Communicate Health Benefits Information More Effectively

All employers have responsibility of guiding their employees about the health benefit schemes offered by them. Even the employees on the other hand also have the right to receive information about the health benefit schemes offered to them. Therefore an employer has the right to inform the employees about certain information regarding the health benefit schemes. For this reason, organizations have created the position of Health Benefit Manager having communication as one of the responsibilities for health benefit related schemes and procedures.

Key information heads to be shared by employer

There is a plethora of information available for communication. It is the skill of the Health benefit Manager to present them in a structured manner on behalf of the employer.

– Employers need to provide a detailed list of information to the employees about what health benefit schemes are provided to them or the scheme they are entitled to.
– Providing information regarding cost sharing as well as arrangements
– To take up necessary steps to resolve problem as well as to deal with appeals.
– To provide and guide its employees about the status of accreditation, certification as well as licensure.
– Provide sufficient and necessary information about the composition of the provider network too.
– To use the emergency care services as when required by the employees of the organization.
– To obtain referrals to specialists
– Most importantly provide all the information regarding the quality, safety of the health benefit plan and the cost of the employer sponsored plan.

Regulatory directives
According to the Employer Retirement and Income Security Act of 1974, it is necessary to provide all detailed information that the employees are entitled to that includes plan rules, covered benefits, documents about the plan management and operation as well. The employees are also entitled to receive a document with the summary plan description, known as SPD. The SPD contains

– Information of the health care services that are covered in the plan.
– Description of what services are being provided by the plan and how these schemes function.
– It provides information also on how to calculate the benefits.
– Explanation on the cost that the plan covers and the cost that the beneficiary has to pay.

Tools and Methods for communicating
There are various methods by which the Health Benefit Manager, on behalf of the employers, can communicate health benefit information to the employees:

– One of the best ways is to communicate with the employees about the health coverage plan but providing too much information of it should also be avoided. The employees should be given the required time to understand the scheme and ask questions if any.

– It is best to explain the changes in simple terms to the employees to make them understand.

– Apart from the employees it is also necessary to explain the health benefit plans to the health benefit managers so that they can explain it to the employees to.

– Employers should be ready to face any questions asked by employees regarding the health benefit scheme and clear their doubts.

– It is equally important as well to be direct and honest when discussing about the coverage plan especially if employees face cost increase due to the coverage plan.

– Discussing the 5C’s too is essential with the employees. This 5C’s include cost, changes in plans, coverage of the plan, comparison of the previous year’s plan and also the current option.

– It is necessary to provide information the employees about the health care providers that are available in the revised and new plan option.

– Providing testimonials of other employees about the changes in health benefit plans can also be quite helpful for the present employees.

– Taking the help of various means like internet, face to face discussions, telephonic conversations, office intranet as well as printed materials can be helpful too. However it is also necessary to use materials that are easily understood by employees.

Using health communication campaigns

What are its advantages?

– It is important for the employers to conduct communication campaigns to educate the employees about the need of health benefit schemes and how they operate.

– The responsible manager’s aim should be to identify the objective and aim of the health care campaign.

– To develop health care message that meets the objectives and aim of the campaign.

– Setting up the criteria for evaluation of the campaign and also the degree to which it is getting conveyed among the employees.

– To implement and the campaign and make sure that the employees understand message that is being conveyed by the employer.

– It is also necessary to make sure that the employees also to address the education need of the employees with language barrier, literacy issues etc.

To conclude, an effective way to communicate about the health benefit scheme is the cornerstone of every business organization. In these schemes, employers can also guide and help its employees to select a scheme and explain every detail they should know. The authority should also explain the new health scheme option and also about the changes in the existing benefits. To improve the health plan costs the employer’s must keep in mind the factor of low health literacy. Health plans and employers should also be able to successfully communicate with employees. Lastly, employees and employers should also be able to communicate clearly about the health benefit plans.

What’s The Definition Of Physical Health and Does Good Health Naturally Mean All Natural Is Good?

Let’s begin with a good health definition in general. The WHO health definition (World Health Organization), albeit from 1948: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Assuming that’s true, what’s the definition of physical health and does good health naturally mean that “all natural” is good, especially as it applies to food?

What’s the definition of physical health?

Is there one?

Based on the WHO health definition as it applies to physical health, is it safe to say that simply because everything is working as it should in the absence of disease or infirmity (weakness or ailment), that we’re not necessarily in good physical health?

What do you think?

I personally believe there is more to being healthy in the moment. On the other hand, I also believe that because we are only guaranteed the present, if you’re healthy, don’t take it for granted. Enjoy it while you can.

I also believe the state of our physical health depends largely on our personal health plan. In other words, it depends on how well we take care of ourselves on a regular basis. That includes:

Eating habits
Exercise habits or lack thereof
Sleep habits
Spiritual habits
General living habits

Without seeming as though I am a pundit, expert or zealot about any of the aforementioned, that I am personally the definition of physical health, the definition of spiritual health, or anything that resembles the definition of good health, in a nutshell, what I’m saying is all the bullet points have a bearing on our physical health.

What do you think?

It’s about good health

One dictionary provides this definition of health:

“The general condition of the body or mind with reference to soundness and vigor: good health; poor health.”

The ancient Roman poet Virgil said, “The greatest wealth is health”.

I couldn’t agree more but I am a bit troubled by the amount of over-emphasis placed on physical health, as if it is mutually exclusive from the other aspects of health.

I believe health is about:

Physical
Mental
Emotional
Spiritual
Financial

The “soundness and vigor” in which we pursue and maintain these factors has a direct and indirect effect on each and every one of the factors.

Furthermore, I find it troubling that the word wealth is so overly associated with money and financial wealth.

It’s not to say that I don’t see the importance of physical health and financial wealth. They are both key components of overall health but they are not stand-alone concepts.

What are your thoughts?

All Natural

The “all natural” phenomenon, especially as it applies to food, is one of the biggest marketing ploys ever. If it’s not a scam, it’s a joke.

It means nothing!

There is a HUGE difference between organic and all natural. Don’t confuse the two and by all means don’t fall for the propaganda that leads you to believe they are one and the same. They’re not.

Organic, at least as it applies to food, is highly regulated. It actually means something. However, keep in mind that just because it’s organic doesn’t necessarily mean it’s healthy.

All natural can mean pretty much anything. As far as the food we eat is concerned, it is not regulated. It is a highly misleading tag.

Don’t be fooled.

I’m not saying don’t enjoy it. I’m not saying all natural is bad. I’m simply saying it’s about as superfluous term as there ever was. There is no depth to it.

My formula

For me, it all boils down to a few simple concepts and principles beginning with:

Honesty
Respect
Best Effort

These are indispensable. They cost nothing and should be applied at all times.

Next are the 5 F’s:

Food – Not just what we eat but includes anything we consume physically, mentally, emotionally, and spiritually. If we are what we eat, this says it all.
Fitness – Includes all the 5 bullet points mentioned above
Finances – Affected by the previous two and affects the previous and next two
Fulfillment – It’s about completion and includes all the bullet points mentioned
Fun – The importance of how it affects health and is affected by it is often overlooked

I have tagged the 5 F’s as the components of a bulletproof life.

To sum it up, all the above is important but the proper balance is the key. I believe too many of us are simply out of balance. Furthermore, there is not a one-size-fits-all balancing act.

Last but not least, from the late, great Redd Foxx:

“Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.”

Agree? Disagree?

Leave comments.

Bob is a retirement planning and safe money professional who specializes in life insurance products and who has more than 20 years experience.

His company, A Bulletproof Life is the 5 F’s: Food, fitness, finances, fulfillment, fun. and is based on his motto: Honesty, respect, best effort

Plan Your Dream or Prepare for a Nightmare.

Different Sorts Of Health Insurance Plans

Health is the biggest asset for any human being and our motto of life must be to stay healthy so that we can enjoy our life till it comes to an end. However, our health is just like a machine, which is vulnerable for many damages with the advent of time. On top of these machines need occasional or regular repairing for their efficiency. Same goes for our health. Our body needs regular checkups so that the organs of our body can perform their task precisely. On the other hand, due to some external forces or influences, like – virus, parasites, etc. and due to some internal organ dispute (such as heart blockage or kidney blockage), we experience major, as well as casual health breakdown issues. Just like a machine, our health requires servicing and the process of servicing the health is call medical science.

Medical science has experienced so many changes due to the advent of technology and new inventions. Today’s medical technologies are pretty robust and highly skillful enough to provide seamless healthcare support to the patients. As the technology has been integrated with the healthcare management and treatment procedures, healthcare or medical treatments also have become quite expensive. This is why we need to plan for our healthcare even if we are not experiencing any health issues at this moment. For a major or minor operation, immense expenses may happen and one needs to be careful about it. To aid people with their finance planning regarding their healthcare or medical treatment, medical insurances have been introduced into the market by the insurance companies, banking organizations and other financial organizations.

Presently, in USA, having a insurance is must for every citizen. To avail medical insurance, buyers need to find a suitable company first. Once the suitable insurance company has been spotted, the next step is to select a good health plan. Now, selecting a insurance plan can be really critical. Several health schemes and plans are there for the buyers to choose, but the million dollar question is – which is the most suitable for you, according to your age, budget and needs? So, let us have a look on different kinds of health:

1. Short Term Health Insurance – This is quite suitable for those, who are presently undergoing economical crunch situations. For short term health, investment is low as the term is short. The benefit is that you can still avail a health plan, even if you are in economic trouble. When, things will be back in shape, you can move to a long term or more beneficial health plan.

2. Full Service Health Insurance – Well, this is kind of a long term health insurance with lucrative offers. This kind of health insurance would be a bit costly and suitable for young or mid-aged servicemen or businessmen.

Apart from these, supplemental health insurance, pre existing condition health insurance are two popular forms of health insurances available in the market.

Health And Wellness Products – How To Make Your Own

Health and wellness products will mean very different things to different people.

Wellness can be defined as ‘the pursuit of a healthy, balanced lifestyle.
For the benefit of this article, wellness products are being looked at in the context
of ‘over the counter drugs, health supplements and health remedies.

While for some people, wellness products might be viewed as an aid to recovery
from illness, for others it might be a means of further enhancing some
aspect of their current health. The variety of and uses for such products
are as numerous as are the the definitions of wellness products or wellness
programs, depending of course upon who is promoting them at any given time.

Whatever your reasons for pursuing alternative care health or health and wellness
products, a common goal is to achieve optimised health and well-being.

There are powerful media images hailing the benefits and safety of many over the
counter drugs, supplements and health and wellness products, every where you turn
these days. They have equally strong claims of being the one and only miracle cure
or solution for one ailment or another. How accurate are these claims though, and
what are the real costs to you in monetary and health risk terms?

Immediately after reading this article, go take a look and do a quick add-up of the
total cost of all the health and wellness products you currently have in stock. I’m
sure the figure will surprise you just as much as learning about the very real and
harmful side effects which can be caused by some of these drugs or supplements
that are supposed to be contributing to your overall state of wellness.

You may also be surprised to know that many of the ‘over the counter drugs you
buy on a regular basis, simply treat the symptoms and not the real health issue.
Needless to say, this approach of focusing on the symptom, side-steps
the crucial requirement of getting to the root cause of your condition or whatever
it is that ails you.

You’re most likely to pursue a wellness product either because you are becoming
wary of the adverse effects of chemically produced drugs or because you’re keen to
recover from ill-health and improve a specific health condition. In some instances it
might be that you just want to optimise your current state of good health.

While some health and wellness products can be an effective measure toward
improving your health, you should note that long-term use of certain over the counter
drugs and some supplements can cause you more harm than good, with the long-
term implications far outweighing any short-term benefits. You may well find that
you are paying far too high a price on the basis of a mere quick fix promise.

For thousands of years, people in lands far and wide have used natural homemade
remedies to manage their health conditions and wellness needs, without manufactured
health and wellness products, that can be detrimental to health. They have purely relied
upon attaining or maintaining health by plants or by other natural means.
It could be argued that with the emergence of chemical and pharmacological methods,
many forms of this natural means to health and wellness have declined. In fact, even
by today’s standards, there are many so-called under-developed countries where
inhabitants’ rely on nothing more than homemade health and wellness products,
gained via natural methods of plants or plant-based extracts.

While conventional medicine relies on scientifically backed research to substantiate
effectiveness and safety. In contrast, similar cannot be said about some alternative
medicines or health and wellness products. There is no such requirement but their
promotion as regard effectiveness are deemed sufficient in themselves as support
for therapeutic or wellness claims.

Herbal remedies in general are harmless, however, certain claims being made by
some health and wellness products promoters, (under the banner of being
‘natural’)) can insinuate their health and fitness products being the
exclusive answer to your health condition or wellness questions, thus putting you
at great risk. Secondly, how open are they being about what’s really inside? You
should always consult your physician over any health concerns, as well as discussing
with him/her your intention or choice of alternative means for treatment with any
health and wellness product or remedy.

Multi-billion-dollar industries have long weald their power by way of
lobbying to gain exemption from FDA regulation. This has been exactly the
case, according to the Skeptical Inquirer, who, on commenting on
the ‘dietary supplement industry back in 1994, states – “Since then, these
products have flooded the market, subject only to the scruples of their
manufacturers”.

The above point is an important one to note in that, while health and wellness
products manufacturers may list ingredients and quantities being used in
specific health and wellness products, there has been no real pressure on them to
do so, or to do so accurately. Furthermore, neither has there been any
watchdog body to ensure they are penalised for this failing.

So, what are the alternatives open to you? Increasingly, more and more people
are turning to do-it-yourself health and wellness homemade herbal remedies.
The distinct difference being that in making your own health and wellness products,
you are in the driving seat. Not only do you have a full awareness of exactly
what the ingredients are and the true quantities, but with the appropriate level of
guidance from a reputable practitioner, you’re more conversant with any health
implications, if any.

With the right know-how, you too can draw on the old-fashioned yet effective
sources to greatly improve your health. For instance, using naturally prepared
herbs, vitamins, minerals and nutritional supplements, essential oils and flower
essences to create real healing solutions that deal with particular health
conditions rather than just the symptoms.

It is in the interest of a health and wellness product manufacturers to promote their
products as being the only option open to you. They don’t want you to know about
the abundant natural resources and health-giving potent attributes of herbs and home
remedies which have been used effectively for thousands of years. You see, these
remedies cannot be patented because you can make them yourself and at a
fraction of the cost.

Whether your goal is to overcome illness, drugs intolerance, allergies or just to
optimise your already good health, with a little know-how, you can start making
your own health and wellness products and remedies, using nothing more than the
readily available natural resources in your home and garden. Not only will you
save your hard earned cash, you also alleviate the risk of serious or harmful
additives and side effects.

Are you interested in learning more about how you can treat numerous common ailments without the harsh side effects, using nothing but natural herbs, vitamins
and nutrients you prepare yourself at home? For instance, did you know that
placing yogurt on your face help to bring water from the deeper layers
of your skin to the surface, moisturizing your skin for the rest of the day and hiding
wrinkles?

Here are just a few more of the many quick and effective remedies you can learn
to make:

1. Natural laxatives

2. Beauty recipes

3. Skin care and cleansing preparations such as acne treatment

3. Herbal shampoos as well as how to treat hair loss

5. Dermatitis

6. Menstrual Pain and PMS Symptoms

Occupational Health: Core Areas of Knowledge and Competence, Part 1

It is not possible to describe a highly complex and dynamic process such as occupational health nursing simply in terms of core activities or tasks. Occupational Health Nurse (OHA) are constantly learning new skills, adapting current practices to meet new needs and developing new approaches to solving problems and therefore their practice is not static but is constantly improving based upon a core range of skills.

However, within this limitation it is possible to describe those core areas of knowledge and competence that occupational health nurses use. The following list is not intended to be exhaustive, but rather to give an indication of the wide range of competencies that occupational health nurses demonstrate in practice.

The Clinician

Primary prevention

The OHA is skilled in primary prevention of injury or disease. The nurse may identify the need for, assess and plan interventions to, for example modify working environments, systems of work or change working practices in order to reduce the risk of hazardous exposure. Occupational health nurses are skilled in considering factors, such as human behavior and habits in relation to actual working practices. The nurse can also collaborate in the identification, conception and correction of work factors, choice of individual protective equipment, prevention of industrial injuries and diseases, as well as providing advice in matters concerning protection of the environment. Because of the occupational health nurses close association with the workers, and knowledge and experience in the working environment, they are in a good position to identify early changes in working practices, identify workers concerns over health and safety, and by presenting these to management in an independent objective manner can be the catalyst for changes in the workplace that lead to primary prevention.

Emergency care

The OHA is a Registered Nurse with a great deal of clinical experience and expertise in dealing with sick or injured people. The nurse may, where such duties form part of their job, provide initial emergency care of workers injured at work prior to transfer of the injured worker to hospital or the arrival of the emergency services. In many instances, where hazardous conditions exist at work, or where the workplace is far removed from other health care facilities, this role will form a major part of an occupational health nurse’s job. Occupational health nurses employed in mines, on oil rigs, in the desert regions or in areas where the health care systems are not yet fully developed will be familiar with a wide range of emergency care techniques and may have developed additional skills in order to fulfill this role. For others, who are working in situations where the emergency services are on hand, they may simply provide an additional level of support beyond that provided by the industrial first aider.

Nursing diagnosis

Occupational health nurses are skilled in assessing client’s health care needs, establish a nursing diagnosis and formulating appropriate nursing care plans, in conjunction with the patient or client groups, to meet those needs. Nurses can then implement and evaluate nursing interventions designed to achieve the care objectives. The nurse has a prominent role in assessing the needs of individuals and groups, and has the ability to analyze, interpret, plan and implement strategies to achieve specific goals. By using the nursing process the nurse contributes to workplace health management and by so doing helps to improve the health of the working population at the shop floor level. Nursing diagnosis is a holistic concept that does not focus solely on the treatment of a specific disease, but rather considers the whole person and their health care needs in the broadest context. It is a health based model rather than a disease based model and nurses have the skills to apply this approach with the working populations they serve.

General Health advice and health assessment

The OHA will be able to give advice on a wide range of health issues, and particularly on their relationship to working ability, health and safety at work or where modifications to the job or working environment can be made to take account of the changing health status of employees.

In many respects employers are not solely concerned with only those conditions that are directly caused by work, but do want their occupational health staff to help address any health related problems that may arise that might influence the employees attendance or performance at work, and many employees appreciate this level of help being provided to them at the workplace because it is so convenient for them. In particular the development of health care services to men at work, younger populations and those from ethnic groups can be most effective in reaching these sometimes difficult to reach populations.

Research and the use of evidence based practice

In addition to utilizing information and knowledge produced by research in various fields to support activities that relate to the occupational health component of their role, occupational health nurses will also utilize fully research information available from many fields to help support the general health of the working population.

Specialist

Occupational health policy, and practice development, implementation and evaluation

The specialist occupational health nurse may be involved, with senior management in the company, in developing the workplace health policy and strategy including aspects of occupational health, workplace health promotion and environmental health management. The OH nurse is in a good position to advise management on the implementation, monitoring and evaluation of workplace health management strategies and to participate fully in each of these stages. Possibility to perform that role will depend upon level of nurse education, skills and experience.

Occupational health assessment

OHA’s can play an essential role in health assessment for fitness to work, pre-employment or pre-placement examinations, periodic health examinations and individual health assessments for lifestyle risk factors.

Collaboration with occupational physician may be necessary in many instances, depending upon exiting legislation and accepted practice. The nurse can also play an important role in the workplace where informal requests for information, advice on health care matters and health related problems come to light. The nurse is able to observe the individual or group of workers in relation to exposure to a particular hazard and initiate appropriate targeted health assessment where necessary. These activities are often, but not exclusively, undertaken in conjunction with the medical adviser so that where problems are identified a safe system for onward referral exists.

Health surveillance

Where workers are exposed to a degree of residual risk of exposure and health surveillance is required by law the OHA will be involved in undertaking routine health surveillance procedures, periodic health assessment and in evaluating the results from such screening processes. The nurse will need a high degree of clinical skill when undertaking health surveillance and maintain a high degree of alertness to any abnormal findings. Early referral to an occupational health physician or other appropriate specialist will be the responsibility of the occupational health nurse where any abnormality is detected. The nurse will be involved in supporting the worker throughout any further examination or investigation, and may help to monitor their health on return to work. Once alerted to the possibility of an adverse health effect the occupational health nurse is in a good position to co-ordinate efforts to re-evaluate working practices in order to help protect others who may be similarly affected.

Where Can You Get Affordable Health Insurance?

What is health Insurance

The main reason why you need an affordable health insurance is to help you plan ahead in case of unexpected costly emergencies. The only way you can accomplish this is to compare prices from most leading insurance companies and also choosing a health insurance plan that best suits you. Back in the days, getting a cheap health insurance plan was simply unaffordable. But these days, individuals, small groups, families and students can choose a health insurance plan that is best for them, e.g. like acquiring a help insurance plan that ensures that an individual suffering from any previous medical condition is not excluded.

Private health insurance plan is totally an unrestricted open market, so those who do not yet have a health insurance plan should consider taking out a plan. For those who are seeking good medical health insurance program, having one is possible through the help of specific companies which specializes in providing health care insurance for individuals and also meeting their requirements and also staying within your budget.

Also for individuals who do not want to use a company, then they can use the internet. One major way Americans get health insurance coverage is mostly through their employers. Many employers them receive health insurance coverage for their workers for a limited time thus enabling them receive health insurance coverage. The internet provides an option for a cheaper health insurance. There are lots of companies that provide all types of health insurance plans, making it possible for you and your family to have a specific reasonable and affordable health care insurance plan. Finding out what kind of reputation the company has and how long the company has been in business is a smart idea.

Having a kind of ideal they have for you is advisable also making sure they have been licensed in your state, because it is of no use getting an insurance with a form which has no license and cant get the exact health insurance you want, many agents will help work hard for you, so you could have an affordable health insurance plan which you and your family could live with without great cost. Everyone wants the best health insurance both for themselves and for their families, but only the best health care insurance can do this with low premiums and full coverage.

What are the advantages of health insurance?

Having the right and the best health care insurance is difficult. In order not to get confused, one needs to decide which the best is by doing his or her research thoroughly. The first step to take includes checking out the credentials and also their past performances of the very company you are considering. Just as on insurance outfits does a background check of individuals before accepting proposals, one should also review the financial status including the customer care services of the insurer, by so doing; you stand the chance to know which health insurance company’s best for you. One major way for you to get ratings of these agencies such as A.M best or Moody’s is by using the better business bureau. Many employers use the health insurance scheme to either attract or even retain their quality employers. The health insurance coverage might be a personal scheme or a group scheme organized and sponsored by the employers for employers who work between 20-29 hours per week.

Companies also do not add cost of fringe benefits alongside health insurance, to the price of their product and service. Over the past decades, the cost of health insurance has increased tremendously, surpassing the general rate of inflation in most past years.

The different types of health insurance includes individual health insurance, affordable employee health insurance which is also known as group health insurance, affordable family health insurance, affordable business health insurance etc, your monthly insurance is determined by certain numerous different things. For instance, most premiums based on or according to your age. So your health insurance rates changes accordingly with the type of health policy you have. If your health insurance is basically for yourselves or your entire family, the procedures must surely have an impact on any quote you are young or advanced in age, self employed receiving health insurance companies will adjust your premium based upon your age and this will also affect the cost of your health insurance.

What are the Disadvantages of health insurance?

Since unforeseen occurrences may occur any time, one will never know when an accident is likely to happen, be it the need to be admitted in the hospital for stitches or a broken bone, you may be in the position to receive help quickly without the worry of receiving a huge bill, unlike when you don’t have a health insurance your credit rating beers all the cost. But you can prevent all this problems from happening and also protecting your credits for your future health financially. Increasing the amount of your health insurance deduction is another way in which you can help make sure your insurance rates are lowered. This higher monthly premium is necessary for anyone who has an existing health problem that requires an extensive medical treatment getting variety of quotes from insurance companies which meets for your health and budgets standards, is a wise decision when selection an health insurance. Searching can be done online and this will have saved you money as well.

Many people feel that they are healthy enough, so they don’t need health insurance because they have never had any major medical problems but one thing to note against the possible health insurance is the protection against the possible health problem that may happen in future. It might happen to you in particular or any member of your family, so why not plan on having an affordable health insurance plan today.

Which Health Insurance Plan Is Best for Me?

Health insurance has proven itself of great help and financial aid in certain cases when events turn out unexpectedly. In times when you are ill and when your health is in grave jeopardy and when finances seem to be incapable to sustain for your care, health insurance is here to the rescue. A good health insurance plan will definitely make things better for you.

Basically, there are two types of health insurance plans. Your first option is the indemnity plans, which includes the fee-for-services and the second is the managed care plans. The differences between these two include the choice offered by the providers, the amount of bills the policy holder has to pay and the services covered by the policy. As you can always hear there is no ultimate or best plan for anyone.

As you can see, there are some plans which may be way better than the others. Some may be good for you and your family’s health and medical care needs. However, amidst the sweet health insurance plan terms presented, there are always certain drawbacks that you may come to consider. The key is, you will have to wisely weigh the benefits. Especially that not among these plans will pay for all the financial damages associated with your care.

The following are a brief description about the health insurance plans that might be fitting for you and your family’s case.

Indemnity Plans

Flexible Spending Plans – These are the types of health insurance plans that are sponsored when you are working for a company, or any employer. These are the care plans inclusive in your employee benefit package. Some of the specific types of benefits included in this plan are the multiple options pre-tax conversion plan, medical plans plus flexible spending accounts, tax conversion plan, and employer credit cafeteria plans. You can always ask your employer of the benefits included in your health care/insurance plans.

Indemnity Health Plans – This type of health insurance plan allows you to choose your own health care providers. You are given the freedom to go to any doctor, medical institution, or other health care providers for a set monthly premium. The insurance plan will reimburse you and your health care provider according to the services rendered. Depending on the health insurance plan policy, there are those that offers limit on individual expenses, and when that expense is reached, the health insurance will cover for the remaining expenses in full. Sometimes, indemnity health insurance plans impose restrictions on services covered and may require prior authorization for hospital care and other expensive services.

Basic and Essential Health Plans – It provides a limited health insurance benefit at a considerably low insurance cost. In opting for this kind of health insurance plan, it is necessary that one should read the policy description giving special focus on covered services. There are plans which may not cover on some basic treatments, certain medical services such as chemotherapy, maternity care or certain prescriptions. Also, rates vary considerably since unlike other plans, premiums consider age, gender, health status, occupation, geographic location, and community rated.

Health Savings Accounts – You own and control the money in your HSA. This is the recent alternative to the old fashioned health insurance plans. These are savings product designed to offer policy holders different way to pay for their health care. This type of insurance plan allows the individual to pay for the current health expenses and also save for untoward future qualified medical and retiree health costs on a tax-free basis. With this health care plan, you decide on how your money is spent. You make all the decisions without relying on any third party or a health insurer. You decide on which investment will help your money grow. However, if you sign up for an HSA, High Deductible Health Plans are required in adjunct to this type of insurance plan.

High Deductible Health Plans – Also called Catastrophic Health Insurance Coverage. It is an inexpensive health insurance plan which is enabled only after a high deductible is met of at least $1,000 for an individual expense and $2,000 for family-related medical expense.

Managed Care Options

Preferred Provider Organizations – This is charged in a fee-for-service basis. The involved health care providers are paid by the insurer on a negotiated fee and schedule. The cost of services are likely lower if the policy holder chooses an out-of-network provider ad generally required to pay the difference between what the provider charges and what the health insurance plan has to pay.

Point of Service – POS health insurance plans are one of the indemnity type options in which the primary health care providers usually make referrals to other providers within the plan. In the event the doctors make referrals which are out of the plan, that plan pays all or most of the bill. However, if you refer yourself to an outside provider, the service charges may also be covered by the plan but the individual may be required to pay the coinsurance.

Health Maintenance Organizations – It offers access to a network of physicians, health care institutions, health care providers, and a variety of health care facilities. You have the freedom to choose for your personal primary care doctor from a list which may be provided by the HMO and this chosen doctor may coordinate with all the other aspects of your health care. You may speak with your chosen primary doctor for further referrals to a specialist. Generally, you are paying fewer out-of-pocket fees with this type of health insurance plan. However, there are certain instances that you may be often charged of the fees or co-payment for services such as doctor visits or prescriptions.

Government-Sponsored Health Insurance

Indian Health Services – This is part of the Department of Health and Human Services Program offering all American Indians the medical assistance at HIS facilities. Also, HIS helps in paying the cost of the health care services utilized at non-HIS facilities.

Medicaid – This is a federal or s state public assistance program created in the year 1965. These are available for the people who may have insufficient resources to pay for the health care services or for private insurance policies. Medicaid is available in all states. Eligibility levels and coverage benefits may vary though.

Medicare – This is a health care program for people aging 65 and older, with certain disabilities that pays part of the cost associated with hospitalization, surgery, home health care, doctor’s bills, and skilled nursing care.

Military Health Care – This type includes the TRICARE or the CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) and CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affair). The Department of Veterans Affair (VA) may also provide this service.

State Children’s Health Insurance Program – This is available to children whose low-income parents were not able to qualify for the Medicaid.
State-Specific Plans – This type of plan is available for low income uninsured individuals.

There are many different types of insurance plans that you may have the prerogative to know about. By learning which health care insurance fits your situation, you can avail of the many options that will likely be of great assistance to you in times when you will need it most. Insurance costs have typically become one of the common draw backs in choosing for an insurance quote. However, weighing the benefits will really matter. Make sure that you always read the benefits, terms and conditions before landing to whichever type of health insurance you choose.

5 Expert Insider Steps to Begin Transforming Your Health & Body Today!

While yes, our team is born in a world of intense high athletic goals such as bodybuilding, it is not our goal to support people to become bodybuilders – FAR FROM IT!;-) So you can relax now!! But it IS our goal to share with you why the lessons from our experience of mastering human health & the body, & how developing a bodybuilder “mentality” for your own life can literally skyrocket you into a level of personal health you never thought possible, while showing you the shortcuts in how to get there! Sound good? Heck, it sounds GREAT to us, because we already know how it can CHANGE YOUR LIFE.

If you are serious about stepping into your greatness of feeling & looking great, take 3 minutes & glean our insight, because this is the single-most MISSING LINK that we see people repeatedly leaving out of their game plan to great health & why they continue to fail at achieving quality health for their lives.

When you have had an experience of taking your mental, emotional & physical self to the level that bodybuilding competition requires, as a coach for others it then allows you to see potential for your clients that they could never envision for themselves without you by their side AND TAKE THEM THERE, and that is the beauty of the gift that we REJOICE in offering others in order to achieve optimal health, energy, & joy for their lives. But to get there…to create a successful transformation of your health & body, you HAVE to begin INSIDE with our 5 MUST-HAVE Steps! Yes, that’s right – the focus begins in the MIND. Time & again we see this process work, and it’s our UNIQUE coaching psychology method that sets us apart, & why we are capable of producing jaw-dropping results with the level of motivational mentality we provide. You can have all the knowledge in the world, but if you fail to develop the DESIRE & MINDSET to IMPLEMENT it, you will never succeed.

Want the insider view to our winning approach to learn how to transform your own health & body? We’re here to offer you the scoop because it’s our desire to support you fully to achieve authentic, preventative health from the inside, out in your lifetime. So where do we begin? There is a prolific spiritual author named John Maxwell, maybe you’ve heard of him, maybe you haven’t – but he writes of numerous spiritual topics & speaks on how we create TRUE transformation for our lives. Below we adapt his words for our article today because it’s a brilliant synopsis of just why & how we work with clients to coach them through mastering their personal health, as there are so many levels to the process.

When we discuss transformation of the physical body, to be successful we cannot deny that mind, body & spirit are woven tightly together in our being & therefore EACH needs to be considered – not just one. Often people when wanting to conquer health or healing goals immediately BEGIN at the physical, they think weight loss, nutrition, exercise…but that is their first step to failure because they’re joining the race before they’ve even laced their shoes!! When we fail to address mind & spirit in the health process we eventually lose the vision of why we’re addressing the physical in the first place & sadly fall off course when interest wanes, times get tough, or we lose our way because the how-to’s become unclear or appear out of reach. But if we start INSIDE & work OUTWARDS friends, GAME ON!!

Our 5 Expert Insider Steps to Transforming Your Health & Body

So these 5 KEY STEPS must be addressed in order to achieve a complete & SUCCESSFUL health & body transformation, and they must also be achieved in order as follows…

1. When you change your (health & body) thinking, you change your (health & body) beliefs.

If you think what you’ve been taught is healthy by the mainstream media is where your learning stops, then don’t expect to achieve great illness-free, authentic preventative health because they don’t teach proactive health approach, they teach reactive wait til you get sick & then act health approach. Begin to change your thinking to change your belief system about your body and health potential.

2. When you change your (health & body) beliefs, you change your (health & body) expectations.

Once you begin to expand your thinking, start to also seek out experts in areas of health & body who have shown & continue to show PROVEN ABILITY TO CREATE TRANSFORMATION RESULTS in their own health & body that you would like to emulate. Begin to sponge knowledge from them vs. what mainstream media claims leads to great health results, & you’ll in turn raise the bar on what you expect from your own health. You’ll see your new mentor/s are just ordinary people too like you, who decided to blaze their own health path about the quality of health they wanted to achieve for their life by taking the road less followed for their own health in life, and YOU CAN TOO – if you follow in their footprints.

3. When you change your (health & body) expectations, you change your (health & body) attitude.

Once your mind becomes opened by experts to your new health possibilities, you’ll have a renewed attitude & confidence about your abilities & empowerment around your personal health & begin to realize that anything you put your MIND to, your BODY can achieve -with the right tools in your toolbox. And THAT is exciting!

4. When you change your (health & body) attitude, you change your (health & body) behavior.

Now that you come to the table with a revitalized health attitude of possibilities & an arsenal from your health mentor, your entire being & behavior begins to shift because your mentor connects you with your own personal ability to achieve great results for your health, and as that continues to happen over and over, your self-efficacy GROWS & GROWS around your capabilities to manage your own personal health, as you transition into your own personal mini-health-expert!

5. When you change your (health & body) behavior, YOU CHANGE YOUR LIFE.

Now that you’ve achieved health & body mastery, you will begin to see an entire energetic, mental & emotional shift in your life that FAR EXCEEDS the physical. Yes, you will look & feel great, but the ways optimal health radiate outwards to all facets of your life will be astounding, as you attain a personal joy in life through health that you’ve never experienced before. No pills, no roller coaster of energy, no food cravings, no more blah approach to life, no more hiding from life within your own body,…you emerge a renewed person, ready to take on your full potential in this life.

This list is the perfect example of why health coaching with experienced experts not only WORKS, but offers you AMAZING, permanent results you could never envision or achieve on your own. With the support of your coaches seasoned & proven mentality of success in health & body transformation, you develop a similar mindset, outlook & body of knowledge in order to reach external goals of physical health & body success!

Aetna Health Insurance Leaving California – Recommended Replacement Plans

Aetna Health Insurance announced they are leaving the California marketplace for individual and family plans. The end date of all their plans is December 31, 2013. All 49,000 Aetna clients still have six months to figure out what health plan they should move to. In this article we’ll give you a simple mapping that recommends which plans you should move to based upon the Aetna health plan you currently have, a “gotcha” to watch out for, and a couple of silver linings to feel good about.

The simplest way to replace your Aetna Health Insurance is to simply look for an alternative plan with the same (or similar) deductible amount. The recommendations below will make that easy to do. With just a little more effort, you could re-think what you need in yearly medical benefits and pick a plan the is a better fit for your current needs. Either way, you should be able to find a good solution listed below.

Aetna Health Insurance Underwriting Is More Lenient

This will be the gotcha for some people. Aetna has always been more willing to accept people with some health conditions. I know a number of my clients are in Aetna plans because they had specific health conditions that the other carriers either would not accept, or would “rate” much higher than Aetna. So this is something you have to be aware of and be careful about.

If you have existing health conditions, or are “too short” (okay… a little over-weight), or have a rated plan with Aetna, then you should definitely talk to a broker before you apply with another health insurance company. You’ll want to have the broker do Pre-Screen Requests for you to see how the other insurance companies will treat your application.

It’s important to do the pre-screen step first, because if you just pick a health plan, apply for it, and then get declined or rated even higher, it will be very hard to get other insurance companies to consider your application.

Let’s start mapping replacement plans…

Aetna Open Access MC Value Plan Alternatives

The Aetna Open Access Value plans are Aetna’s low-cost option. The Value plans offer a number of different deductibles, $8,000, $5,000, $2,500, and provide 3 office visits for a simple copay, and coverage for Generic prescriptions.

This plan description matches very closely to what is offered in the Anthem Blue Cross SmartSense plans. If you only need two office visits rather than three, then the best choices are the Health Net PPO Advantage plans and the ClearProtection plan from Anthem Blue Cross.

If cost of the plan is one of your major factors, then here is how the alternative plans above should be used.

Health Net PPO Advantage 3500 – offers the best overall value (cost vs benefits)
Health Net PPO Advantage 6500 – is usually the lowest cost option
Anthem Blue Cross ClearProtection 3300 – Anthem’s lowest cost solution
Anthem Blue Cross SmartSense 6000 – closest match to Aetna’s Open Access Value 8000, but lower cost
Anthem Blue Cross SmartSense 3500, 2000, 1000 – if you feel more comfortable with lower deductibles

In the majority of cases, the alternative plans from Anthem and Health Net will be lower cost than the comparable Aetna Value plans. You’ll need to review health insurance quotes to see how the pricing looks for your location in California.

Aetna alternative plans from all major health insurance companies in California. The best plans!

Aetna Open Access MC Plan Alternatives

The Open Access plans are Aetna’s high-end offerings. These plans offered unlimited office visits for just a copay, provided both Generic and Brand name prescription coverage, and offered deductibles of 5,000, 3,500, 2,750, and 1,750.

The best mappings of the Open Access plans are the following:

Cigna Open Access Value plans – Cigna’s entry plans, but very similar to the Aetna plans but without brand name prescription coverage
Anthem Blue Cross Premier plans – these plans are the top of the line from Anthem
Cigna Open Access plans – the high-end Cigna plans
Blue Shield Shield Secure Plus plans – Blue Shield’s top end plans

Health Net does not have any plans that provide unlimited office visits and coverage of brand name prescriptions, so there are no options listed.

Aetna Open Access MC High Deductible Plan (HSA Compatible) Alternatives

These are Aetna’s entry in the Health Savings Account (HSA) compatible market. Like all HSA plans, they provide no benefits except zero-cost preventive care until after you reach the deductible. The plans come with two deductibles, either 5,500 or $3,500.

The mappings for these HSA plans is the following:

Health Net CFB HSA 4500 plan – this is the best value HSA plan in the market
Health Net CFB HSA 6000 plan – this is the overall lowest cost HSA plan
Blue Shield Saver HSA plans – these are lower cost than the other non-Health Net HSA plans
Cigna Health Savings 4900 plan – good general purpose plan
Anthem Blue Cross Lumenos 5950 plan – Anthem’s last remaining HSA plan

Are You Looking For Lower Out Of Pocket Risk?

Some shoppers may be looking to lower premiums AND lower the OOPM’s they have had in the past. If this is your wish, then here are a couple of options you should explore:

Health Net CFB PPO Standard plans – the OOPM in these plans is equal to the deductible, and 2 office visits for a copay
Cigna Open Access Value 5000/100% – the OOPM is the same as the deductible, and the plan offers unlimited office visits

These alternative plans will cost a little more than the direct replacement options listed in the sections above. However, the attractiveness of having lower risk if an accident or a medical condition starts is very compelling.

Silver Linings In The California Aetna Health Insurance Decision

I believe that Aetna is just the first in a line of large and small health insurance companies that will leave the California individual and family health insurance marketplace over the next 3-5 years. Aetna had a very small market share, and would have a hard time competing with the insurance companies that dominate the California market. So having Aetna leave now will reduce the turbulence we see during the Health Care Reform roll-out later this fall.

The first silver lining in all of this is that Aetna plans tend to have very high Out-Of-Pocket Maximums (OOPM). As an example, for a family, the Open Access Value 8000 plan has an OOPM of $25,000, while the Anthem Blue Cross SmartSense 6000 plan and the ealth Net PPO Advantage 6500 have a $19,000 OOPM.

This is one of the reasons people have stayed away from new Aetna plans unless no other health insurance company would accept them. There are plenty of plans from Health Net, Anthem Blue Cross, Cigna, and Blue Shield that will have lower OOPM’s than the Aetna plans.

The last silver lining of this change at Aetna, is that Aetna plans have not been very competitive the last couple of years. So changing to comparable plans will give you a reduction in premiums. With the information we’ve given you above, you should be able to find a good Aetna replacement plan, now go forth and prosper.

Health Care Fraud – The Perfect Storm

Today, health care fraud is all over the news. There undoubtedly is fraud in health care. The same is true for every business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. There is no question that health care providers who abuse their position and our trust to steal are a problem. So are those from other professions who do the same.

Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes in a health care fraud shell-game operated with ‘sleight-of-hand’ precision?

Take a closer look and one finds this is no game-of-chance. Taxpayers, consumers and providers always lose because the problem with health care fraud is not just the fraud, but it is that our government and insurers use the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Cost Estimates

What better way to report on fraud then to tout fraud cost estimates, e.g.

– “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” [Senator Ted Kaufman (D-DE), 10/28/09 press release]

– The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.

– The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen every year in scams designed to stick us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at best. Insurers, state and federal agencies, and others may gather fraud data related to their own missions, where the kind, quality and volume of data compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation at all, the little we do know about health care fraud and abuse is dwarfed by what we don’t know and what we know that is not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care – vary from state to state and from payor to payor – are extensive and very confusing for providers and others to understand as they are written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers instruct providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report to get paid – in some cases codes that do not accurately reflect the provider’s service.

Consumers know what services they receive from their doctor or other provider but may not have a clue as to what those billing codes or service descriptors mean on explanation of benefits received from insurers. This lack of understanding may result in consumers moving on without gaining clarification of what the codes mean, or may result in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – especially if it is Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do very little to proactively address the problem with tangible activities that will result in detecting inappropriate claims before they are paid. Indeed, payors of health care claims proclaim to operate a payment system based on trust that providers bill accurately for services rendered, as they can not review every claim before payment is made because the reimbursement system would shut down.

They claim to use sophisticated computer programs to look for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to study the problem and share fraud information. However, this activity, for the most part, is dealing with activity after the claim is paid and has little bearing on the proactive detection of fraud.

4. Exorcise health care fraud with the creation of new laws

The government’s reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately results in the government introducing and enacting new laws – presuming new laws will result in more fraud detected, investigated and prosecuted – without establishing how new laws will accomplish this more effectively than existing laws that were not used to their full potential.

With such efforts in 1996, we got the Health Insurance Portability and Accountability Act (HIPAA). It was enacted by Congress to address insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted in the creation of a number of new health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Relating to Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it will build on fraud prevention efforts and strengthen the governments’ capacity to investigate and prosecute waste, fraud and abuse in both government and private health insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense mental state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

What’s one person’s fraud (insurer alleging medically unnecessary services) is another person’s savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform a possibility from those pushing for health care reform? Unfortunately, it is not! Support for legislation placing new and onerous requirements on providers in the name of fighting fraud, however, does not appear to be a problem.

If Congress really wants to use its legislative powers to make a difference on the fraud problem they must think outside-the-box of what has already been done in some form or fashion. Focus on some front-end activity that deals with addressing the fraud before it happens. The following are illustrative of steps that could be taken in an effort to stem-the-tide on fraud and abuse:

– DEMAND all payors and providers, suppliers and others only use approved coding systems, where the codes are clearly defined for ALL to know and understand what the specific code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

– REQUIRE that all submitted claims to public and private insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation is not present claim isn’t paid. If the claim is later determined to be problematic investigators have the ability to talk with both the provider and the patient…

– REQUIRE that all claims-handlers (especially if they have authority to pay claims), consultants retained by insurers to assist on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the government to exhibit that they have the requisite understanding for recognizing health care fraud, and the knowledge to detect and investigate the fraud in health care claims. If such accreditation is not obtained, then neither the employee nor the consultant would be permitted to touch a health care claim or investigate suspected health care fraud.

– PROHIBIT public and private payors from asserting fraud on claims previously paid where it is established that the payor knew or should have known the claim was improper and should not have been paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education programs for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to investigate fraud in their respective jurisdictions; as well as funding other health care related activity.

– PROHIBIT insurers from raising premiums of policyholders based on estimates of the occurrence of fraud. Require insurers to establish a factual basis for purported losses attributed to fraud coupled with showing tangible proof of their efforts to detect and investigate fraud, as well as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a regular course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status when they have the ability to review claims before they are paid, but choose not to because it would impact the flow of the reimbursement system that is under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a part of the cost of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders in the form of higher premiums (despite the duty and ability to review claims before they are paid). Do your premiums continue to rise?

Insurers make a ton of money, and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, as well as going after monies paid on claims for services performed many years prior from providers too petrified to fight-back. Additionally, many insurers, believing a lack of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the government (and insurers) have assigned more people to investigate fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the increase in the numbers of investigators, it is not uncommon for law enforcers assigned to work fraud cases to lack the knowledge and understanding for working these types of cases. It is also not uncommon that law enforcers from multiple agencies expend their investigative efforts and numerous man-hours by working on the same fraud case.

Law enforcers, especially at the federal level, may not actively investigate fraud cases unless they have the tacit approval of a prosecutor. Some law enforcers who do not want to work a case, no matter how good it may be, seek out a prosecutor for a declination on cases presented in the most negative light.

Health Care Regulatory Boards are often not seen as a viable member of the investigative team. Boards regularly investigate complaints of inappropriate conduct by licensees under their purview. The major consistency of these boards are licensed providers, typically in active practice, that have the pulse of what is going on in their state.

Insurers, at the insistence of state insurance regulators, created special investigative units to address suspicious claims to facilitate the payment of legitimate claims. Many insurers have recruited ex-law enforcers who have little or no experience on health care matters and/or nurses with no investigative experience to comprise these units.

Reliance is critical for establishing fraud, and often a major hindrance for law enforcers and prosecutors on moving fraud cases forward. Reliance refers to payors relying on information received from providers to be an accurate representation of what was provided in their determination to pay claims. Fraud issues arise when providers misrepresent material facts in submitted claims, e.g. services not rendered, misrepresenting the service provider, etc.

Increased fraud prosecutions and financial recoveries? In the various (federal) prosecutorial jurisdictions in the United States, there are differing loss- thresholds that must be exceeded before the (illegal) activity will be considered for prosecution, e.g. $200,000.00, $1 million. What does this tell fraudsters – steal up to a certain amount, stop and change jurisdictions?

In the end, the health care fraud shell-game is perfect for fringe care-givers and deviant providers and suppliers who jockey for unfettered-access to health care dollars from a payment system incapable or unwilling to employ necessary mechanisms to appropriately address fraud – on the front-end before the claims are paid! These deviant providers and suppliers know that every claim is not looked at before it is paid, and operate knowing that it is then impossible to detect, investigate and prosecute everyone who is committing fraud!

Lucky for us, there are countless experienced and dedicated professionals working in the trenches to combat fraud that persevere in the face of adversity, making a difference one claim/case at a time! These professionals include, but are not limited to: Providers of all disciplines; Regulatory Boards (Insurance and Health Care); Insurance Company Claims Handlers and Special Investigators; Local, State and Federal Law Enforcers; State and Federal Prosecutors; and others.