(303) 369-3200

Friday, 24 August 2018 10:30

Healthcare Claims Get Even More Confusing

At Fall River we are committed to helping our members understand their health benefits and provider bills. We know that navigating the benefits world can be confusing, and unfortunately, we are seeing more and more claims situations that prove it’s getting ever more complicated. 

Here are recent examples of some complex and downright outrageous claims issues we want you and your members to be aware of.

Published in Best Practices
Monday, 13 August 2018 09:25

The Battle to Cut Pharmacy Costs

This past May, the Trump administration released its plans to reduce pharmaceutical prices on four fronts. The policy was laid out in a blueprint which describes the various fronts the Center for Medicare and Medicaid Services (CMS) and the department of Health and Human Services (HHS) propose to take to alleviate the problem. The four areas the administration proposes to target for action are increasing competition, better negotiation, creating lower list prices, and reducing patient Out-of-Pocket spending. Since all employer plans are impacted by the rising costs of prescriptions, we are encouraged to see active steps proposed to address the problem.

Published in Industry Trends

On July 25, 2018, the House of Representatives passed two health care bills, H.R. 6199 and H.R. 6311, that would make significant changes to Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs) and Health Reimbursement Arrangements (HRAs). Republicans are pushing to expand HSA usage with a number of Democrats leaning toward supporting these bills as well. Both bills would still need at least 60 votes from the Senate to go into place, which may not be possible before the end of this Congressional session in December.

Published in Healthcare Reform

Employers with 15 or more employees whose wellness program include biometric testing or health risk assessments (HRAs) may need to reconsider their wellness incentives, as changes to the rules governing either of these wellness plan features go into effect January 1, 2019. 

Published in Wellness

The expansion of Association Health Plans (AHPs) has arrived. The U.S. Department of Labor announced regulations that will allow these plans to become effective as early as September 2018. AHPs allow small business to band together to purchase health insurance. Continue reading to understand whether these Association Health Plans might be a fit for your organization. 

Published in Healthcare Reform

If you have a self-funded or partially self-funded plan (including all “Level Funding” plans), you need to know about New York State’s Health Care Reform Act (HCRA) of 1996, even if you don’t have employees in New York. The HCRA, which still applies today, was created to generate funding for a wide variety of health care initiatives in the state, and requires providers of health care services and Third Party Administrators (TPAs) to participate in that funding. In 1997, the State created the New York Public Goods Pool to collect funds for those initiatives and for indigent care in the state. 

Published in Industry Trends

The Patient Centered Outcomes Research Institute (PCORI) fee is due July 31, 2018 for employers with any type of self-funded plan and/or a Health Reimbursement Arrangement. The fee helps fund unbiased research that evaluates the clinical effectiveness of medical treatments regardless of the profit potential. This fee is also known as the Comparative Effectiveness Research Fee, or CERF.

Published in Compliance

When consumers need to access emergency health care services, they usually do not have the time nor presence of mind to determine whether a provider treating them is in-network or not. When those emergencies expose them to out-of-network providers, the provider or facility may “balance bill” the consumer for amounts beyond what the insurer paid. This out-of-network balance billing can create financial burdens and undermine the consumer’s confidence that health insurance will protect them from financial hardship.

Published in Industry Trends

Reference Based Pricing (RBP) is a cost containment strategy that some larger employers have implemented to help place a cap on the cost of larger medical services.  It’s a savvy strategy that, in the past, has worked best with self-funded large employers but is gaining steam across employers of all sizes.

Published in Industry Trends
Monday, 14 May 2018 09:48

The Latest ACA Regulatory Changes

The final Affordable Care Act provisions for 2019 have been released and they are in line with the regulations proposed on October 27, 2017. The provisions primarily concern the out-of-pocket maximums, Essential Health Benefits (EHBs), and the Marketplace.

Published in Healthcare Reform
Page 1 of 15