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Managing Employer Sponsored Benefits

Explore the history, challenges, and future of employer sponsored benefits in Houston and nationwide. Discover the impact of mandates, government surveillance, and public mind control on healthcare. Learn about waste, fraud, and abuse in the system and how to combat it. Find out how to navigate the complex world of health(care) benefits and ensure quality coverage for employees.

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Managing Employer Sponsored Benefits

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  1. Managing Employer Sponsored Benefits …or Houston (and the nation), we have a problem! David KesterHarris County

  2. TRIVIA • 1984? 1994? 2014? • 328, 1,342 or 2,400 pages? • A national health board • Regional alliances • A Standard Benefits Package • Employer Mandates • Spending Caps/Fee Controls • Government Surveillance/Public Mind Control

  3. The ACA … Back to the Future or is it the Song that Never Ends? Marine Hospital Service (1798) SSA (1935) ADEA (1967) HMO Act (1973) ERISA (1974) Retirement Equity Act (1984) Deficit Reduction Act (1985) COBRA (1986) Unemployment Compensation Amendments Act (1992) ADA,FMLA (1990-93) Parity Laws/HIPAA (1996) BBA/TRA (1997) EGTRA (2001) MMA (2003) PP(ACA) (2010) R&R Act (2016, 2017, 2018, 2019?)

  4. Where have we been, where are we now, and where are we going? • Congress…. • The President • DHHS, EEOC, DOL , IRS • The Supreme Court • State Legislatures

  5. Why do we provide(employer sponsored) health care? • It (used to be) optional • Because we have to… • Because we care

  6. “Health(care)” Benefits? • Medical • Wellness plans? • Dental? • Vision? • Long Term Disability? • Life Insurance? • Long Term Care? • Legal Assistance Benefits? • Pet Insurance?

  7. Who, What, When, Where, and How? • The ACA and other mandates form the base benefits (90% of the Who, What and When) • Who we cover • Essential Benefits • Waiting periods • Employers (partially) decide on the rest • Deductibles/Co-Payments • Out of Pocket Maximums • Employers define where (in most cases except ER) and the funding • PPO/POS/HMO • Self Insured/Fully Insured/Pooling • “Consumer Driven,” “Value Based” Networks, HSA • Few people know how…and that is a problem! • HOW is a REAL problem!

  8. Waste, Fraud and Abuse • Institute of Medicine Estimates 28% of total cost • ($750,000,000,000 in 2009) • FBI Estimates of fraudulent billing • ($260,000,000,000 in 2010) • HHS/OIG/DOJ • (600 charged in health care schemes, $2.6 billion in 2017)

  9. Waste Source: Institute of Medicine (IOM). 2012

  10. Fraud (Just a Few Examples) • Billing for services not provided • Falsifying “medical necessity” • Upcoding treatments or treatment plans • Failing to report overpayments • Duplicate Billing • Identity Theft

  11. Abuse • Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. - Misusing codes on a claim; - Charging excessively for services or supplies; and - Billing for services that were not medically necessary. Source: Johns Hopkins Medicine, 2018

  12. What Can You Do? • Ask Questions • Pay Attention • Involve/Engage Authorities • Various Reporting Agencies • Carrier • TDI/Pharmacy Board/Medical Board (State) • OIG/HHS (Federal) • National Health Care Anti-Fraud Association • Communicate with Members • Don’t wait

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