In its inimitable fashion, Marketplace Radio has dissected the controversies swirling around definition of “medical loss ratio” in health care reform. The new law limits insurance industry overhead (what it charges over and above the actual cost of care) to 20 percent of premiums (15 percent for large plans). Prior to reform, medical loss ratios could run as high as 35 percent for some small business and individual plans.
The government outsourced the task of determining what constitutes health care and what constitutes overhead to the National Association of Insurance Commissions, which published a draft of the proposed new rules on Thursday. Intense behind-the-scenes lobbying by insurers influenced a few of the rules, but for the most part, according to various press reports, they didn’t get their way.
For instance, the Association of Health Insurance Plans, the trade group for insurers, argued for including all anti-fraud investigation and enforcement expenses in health care. The NAIC allowed those expenses, but only up to the amount actually recovered from scamming providers.
With the Rise of AI, What IP Disputes in Healthcare Are Likely to Emerge?
Munck Wilson Mandala Partner Greg Howison shared his perspective on some of the legal ramifications around AI, IP, connected devices and the data they generate, in response to emailed questions.
One insurer asked that all patient information and communications be included as a health care expense. Again, NAIC allowed it, but only if it was personalized to the patient and mentioned a specific condition relevant to that patient. General communications — like the e-newsletter from my insurer that crowds my inbox once a month — will be excluded. That seems exactly right to me. The call centers that Health Dialog runs for various insurance plans, for instance (see this GoozNews post), would still be considered health care expenses because they are reaching out to specific patients with information specific to their treatment.
Kudos to Marketplace for its creative use of the internet to make publicly available documents that shed light on an important regulatory issue. Insurers are increasingly blaming the new mandates in health care reform for escalating rates. These regulations guarantee that the rate increases they seek from state regulators truly reflect higher health care costs and are not simply a ruse to pad profits.
A Personalized Approach to Medication Nonadherence
At the Abarca Forward conference earlier this year, George Van Antwerp, managing director at Deloitte, discussed how social determinants of health and a personalized member experience can improve medication adherence and health outcomes.
