Calculating Charges for Out-of-Network Health Services Print E-mail
Written by Karina Gonzalez | Florida Healthcare Law Firm Blog   
Thursday, 24 July 2014 17:10

A healthcare provider's "billed charge" is usually the total charges billed before applying any contractual discounts. Where there are no contractual relations, a provider's charge may be considered the equivalent of fair market value for the service provided. But what is fair market value? If the provider is contracted the rate is confidential and not subject to disclosure. If the provider is non-contracted, there is no standard billing rate for providers, making it difficult to get reliable rate data on what is fair market value for similar services or similar providers. One Florida court has found that "fair market value" is the price that a willing buyer will pay and a willing seller will accept in an arm's length transaction.
Unlike the uncertainty surrounding calculation of charges for out-of-network providers, emergency services are covered under Florida's HMO statute and compensation is the lesser of: (a) the provider's charge, or (b) the usual and customary provider's charges for similar services in the community where the services are provided, or (c) the charge agreed on between the HMO and the provider. Fla. Stat. ยง641.513 (5) (b).

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Last Updated on Thursday, 24 July 2014 17:21
Specialty Care Is A Challenge In Some ACA Plans Print E-mail
Written by Carrie Feibel, Houston Public Media   
Wednesday, 23 July 2014 13:25

khn logo black  Primary care doctors have reported problems making referrals for patients who have purchased some of the cheaper plans from the federal insurance marketplace. Complaints about narrow networks with too few doctors have attracted the attention of federal regulators and have even prompted lawsuits.
But they're also causing headaches in the day-to-day work of doctors and clinics. "The biggest problem we've run into is figuring out what specialists take a lot of these plans," said Dr. Charu Sawhney of Houston.

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Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Last Updated on Wednesday, 23 July 2014 13:34
Clash of the Titans: Big Pharma vs. Big Insurance Print E-mail
Written by Luis Collar, MD | Sapphire Equinox   
Thursday, 17 July 2014 11:34

Sovaldi (sofosbuvir), the new hepatitis drug manufactured and marketed by Gilead Sciences, has garnered considerable media attention over the last several months. The drug was approved by the FDA in December after phase III clinical trials showed it was highly effective in the treatment of chronic HCV infection. In fact, with an overall SVR (sustained virologic response) of 90% for the genotypes studied, Sovaldi may represent a cure for many of the 3.2 million Americans afflicted with the disease.
Sovaldi's price, however, has raised more eyebrows than its efficacy. At around $1,000 per pill, or $84,000 for a twelve-week course of treatment, there's no denying it's expensive.

And given its hefty price tag, it's no surprise that most insurance companies now require prior authorization before patients can obtain the drug. So is Sovaldi too expensive? Maybe it is, maybe it isn't; we'll address that shortly. But should insurers ever be allowed to require prior authorization for a drug, regardless of its price?

The two industries most relevant to this discussion possess diametrically opposed...

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Sponsor Showcase Print E-mail
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Thursday, 17 July 2014 00:00
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Last Updated on Thursday, 17 July 2014 12:10

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