed the state to fine negligent assisted living homes more easily.

The bill stalled in the House’s calendar committee, but items such as organizing a system for the tracking of the severity of assisted living homes’ violations were enveloped into HB 2025, a bill aimed at minimizing abuse in memory care facilities, that passed to the governor’s desk at around 5 p.m. on Friday.

A 2014 Kaiser Health Foundation analysis found Texas had the worst nursing homes in the U.S. based on criteria such as percentage of facilities with deficiencies, the average nurse’s hours per resident per day and percentage of facilities with above- average health inspection grades.

Medicare reviewers gave nursing homes in Wheeler, Dumas, Amarillo and Clarendon one star out of five for overall quality.

Texas AARP Associate State Director Amanda Fredriksen said legislation such as Price’s was needed to stop malfeasance in senior homes that place residents at risk.

“Texas is pretty much at the bottom when comes to the quality of care in nursing homes, which is why SB 932 and HB 2025 are so important to the AARP,” Fredriksen said.

“When you have the chronic quality of care problems that we have and facilities are rarely sanctioned, then what’s the motivation for those facilities to improve their overall quality of care?”

Source: Amarillo’s Four Price pushes 10 health care bills through Legislature | amarillo.com

Posted in Government Regulations, Industry Updates

Texas Legislature Passes Balance Billing Mediation Expansion

The Texas Legislature has passed Senate Bill 507 by Senator Kelly Hancock (R-North Richland Hills) to give more Texans recourse when they receive unexpected medical bills.

“No Texan looks forward to visiting a surgical center or emergency room,” said Senator Hancock, “but when that happens, hidden charges and surprise bills should be the last thing on their mind.”

Balance billing is common practice in the healthcare system. It occurs when patients are directly billed by a provider for the portion of medical expenses not covered by their insurance. Often times these bills are a shock to the patient. For instance, patients admitted to an “in-network” facility may unknowingly receive treatment from an “out-of-network” doctor and wind up with a hefty bill.

In 2009, Sen. Hancock passed legislation establishing a Texas Department of Insurance (TDI) mediation system for consumers caught in this type of balance billing nightmare. Mediation is working for consumers when it is available. Mediation proceedings have saved patients millions and virtually all claims are settled.

SB 507 expands the TDI mediation system to include all types of out-of-network providers treating patients at in-network hospitals and other facilities, including freestanding emergency departments. It also allows mediation for emergent care balance bills over $500 at any healthcare facility, whether in or out of network.

Public school teachers and retirees will be glad to hear the legislation expands mediation protections to more than 250,000 Texans enrolled in the Teacher Retirement System health plan (TRS-Care) and 430,000 enrolled in the self-funded TRS-ActiveCare program.

Perhaps one of the most useful components of this legislation to the average patient is the disclosure requirement. Health care providers and other facilities must include the following statement on eligible balance bills: “You may be able to reduce some of your out-of-pocket costs for an out-of-network medical or health care claim that is eligible for mediation by contacting the Texas Department of Insurance…”

Sen. Hancock’s legislation has support from  the Texas Association of Health Plans, the Texas Medical Association and AARP, among other consumer protection organizations. To read the bill, visit: www.legis.texas.gov.

Source: Texas Legislature Passes Balance Billing Mediation Expansion – State of Reform | State of Reform

Posted in ER Billing, Government Regulations, Industry Updates