HSA Providers / Rating the complete package

[Guest tradbourne]

We need a Consumers Report style analysis of the HSA options available to consumers. Integration of the HSA account with your medical providers seems to me to be a big issue and a well designed backend processing system could make HSA's user friendly. I don't relish managing my deductibles etc.... Some companies propose using a debit card for your health care purchases that automatically withdraws money from your HSA until you meet your deductible.

I am currently considering Golden Rule and American Community. Should I be considering others? Are there any winners / losers out there?

Tim in MI

[GBurns]

I was not aware that American Community offered an HSA. I thought that they were HDHP only.

However, I would be more concerned with the reputation of the provider of the HDHP regarding payment of claims. Certain insurers do not have a very good reputation and I suggest that you do some research and also find out from your Dept of Insurance how many complaints have been filed, and what investigations and actions have involved these companies. Especially look at what the Schedule S (or F) that they have on file. This is the required Schedule on which they have to report Resisted and disputed claims. It is usually not filed timely and usually has a substantial number missing. Apparently some insurers are willing to pay the fine rather than give full disclosure.

I would also be concerned as to how service providers will be accepting HSA/HDHP in your area especially involving these companies. In some areas the service providers are demanding full payment up front or a large deposit. One reason is that for most Drs visits the full price cannnot be readily determined until the billing is done and coded and even then the amount that will be paid by the insurance company is not known.

With standard insurance whether PPO or HMO the co-pay etc is smaller and so the service provider is willing to extend credit and collect later. However, with HDHPs many of the insurers have no established relationship with the Drs etc, the insurance company payment schedule is not known and the deductible is too large for credit to be extended.

[Guest tradbourne]

> I was not aware that American Community offered an HSA.

American Community Mutual Insurance Co. call their HSA, the Community Med HSA and the HDHP premium is a little higher than Golden Rule.

> I would be more concerned with the reputation of the provider of the HDHP regarding payment of claims.

Can you tell me how and where to go to do this. Is it online?

> In some areas the service providers are demanding full payment up front or a large deposit.

Yes, this is my area of concern. We currently use Blue Cross, and the service providers are so familiar with it that it is a joy to use. The debit card might make that workable, but I would want the health care folks to be doing the auditing of the Doctor's bill to ensure that any appropriate discounts are taken. Is this even possible, or would I become the responsible party for auditing charges?

Tim in MI

[GBurns]

You get the information from your State regulator of insurance companies, which in MI can be a challenge.

Within the Dept of Labor & Economic Growth there is an Office of Financial and Insurance Services which is divided into (1) the Office of Financial Evaluation which has an Enterprise and Insurance Examination Division, (2) the Office of Policy, Conduct and Consumer Assistance which has both a Health Plans Division and a Market Conduct Division. Between them they would have the information that I referred to in my post.

There is an OFIS number that might help to locate the people with the information. Do not take your answers from any telephone Customer Service Rep, get to someone in a higher position who actually works in the relevant section and actually handles such issues 1-877-999-6442.

Community Med HSA is NOT an HSA. As per their own website "The Community Med HSA is a qualified high deductible health insurance plan that can be combined with a health savings account". So combining it with an HSA would be up to you to find a Trustee.

[Guest tradbourne]

Thanks for the insurance evaluation options.

Per finding your own trustee: How big a deal is that anyways? I assume that means that I give up any possibility of my bill auditing being done by the insurance company??

[GBurns]

Why do you think that an insurance company auditing your bill has any benefit to you?

In all these years that you ,and others that you know, have had health insurance, When has any insurance company bill audit ever given you back money or reduced your copay or deductible?

With an HSA as with a regular plan you pay your portion and the Dr bills the insurance company for the rest. Why would an audit do anything for you?

[Guest tradbourne]

You are correct, I have never benefited from these audits, but the insurance companies have. I still want 2 types of checks and balances. I consume only the health care I need, and the bills are audited to make sure that only appropriate charges are paid by me.

With regular health care, you pay your copay and the Dr bills the insurance company what he wants, but the insurance company only pays what they have agreed for that procedure less your copay. Typically the Dr writes of the rest as uncollectible unless he tries to collect from the patient. If the Dr doesn't have a good relationship with the health insurance company he may try this, but it's not my experience that this happens often.

My understanding of an HSA is that likely the insurance company will not be paying anything. I don't plan on hitting the $5250 family deductible at all unless there is a family emergency, so I will be paying everything. Therefore the Dr only bills me. If we can somehow have this flow through the insurance company, we can ensure that the Dr doesn't overbill. Otherwise who will know? Health care is too complex for anyone to understand why some lab work should only be billed at $220 rather than $280.

[GBurns]

The danger in your scenario is that you will be paying much more than necessary because not only because you would have no idea what are normal or reasonable charges but mainly because you have no idea what the appropriate services are.

You say that "the bills are audited to make sure that only appropriate charges are paid by me", How do you know what should or should not be on the bill? Doesw the bill that you look at have the ICD and CPT Codes? Do you know what these mean and what should or should not be there? While it is simple when there is only a small co-pay at stake, it is a different animal when you are dealing with a lerge deductible.

In billing an insurance company or even Medicare a specific form (HCFA 1500) has to be used and specific codes entered. Medical bill coding is complex. It consists of diagnostic codes and procedure codes. The procedures much match the diagnosis. But the system is so complicated that it needs scrutiny. The standardization of Forms and Codes is an attempt to help reduce the fraud and errors, but that has not been very successful. Overpayment, mispayment, unnecessary payment, fraudulent claims are probably the major cause of rising healthcare costs. Here is a simplistic explanation of the billing problem:

http://www.hssweb.com/pdfs/NewPDFs/Collate...care_crisis.pdf

If the insurance companies and Medicare with all the resources at their disposal cannot control this aspect, Do you think that you can?

Do you have any idea what should be done and charged regarding any particular visit to a Drs office? Since you have no idea, How will you know whether or not you have been charged properly?

Currently and in the foreseeable future the consumer using an HSA/HDHP will be at the mercy of the Dr's billing system.

Do yourself a favor and do a Google search on "HSA provider balance billing" and read some of the warnings about what might happen if the provider is not bound by contract to not balance bill you etc. Also ask some of the possible Drs, hospitals and service providers that you might possibly use, what their current practices are regarding HSAs, Cards, up front payments etc are before you get an HSA/HDHP from any company especially those 2 that you have chosen.

[Guest llerner]

Even if the insurance company does not pay, you need to run into through their claims in case you ever meet the out of pocket maximum. Otherwise, they will not pay the 100% after the out of pocket maximum is met because they have no record

[Guest tradbourne]

GBurns, thanks for your analysis. Perhaps I was confusing in my posting. I believe you and I are saying the same thing. I agree with you that I cannot possibly audit the bills that I would be paying. Since in a HDHP I am paying 100% of the costs until I meet the deductible, I need help in determining if these bills are reasonable and justifyable. For this reason, I want some expert agency to audit these bills on my behalf. This could be the insurance company, or some other group acting in my best interest to ensure that I really needed to pay this bill in the total amount being billed.

Thus the 2 systems of checks and balances I would like to see are :

1. Me requesting and consuming only medical services that are necessary.

2. Some expert agency acting on my behalf auditing the bills that are sent to me to ensure that they are indeed reasonable and justifyable.

Is this possible with an HSA and a HDHP, or does the second step only happen once deductible is met and the insurance company is paying?

Thanks for the linked document. It confirms the need for having this second check and balance in the system.

Also thanks for the Google hint. I'm not sure I understand "balance billing" but it sounds like they are hinting that this may be a problem.

Tim

[Guest tradbourne]

llerner:

Yes somehow the money needs to flow through an accounting and audit system even if you pay it yourself for the reasons you mention.

The other reason to have them flow through an audit system is that we need a way to put checks and balances on the system.

Tim

[GBurns]

tradbourne

There are medical claims review services that will look after your interests but they usually only handle large claims. That is because the take a % of the savings and there has to be enough $$$ to cover even basic clerical time.

It is a possibility that your insurance company might be willing to process your claims even though not paying them until the deductible is met, but this might be resisted by their provider network since it will reduce the provider revenue. However, as llerner points out your claims might have to be run through your insurance company anyhow so that they can keep track of your meeting your deductible. It might be good to find out how these HDHP providers will know when you have met your deductible. If they will be running the claims through their system, you should ask whether they will be repricing to their provider contract payment schedule or using the "retail price" that you paid. This might give you the ability to get the providers to give you the insurance company's discount rate instead. If the insurance company is going to process claims before you meet the deductible, then you will be by default getting some level of bill auditing.

It might be also be possible to use a PPO repricing service. These services are usually available to group plans for use with out-of-network useage. It might be possible to find 1 that will do small individual claims.

Regarding "requesting and consuming only medical services that are necessary". Even Drs and insurers cannot agree on what is necessary and proper. Without knowledge of treatment protocols, DRGs and the relationship between Procedures and Diagnoses, it would not be possible to know what to request or what is necessary.

Last year USA Today and other newspapers ran articles that showed that American are not getting optimal care and the AMA agreed. In the 7 selected major diseases around 50% of treating physicians did not know the basic treatment protocols, plus also around 50% of diagnoses were wrong. If Drs cannot get it right, What chance does a layman stand?

[Guest tradbourne]

This is an excellent exchange of information. Regarding reprocessing and auditing, we will have to find out more about who offers what. It seems that this information is not readily available yet.

Regarding consuming only services that are medically necessary, this is something that the health care consumer will have to ultimately decide. I don't want the Dr or the insurance company making those decisions because they are influenced by 2 powerful interests that aren't necessarily in my best interest. These are:

1. Minimize liability from bloodthirsty trial lawyers because they didn't do enough medical procedures and tests.

2. Minimize medical costs because they did too many procedures and tests.

If I am willing to bear the liability for not doing something, and I am willing to bear the cost of doing something, then it should be my decision.

Finally per your last point from the USA Today article, if Americans are not getting optimal health care here in the USA where the best is available, I'm not sure what the next steps should be.......

Tim

[Guest fritzreb]

I have only been participant an HDHP w/ HSA with Aetna since 1/1/2005 and had my first drs. appt. a few weeks ago. The physician office submitted the claim to Aetna, and I have since received an EOB indicating the drs. visit was $75 and the discounted rate I was responsible for paying was $63. Regardless of whether or not I have met my deductible, all claims must be submitted to the insurance carrier to receive the rate the carrier has negotiated and for the carrier to track deductible expenses. Even if I was participating in a plan with a $100 deductible my claim would still have to be submitted to the insurance carrier and my responsbility would have still been $63, not $75.

Aetna does provide the service where my HSA can be debited to pay the physician directly, but I elected not to have payment made from my HSA simply because I want to save my HSA funds to pay for either larger medical claims I may incur at a later date or for dental expenses I anticipate next year.

[GBurns]

jamescagney2000,

You stated that "the client does to the Dr office, submits his card, discounts get applied.." What card is this? Tradbourne's post is regarding a Debit type card for the HSA not a coverage card for the HDHP.What is the purpose if the client is not paying at the time of service? Then you stated that "the client is sent a bill which he pays through his HSA account " Does this mean that nothing not even the office visit co-pay is paid at the time of service?

In the original post tradbourne stated that he would be using a Debit type card. The procedure you outlined would render a debit card useless wouldn't it, if no debit is made at time of service.

[GBurns]

tradbourne

This is an example of what faces HSA users in the real world. Reports like this are frequent and becoming even moreso:

http://www.post-gazette.com/pg/05072/470126.stm

As it points out, in many cases (probably most) the consumer will never know the discount rate and will therefore pay at "retail". Additionally the consumer will not be able to find out prices up front or in advance so will be unable to shop around in the cases that are not emergencies. There is no shopping around in emergencies. In the cases cited, a user of an HSA would be paying more than a user of traditional insurance and it seems that there would be no savings or benefit from using an HSA/HDHP.

Have you run any "What if?" scenarios to see whether or not using an HSA/HDHP would save any money and would any savings be worth the risk and effort. I have done over 3,000 What ifs and there are very few situations that favor an HSA/HDHP.

[Guest fritzreb]

It is not the amount of the deductible ($100 or $1,000) that determines a discounted rate. Insurance carrier network discounts apply to individuals regardless of the amount of their deductible. Individuals with a $100 deductible still must file claims with their insurance carrier so the insurance carrier can track deductible expenses and receive applicable discounts, just as indiviudals with a $1,000 deductible must file claims with their insurance carrier so the carrier can track deductible expenses and receive applicable discounts.

It is obvious that individuals with health insurance coverage (regardless of the amount of their deductible) need to be educated about notifying service providers of insurance coverage, the difference between in-network and out of network benefits and submitting claims to insurance carriers, even if they know they have not yet met their deductible. Individuals with a $100 deductible visting an out of network provider and/or receiving services not covered by their health insurance policy will pay more than individuals who receive covered services from an in network provider. The same is true for those with a $1,000 deductible.

[GBurns]

In many cases (possibly the majority) insurance carrier discount is neither known by the individual nor applied to the individuals bill for purposes of reducing the insured person's share/deductible etc.

[Guest fritzreb]

I am very surprised. We have thousands of covered employees and dependents and have never encountered this problem. In my experience and the experience of my co-workers and clients, both participants in high deductible health plans and those in lower deductible health plans($100 - $500) have never had a problem with physicians/facilties/etc. submitting the invoice to the insurance carrier for adjudicuation and discounting prior to billing patients and the insurance carriers and/or TPAs have been great about providng EOBs in a timely manner. Maybe because our employees and clients are primarily located in a large metropolitan area where providers are more aware of procedures for filing of claims??

[GBurns]

The article that I submitted covered a large metropolitan area (Pittsburgh) and quote not only insurers such as Highmark but also large service providers (medical centers and hospitals) in large Metro areas along with industry observers from large groups also in major metropolitan areas including D.C and Atlanta.

Look again at the persons quoted, who they represent and their locale. I would say that almost each and everyone of them handles more lives than you do in an area just as metropolitan as whatever area you are in. It would seem that from this, the majority would not agree with your viewpoint.

There have also been a number of lawsuits involving a few BCBS carriers, Aetna and UHC over the fact that the consumer pays the deductable based on the retail price not on the discounted price. The decisions have gone both ways based on each particular set of facts. So it has nothing to do with Metropolitan areas, it has to do with the contracts.

[Guest tradbourne]

I would like to post a followup. It seems that the 2 carriers that I mentioned, American Community and Golden Rule have slightly different administration processes.

With American Community, you present your Medical card and it states that you have a $0 copay. The Dr's office then submits the charges to the insurance company where they are repriced pased on the PPO pricing. Assuming that you haven't reached your deductible, this amount of money then comes out of your HSA account automatically with no effort by yourself.

With Golden Rule, you have to write a check to cover the cost once the bill has been repriced by the insurance company. This is slightly more hassle but Golden Rule is more competitively priced in my case so the decision is difficult.

regards

Tim in Michigan

[GBurns]

In your American Community scenario, When does the money get taken from the card and When do you know how much it will be? How long does it take for the Drs Office to submit the claim? Will you know what was claimed?

In your Golden Rule scenario, How long does it take for the Drs Office to submit the claim? Will you know what was claimed?

The problem is that if you do not know what the result of the re-pricing is you will not know whether or not you were charged at the re-priced amount or at the retail amount.

What happens if the claim is denied partially or in full?

[Guest tradbourne]

Good questions. I believe the timing of the money being withdrawn is related to the "explanation of benefits" statement. This statement will show any repricing. Perhaps someone with more HSA experience can chime in?

I suppose each Dr's office will have a different process for filing claims. Since it is their income, I doubt they will wait very long to file the claim.

Tim

[GBurns]

Have you ever seen the results of any repricing on any EOB that you have ever received while under any insurance plan?

[Guest ajlake]

Would it not be in the carrier's best interest to minimize the out-of-pocket cost to the consumer? The sooner the consumer burns through the deductible, the sooner the insurance company begins paying. It seems to me that the insurance company and the consumer would have a common interest in this regard. It is in neither party's interest for the consumer to pay retail.

I'm currently considering converting our firm from American Community PPOM to an American Community HSA. Prescriptions are the biggest issue in our scenario.

[Guest jamescagney2000]

Finally, A site that allows you to search for HSAs in your own state!

www.greatlakeshsa.com

[GBurns]

For at least 12 months there has been www.hsainsider.com

And since an HSA is of no use without the HDHP, What good is it to have HSA providers only?

[Guest jamescagney2000]

For the last 12 months hsainsider.com contained an alphabetical listing of HSA providers consisting of 60 companies. If you wanted to find one in your state, you had to scroll through 7 pages of companies. More importantly, if you wanted to find out the fees associated with each account, you had to either call the company or try and find it on their website. Some listed their fees, but when you would call, the fees would be different? Now hsainsider is charging companies $1.85 per click to be on the site. The result was 16 companies are now listed on their site. Not exactly the best sample size considering the other database has 120 companies.

What good is it to have HSA providers only?

There are thousands of companies, state and federal workers that now have HDHP coverage. However, their employers are not, nor can they force their employees into one provider. They can only suggest various providers. Secondly, small businesses and individuals are getting HDHP that do not have a HSA provider integrated into the account or the fees are so high that people want to shop around for a better fees structure. Lastly, many people want their banking accounts setup locally, not in Kansas! Apparently there is "some good" to having a list of HSA providers.

[GBurns]

"There are thousands of companies, state and federal workers that now have HDHP coverage."

But the majority are not HSA eligible anyhow. What do the USPS and most of these many thousands of employees have, for example? An HDHP with HRA.

Having a HDHP is not the sole critieria for having an HSA. What do you think most HRA users have as insurance coverage? An HDHP but 1 that is not HSA eligible.

[Guest jamescagney2000]

I GET 30 CALLS A DAY FROM PEOPLE ALL ACROSS THE COUNTRY WITH NO IDEA AS TO WHERE THEY CAN OPEN A HSA ACCOUNT. WITH 4000 HSA CLIENTS IN THE LAST 18 MONTHS, SOMEONE IS LOOKING FOR AN HSA PROVIDER! I CAN ONLY SAY WHAT MY CUSTOMERS AND BROKERS ARE TELLING ME!

[GBurns]

What you are really saying is that there are a lot of agents selling a "pie in the sky" package to a lot of people who have no idea whether they could complete the package or not?

In simple words, they were buying (sold) a HDHP in order to put the premium savings somewhere somehow if they ever find a place to put it and if not then they would just enjoy the lower premiums and pray that they do not have anything catastrophic or would not have major out-of-pocket expenses while not getting the promised tax break.

Because of your phrasing ... "I GET 30 CALLS A DAY FROM PEOPLE ..." I have to ask if you have a vested interest in setting up HSAs and financial interest in Great Lakes HSA ?

[Guest fritzreb]

Both United Healthcare and Aetna have reported employer interest in HSAs outpacing HRAs since January 2005 and expect employers currently offering HRAs w/ a high deductible health plan to either add an HSA eligible health plan in 2006 or to replace their current high deductible health plans w/ an HRA with an HSA eligible plan. Even though Treasury didn't release HSA guidance until July 2004, too late for many employers to add HSA eligible HDHPs and an HSA for January 2005, Wells Fargo is opening 10,000 HSAs a month and Mellon is adding 5,000 a month. Both financial institutions are expecting a huge deposit increase beginning in January 2006 as employers (both large and small) provide HSA eligible HDHPs to replace current HRA plans or in addition to current HRA plans.

[GBurns]

Since there are other reports that are less optimistic, I guess that we will all have to wait and see how it pans out by February 2006. By the way, employer interest quite often does not translate into employer adoption.

[Guest jamescagney2000]

What you are really saying is that there are a lot of agents selling a "pie in the sky" package to a lot of people who have no idea whether they could complete the package or not?

GB,

How does a health plan with a higher deductible, become a "pie in the sky" package? Before HSAs came along, people had high deductible policies without the HSA option. Were those policies pie in the sky packages as well or did the HSA tag turn them into the evil they have become? When I raised my deductibles on my auto insurance to $1000, did I purchase a pie in the sky policy as well?

[GBurns]

The agent sold and the person bought a "package" that consists of a HDHP and an HSA with the idea of saving money and taxes through the use of the HSA.

The "pie in the sky" exists when there was no way to get the HSA (no available provider) therefore no tax benefits, no savings and increased exposure to financial loss.

"Pie in the sky", something that will not be attained or received as expected.

It has nothing to do with high deductibles, it has to do with there being no way to complete the "package".

[Guest jamescagney2000]

I 100% believe that HSA accounts will be a huge mess in 2-3 years. Giving the customer 100% control of these funds will lead to numerous problems. Once the accounts get to $2000-$3000, I am certain people will start using the money to buy a variable of non-medical items - Flat screens, computers, pay off credit card debt, etc. The ball won't drop until these people get audited by the IRS and claim they were never told of the regs. Then again, they said 401K plans would never work......

[GBurns]

Yes, they said 401(k) plans would not work. There were many many problems in the early years and there are still problems even with operational, compliance and testing issues. Some areas are still getting changes and clarification after all these years. And guess what? These are not even with the participants, these are with the experts who provide services.

On the participant side there is still a big mess with lack of appreciation, undertsnading and investment choices. Large numbers will not participate or contribute because the do not understand or feel safe. Large numbers will not make even basic investment decisions. Large numbers who make the decisions, do so badly and lose much of their savings.

After all these years education is still a big issue and as a result there are many who will say that 401(k)s do not work as intended.

Will HSA contributions, investments and proper use (for eligible expenses) be any different? Only time will tell.

Will HSAs deliver any relief from soaring medical costs and imprudent utilization? Will the concept be properly understood and used ? Who knows? Again only time will tell.

Can a potential mess be avoided? Yes, If the effort is made by those promoting the concept. But the question is more Will they? So far it seems No!. The interest seems to be in getting as many signatures in whatever way for whatever reason possible regardless of need or understanding.

[Don Levit]

HSAs can be popular, if the cash balance grows along with the deductible. Particularly at the lower deductibles, for every $1000 increase in the deductible, one may save $400 in premiums.

Don Levit