How employers can contain health care fraud, waste and abuse

Health care in the U.S. encompasses a large and complex system fueled by large sums of money. Unfortunately, it is also a system that is ripe for fraud.

Add to that a general unfamiliarity and uncertainty about how many aspects of the system operate, especially since the implementation of the Affordable Care Act (ACA), and you have an invitation to deceive.

“Positively, the ACA has created some new tools to combat health care fraud and abuse,” says William Gedman, CPA, CIA, CHC, vice president of Fraud & Abuse and chief compliance officer for UPMC Insurance Services Division. “The law has created tougher rules and sentences for health care fraud. But new rules and regulations can also mean those that want to do wrong just come up with new scams.”

Smart Business spoke with Gedman about fraud, waste and abuse in this new era and how employers need to be diligent about containing it.

What is health care fraud and abuse?

Under the Health Insurance Portability and Accountability Act, fraud is defined as knowing and willful attempts to defraud any health care benefit program. Abuse is defined as acts that are inconsistent with sound medical or business practice.

The most common types of fraud and abuse are misrepresentation of services, altering claim forms for higher payments, billing for services not performed and providing medical services that are unnecessary based on the patient’s condition.

Waste can be defined as extravagant, careless or needless utilization of health care benefits or services that result from deficient practices or decisions.

How extensive is the problem?

According to the National Health Care Anti-Fraud Association (NHCAA), fraud and abuse in the health care system is estimated to cost tens of billions of dollars a year. There also can be a physical safety risk for people who are subjected to inappropriate medical services or given services by providers who are not licensed or qualified to provide them.

Because the health care billing and reimbursement process, coding convention and compliance requirements (including those of the ACA) are so complex, it almost fosters an abusive system. The complexity can make fraud difficult to detect, and the creativeness of abusers adds to the challenge.

Has the ACA had a positive impact on curbing fraud and abuse?

Yes. Part of the ACA includes an assortment of tools to fight fraud. These include new rules and sentences for criminals, enhanced screening of providers and suppliers, state-of-the-art technology such as advanced predictive modeling technology that targets highly suspect behaviors, as well as an additional $350 million over 10 years that will be used to boost anti-fraud efforts.

What can an employer do to protect employees from health care fraud?

Education is a must. People need to understand the possible types of fraud, waste and abuse. Employers should be very selective and demanding when choosing an insurance carrier. Make sure your insurer has strong controls to detect and prevent fraud and the infrastructure to investigate and partner with law enforcement to prosecute cases of fraud and abuse.

Awareness is essential for protection against fraud. Employees must educate themselves about potential types of fraud, waste and abuse, and play an active role in their health care. Ask questions of providers if you are not sure about their course of care. Also, closely review your Explanation of Benefits and understand all services rendered and billed to your insurer. This is the only way to determine if you and your insurance company are being appropriately charged for services performed or supplies/equipment provided.

Finally, both employers and employees should be aware of organizations or agencies that play a significant role in educating about health care fraud, waste and abuse. Those organizations also play a role in lobbying for new or revised regulations, partnering with law enforcement and/or prosecuting cases. At the top on the list would be the NHCAA and government agencies such as the Department of Justice and the Centers for Medicare and Medicaid Services.

Insights Health Care is brought to you by UPMC Health Plan

How setting up a telemedicine program for plan members benefits everyone

The next time your child is sick, what if you or your employees had the opportunity to speak with a physician without leaving the office or home? Instead of sitting in a doctor’s office for hours, you make a quick phone call, explaining the symptoms to a nurse. Then, shortly after, you’re able to talk with a doctor who can prescribe medication.

Telemedicine programs that allow you to do this are becoming more popular as it takes longer and longer for patients to see their doctor, which is partly due to more primary care physicians (PCP) getting out of the industry.

“We’re finding more and more employees and members that are stating it’s taking two and three weeks to get in to see their PCP for non-emergency conditions,” says Susan Lehne, account manager at HealthLink.

The research firm Merritt Hawkins, a part of AMN Healthcare, surveyed 1,400 medical offices to track the average time needed to schedule a new patient doctor appointment in 15 large metropolitan areas. Wait times ranged from one day to eight months with an average of 19 days.

Smart Business spoke with Lehne about how a telemedicine program can help both employees and employers.

If a health plan includes a telemedicine program, how would it work?

With telemedicine programs offering extended and weekend hours, or even 24/7 access with some, health plan members are able to call and first talk with a customer service representative at their convenience. Once they give information like name and date of birth, the telemedicine rep looks up their eligibility file and covers the method of payment — although some plans cover the cost at 100 percent to encourage use.

Next, the call is handed over to a nurse who goes over the symptoms and builds a history of current prescriptions and when you last visited your PCP.

Then, the member agrees to continue the consult with a physician, finding time for a follow-up phone call. The doctor, in the meantime, listens to the phone recording and goes over the case file.

At the time of the follow-up, both the physician and nurse talk with the patient, just like in an office setting. In addition, the nurse makes an outreach call within 24 hours to follow-up.

It’s important to note that telemedicine programs have no problem recommending a specialist or that you go back to your PCP. They also may request blood work or additional tests.

What are the benefits to a program like this?

When an employee consults with the telemedicine program, rather than going to a clinic or emergency room, there can be significant cost savings for the employer as well as the health plan member in terms of co-pay costs. Telemedicine programs have been found to reduce the amount of emergency room and urgent care visits.

Another benefit is convenience — a telemedicine program can decrease the time away from the office. A parent who needs to discuss a dependent child’s symptoms doesn’t always have to leave the office, and once he or she talks to a physician and feels better about the next step, they will be more able to focus on their work.

What else is important to know about setting up a telemedicine program?

A telemedicine program can be set up from either a self-funded perspective or added to a fully insured plan as part of the premium. Either way, the first step is to talk to your health care broker.

You do want to pay attention to how you’re charged. Typically when you incorporate a telemedicine program into your plan, it’s on a per employee or per member per month cost basis. However, some programs are set up on a per consult basis; so, if your membership is not utilizing it a lot, you’re not going to be charged as much.

Communication to members is key. Make sure they know this is an option, and then keep reminding them. Many times an employer announces the program initially, but then members have a tendency to forget.

Telemedicine is just another avenue to health care that you may want to seriously consider adding to your health plan’s arsenal. In fact, the American Telemedicine Association has found that 70 percent of U.S. patients are comfortable communicating with doctors via text, email and video.

Insights Health Care is brought to you by HealthLink

How less strain may help make your organization healthier, more productive

Stress in the workforce has become one of the biggest problems in business today. It has been called a global epidemic, with numerous studies encouraging businesses to be more proactive in helping their employees manage stress.

“Every day, people deal with stress at work or in their personal lives — or probably both,” says Veronica Hawkins, Medical Mutual’s Vice President, Government Accounts, which includes the State of Ohio and Ohio Public Employees Retirement System. “Organizations need to understand the effect it can have on the health of their employees and what that means for the future of their business.”

Smart Business spoke with Hawkins about how stress in the workplace can impact an organization’s bottom line and what can be done to help employees manage stress and be healthier and more productive in the process.

Why is it important to manage stress in the workplace?

With the high demand and fast pace of today’s work environment, employees at practically every level of an organization are dealing with some level of stress. By providing stress management resources, you can help employees be healthier and control your health care costs. Healthy employees are often happier and more productive workers, so it benefits your business to offer assistance to reduce stress whenever possible. In many cases, turnover and absenteeism rates can also decrease.

What effect does stress actually have on a person’s health?

Of course, there are the immediate effects, which can include headaches, upset stomach and loss of sleep. But there are also more long-term consequences. Chronic stress can weaken the immune system, which makes it tougher to fight off illness, causing people to get sick more often. It’s also linked to high blood pressure, abnormal heartbeat, heart attacks, anxiety and depression. These conditions, and others, can even get worse as a result of continuous stress.

What are the best ways for people to reduce their stress levels?

Diet, exercise and adequate sleep are definitely very important. When your body feels good, your mind often does, too. While people often adopt poor eating and lifestyle habits as a form of stress relief, those habits actually make the symptoms worse. Just 30 minutes of exercise a day can have a significant impact on stress as well. Even at work, if feasible, employees should be encouraged to do things like go for a walk at lunch or use the stairs instead of the elevator.

Beyond diet and exercise, learning how to manage time can make a big difference. In the workplace, it’s helpful to keep track of projects and deadlines and prioritize effectively. Employees should also be encouraged to discuss challenges that arise in meeting deadlines or ask for help. That will help reduce stress for those employees and make sure projects get done on time.

What can organizations do to help their employees?

Many companies will offer employee assistance programs (EAPs) and stress management training. These programs are designed to help employees understand the nature of stress, its sources and how stress can affect a person’s health. They teach employees personal skills to reduce their stress levels, such as time management or relaxation techniques.

EAPs will also provide individual counseling for employees who need help coping with work or personal issues. Some companies will even work with EAP counselors or professional consultants to help them identify the most stressful aspects of their workplace and develop strategies to reduce or eliminate them.

What else should we understand about stress?

Unfortunately for most of us, it’s tough to get rid of all the stress factors in life. But everyone can find ways to manage and control how he or she responds and reacts to these stressors. Helping your employees along in the process could help your organization be healthier — both physically and financially.

Insights Health Care is brought to you by Medical Mutual

How a workplace wellness program can be convenient and inexpensive

Setting up a wellness program at your company shouldn’t be burdensome. And if you need some encouragement that it will pay dividends, turn to Rand Corp.’s recent Workplace Wellness Programs Study, which found that for each $1 invested in a workplace wellness program, $1.50 is returned.

There are several levels of activities that you can offer, depending on how involved you want to be, from blood pressure screenings to weight loss to smoking cessation programs.

“It’s important to really assess health risks that are impacting your own employee population,” says Amber R. Hulme, Medical Mutual Vice President for Central and Southern Ohio. “Wellness programs also help with absenteeism — they help make people feel better and make them want to come to work. The better you feel, the more you are engaged.”

Smart Business spoke with Hulme about how to start a workplace wellness program.

Where do you start? Do you check with your insurance provider for resources and incentives?

Yes — do that initially. You want an official baseline of your employees’ health risks. A baseline is easy to achieve with a health screening and health assessment questionnaire, which is often done online.

Health screening is vital so people know their numbers. But the health assessment is where you really get the data behind the screenings. A minimum of 30 employees is a good number to establish a baseline.

Are wellness programs suitable for companies of any size?

Yes. Obviously, the larger the employee base, the more data you can work with. For example, Medical Mutual can provide a report showing the percentage of tobacco users, diabetics or overweight employees based on a large enough sample size. You can then develop a wellness program that addresses the primary concerns of your employee population. The program can include incentives to encourage employees to go to a gym or participate in other fitness-related initiatives. But a wellness program can work regardless of the size of the company and doesn’t require an on-site gym. If you do have a gym, that’s great, but it doesn’t mean you have to have one. There are plenty of creative ideas that can be used to make a great wellness program.

What about a company culture factor?

Making wellness part of your company culture is important; employees should feel that it’s an initiative from the top. The culture of the organization really needs to change to be more focused around lifestyle behaviors that make employees healthier.

Another thing to consider is how to best communicate with your employees. Survey your employees to find out what type of communications would help drive their performance.

Should a company offer incentives for employees to join the wellness program?

Use your survey to learn about what rewards are worth the extra effort. Don’t just throw a large amount of money at employees with the expectation that it will engage them.

You may be surprised how a small incentive or recognition by the company can promote participation. Allow your employees to participate online to select the wellness programs. Consider having an employee wellness committee. Ask employees to get involved, so it’s not just coming from management, but from everybody. Having all levels of the organization involved in trying to improve their health is important to a company.

What is the final step?

Make sure to have senior management buy in. If you get your CEO or CIO or whomever involved and active in the wellness program, employees can share in the experience with someone at that level. This upper-level buy-in can encourage participation because employees feel they are all part of the same team.

When employees see that management cares enough about wellness to participate, it makes an impact. And that participation can lead to positive communication and interaction.

A good wellness program impacts everybody in the company, no matter their job title. It puts everyone on the same playing field because we all go through the same struggles.

Insights Health Care is brought to you by Medical Mutual

How to build a narrow health care network to fit your group’s needs

Self-funded or partially self-funded health plans continue to be a growing trend for employers interested in more control over their health care costs. In 2013, 83 percent of covered workers at larger firms — 200 or more employees — were enrolled in partially or completely self-funded plans, according to an annual survey by the Kaiser Family Foundation and the Health Research & Education Trust. For small firms, self-funding included 16 percent of covered workers.

In addition, 6 percent of firms offering fully insured plans reported on the survey that they intend to switch to self-funding.

But with self-funding, employers can achieve additional savings by understanding how to build narrow networks to go along with their benefit plans.

“We’ve built five of these narrow networks in the past 12 months. It’s picking up momentum. We’re seeing quite a bit of interest,” says Erin C. Davidson, a sales account executive II at HealthLink. “If you’re looking to get creative to control costs that’s the way to do it.”

Smart Business spoke with Davidson about how to get started on building the best narrow network for plan members.

Once you decide to self-fund and need a narrow network, what is the first step?

The first step would be to work with your broker or current health care carrier or network to see if that carrier or network performs this service. If they don’t, it may be in the employer’s best interest to find a managed care network that can provide you with this area of expertise.

Why is this partnership with a managed care network so important?

The managed care network can perform modeling of the narrow network contract to ensure it is successful.

A managed care network also can help protect the employer. A sophisticated contracting team can help incorporate language about charge master increase limits, stop loss provisions and excluded services to keep employers from being exposed to higher billed charges from hospitals.

What’s an example of how a narrow network provides value to employers?

In one instance, two hospitals in the same county yielded a 50 percent discount. However, using the managed care network’s modeling tools, each cost of care could be further examined to look at the types of cases treated and average cost per patient. The adjusted cost at the two hospitals was $16,755 per day or $9,891 per day. Then, the employer can still provide members access to care at the most costly facility, but benefit plan designs can be implemented to drive members, via reduced out-of-pocket amounts, to the lower cost provider.

Are there certain businesses that should make building a narrow network a priority?

There is no one industry or type of business that can benefit more from a custom contract. However, there are certain scenarios that are more ideal. A community with two hospitals can provide higher cost savings. Companies with dense population centers in a tight geographic area, such as 100 or more employees living in one community, also are able to create stronger networks. This is because these employers have more ability to steer members to certain facilities, which a hospital system wants to encourage.

What best practices can ensure an organization is getting the most value?

The key is to ensure you’re continually improving, and that takes a collaboration of the provider or employer, broker and managed care company who all work together to ensure claims are objective and being met.

In addition to narrow network development, there are other best practices like steering members to domestic centers of excellence, gain share models and reference-based pricing, which are all variations on the same theme. They all try to incorporate leverage, steerage, improved outcomes and transparency in an effort to reduce costs. So, ultimately, a strategy is for employers to employ some, if not all, of these to find the right fit.

Most importantly, you don’t have to do this alone. That’s why the right managed care network is so important.

Insights Health Care is brought to you by HealthLink

How to educate employees on emergency department use

Using an emergency department (ED) for routine treatment is generally seen as a waste of health care resources and a contributor to rising health care costs.

But any employer hoping to be able to educate his or her employees about judicious use of the ED has to understand this is no easy task. Not even hospital employees have fully gotten the message. A recent study by Thomson Reuters found that hospital employees spent 10 percent more on health care and were 22 percent more likely to use the ED than employees in other industries.

“There are reasons that people continue to use the ED for non-urgent care,” says Dr. Stephen E. Perkins, vice president of Medical Affairs for UPMC Health Plan. “Understanding the factors behind the usage is an important first step toward reducing unnecessary ED visits.”

Smart Business spoke with Perkins about how to educate employees concerning ED use in order to reduce costs and improve care.

What are some reasons people like to use the ED for non-acute care?

Basically, when primary care is thought to be inadequate for the problem, and patients feel they cannot get timely care anywhere else, many will consider using the ED.

Getting in to see a primary care physician on short notice can be difficult, if not impossible, and physically getting to a physician’s office is a problem for some as well. In contrast, going to an ED means being seen — at least, initially — immediately. Transportation to an ED is often easier; some who arrive are even transported by ambulance.

Also, some patients ‘trust’ hospitals more than outpatient facilities such as urgent care centers. The sense that a hospital is the place for any serious ailment has been ingrained in many people over the years.

How big a problem is this?

A recent Rand Corporation study found 37 percent of all ED visits could be considered to be ‘non-urgent.’ The definition of non-urgent care may differ, but generally speaking, that statistic indicates many people are being treated in EDs who could be served as well, or better, in other settings.

What do employers need to do to engage and educate their employees about appropriate ED use?

Employers need to build awareness of ED alternatives. Employees need to know more about what urgent centers can and cannot provide. They also need to know that primary care can be a more viable option. Employers must educate employees about facilities such as urgent care centers, which are more appropriate for certain conditions.

Patients need to use good judgment in deciding whether to go to an ED. They need to learn the signs of serious illness and then trust their instincts.

When possible, calling a primary care physician and describing your condition is a preferable first step. If the physician is your regular physician, he or she will understand your health history and can direct you to the care that would be most appropriate.

What kinds of symptoms would warrant going to an ED and which do not?

It is appropriate to go to an ED if you notice symptoms like chest pains, trouble breathing, a head or back injury, persistent bleeding or vomiting, loss of consciousness, poisoning, a major burn or cut, or choking. For other medical emergencies such as a minor sprain, a small cut or a sore throat, treatment is better suited for an urgent care center or a primary care physician’s office.

Many physicians now have evening and weekend hours, so even if the office is not open, a doctor is on call. He or she can listen to your symptoms, taking into account your health history, to prescribe a course of action. This could include a visit to an ED or urgent care center, or the physician could schedule an office appointment or give instructions for treating a problem at home.

Employees also need to know that urgent care centers offer many similar services as EDs, such as X-rays and blood tests.

Why should employers take the time to educate employees about ED usage?

It is important to build awareness of ED alternatives because reducing non-urgent use of the ED, which in turn lowers health care costs, requires that you engage and educate people on how to choose appropriate care.


Insights Health Care is brought to you by UPMC Health Plan

How to better manage your workforce during times of change

The old adage that “change is the only constant” certainly holds true in the workplace. Change can be technological, systemic or organizational. Whatever its form, some kind of change is inevitable.

“Leaders will always be faced with turnover, the implementation of new systems, reorganization and other changes to their environment,” says Tom Koloc, LPC, NCC, a senior account manager for LifeSolutions, an employee assistance program, which is part of the UPMC Insurance Services Division. “What’s important is to know how to manage change and handle the transition.”

Smart Business spoke with Koloc about how change impacts employers and employees, and how to best manage it.

Is there a difference between change and transition?

William Bridges, who authored the book, ‘Managing Transitions: Making the Most of Change,’ writes that change is situational and, to some extent, external to the people involved. Change is often sudden and abrupt and provides employees with little or no time to prepare. Some examples of workplace change would be changes in leadership or work rules, such as ones that govern overtime.

In contrast, transition can be slow. It’s the internal psychological process through which people gradually accept a new situation and the changes that come with it.

What is management’s role during the transition period?

The way leadership handles transitions can significantly impact the outcome. The first part of a transition period usually involves denial, shock and anger. The loss that employees feel can be both tangible and intangible. But in all cases, it is important for leaders to express empathy for what employees are going through and to be specific about any policy changes.

Generally, transition requires an understanding of and support for what the employees are experiencing.

What should leaders focus on?

It’s important to respect the past, and not be negative or ridicule the old ways of doing things. The change may be for the better, but employees have invested time, energy and emotion in the way things were done in the past and that needs to be respected.

Employees also need to be given details about changes, as well as an opportunity to ask questions. Employers need to embrace communication avenues because communication is one of the best ways to ease fears of the unknown. Regularly sharing updates when available is a good practice. Remember, when employees hear nothing, they are more apt to fill the void with rumors.

Above all, be visible during these periods. Leaders who interact with employees will raise their employees’ level of engagement.

How does a leader deal with skepticism?

Skepticism and ambivalence can change to hope and enthusiasm if leaders remember what Bridges calls the four Ps, which are:

  • Purpose: It is important to explain why changes are happening. Explaining the rationale behind change can help people get beyond their initial resistance.
  • Picture: By sharing a vision of what the new organization will look like and feel like, you can break down resistance.
  • Plan: Lay out a detailed step-by-step plan. A timeline can help keep people on task.
  • Part: Give employees a part to play in the new arrangement. With responsibility, employees gain a sense of ownership.

What else should employers know?

Managers and supervisors play an integral role in how effectively their staffs navigate workplace change. But a transition can be equally as challenging for leaders. Leaders must deal with their own reactions, while they successfully usher staff through a challenging experience or situation. Leaders need to know that taking care of themselves is not only good for them personally, but also sets a great example for employees.

A leader who can acknowledge a personal sense of loss or other honest reactions, while also demonstrating optimism moving forward, will be the most effective.

As always, communication is an essential part of any transition. And, don’t be afraid to reach out for resources, such as an employee assistance program.

Insights Health Care is brought to you by UPMC Health Plan

How to encourage medication adherence to decrease health costs

Chronis Manolis, RPh, vice president of pharmacy, UPMC Health Plan

Chronis Manolis, RPh, vice president of pharmacy, UPMC Health Plan

It was the late C. Everett Koop, a former U.S. surgeon general, who once famously said: “Drugs don’t work in patients who don’t take them.” That’s a simple way to look at a costly and complex problem — medication non-adherence — where the failure to take drugs on time in the dosages prescribed is both dangerous for patients and costly to the health care system.

“There are a number of reasons that people either don’t take their medication or stop taking it before they should,” says Chronis Manolis, RPh, vice president of pharmacy for UPMC Health Plan. “But what it often comes down to is a lack of understanding of the disease and a lack of respect for the condition.”

Smart Business spoke with Manolis about the problem of medication non-adherence and the ways it can be addressed.

What does medication non-adherence cost?

This problem impacts the cost of health care in many ways. According to the Express Scripts Drug Trend Report, $329 billion was spent on avoidable medical and pharmacy expenses as a result of patients not being adherent to medication treatments. Approximately 50 percent of patients do not take their medication as prescribed, which results in increases in the overall cost of treating chronic conditions and increases the number of hospitalizations and emergency department visits.

Why is medication non-adherence a persistent problem?

Clearly, there are a number of reasons why people may not take their medicine as directed by their physician. Consider, for example, people who have asymptomatic conditions such as high blood pressure, cholesterol disease and Type 2 diabetes. For them, taking medication may have no immediate effect on the way they feel. And, when medicine does not make you feel better, some don’t understand why they need to take it. As a consequence, many do not.

What are other factors that contribute to medication non-adherence?

Well, first, there’s the cost of the prescription. If there’s no generic available, it can be expensive, and a patient may simply choose not to purchase it. Then, there’s forgetfulness, which is a factor for older patients, but also for others as well. Some patients may avoid taking medicine because they fear the possible side effects. Others may not take it because they do not believe that the medication is truly effective.

But, what is often the underlying cause is a basic lack of understanding of their condition. Many patients do not realize they are taking medicine now in order to stay healthy in the years to come and to avoid a more serious condition 10, 20 or 30 years later when it will be too late to treat it with medication. For some, that’s a hard concept to grasp.

What kinds of solutions would help promote medication adherence?

Solving the problem of medication non-adherence is complex because there is no ‘one size fits all’ solution. A comprehensive, multi-pronged solution is needed to improve medication adherence.

These include promoting the need for more conversation between physicians and patients concerning the importance of medication in the overall treatment plan. There also needs to be a way to involve pharmacists more. Pharmacists are uniquely positioned to reinforce the message regarding the importance of medication. This can include encouraging patients to use their medication as prescribed and asking patients if they understand why they are taking a drug and if they understand the condition that it’s being used for.

Health plans can play a role as well because they can determine if patients are refilling their prescriptions in a timely manner. Health plan pharmacists can reach out to non-adherent patients and provide customized solutions and tools for patients to improve adherence. Additionally, health plan pharmacists can help triage specific patient adherence issues to other members of the health plan’s team including care managers and health coaches. For example, if cost is a factor, often less expensive generics are available. If forgetfulness is a problem, pillboxes or enrolling in refill reminder programs could work. Or, finding a substitute for the medication or changing dosing and/or frequency of the medication can eliminate side effects.

Chronis Manolis, RPh, is a vice president of pharmacy at UPMC Health Plan. Reach him at (412) 454-7642 or [email protected]

Save the date: Join UPMC WorkPartners for an upcoming webinar, “Best Practices for Return-to-Work,” at 10 a.m. Aug. 6. To register, contact Lauren Formato at [email protected] or (412) 454-8838.

Insights Health Care is brought to you by UPMC Health Plan

How postponing the employer mandate impacts your business

Mark Haegele, Director, Sales and Account Management, HealthLink

Mark Haegele, Director, Sales and Account Management, HealthLink

When the news came out July 2 that the Affordable Care Act (ACA) employer mandate — the enforcement of the shared responsibility requirement — would be postponed until 2015, you may have felt relief. But for many large-group employers, it’s not so simple.

“This is not a reason to put your head back in the sand,” says Mark Haegele, director of sales and account management at HealthLink. “Keep your eyes open. See what’s going on. Run some cost benefit analyses of different scenarios of offering different levels of coverage, or not offering. The bulk of the health care reform law is still being implemented on Jan. 1, 2014.”

In fact, Haegele says in some instances it may make sense to follow the employer mandate now, as waiting until 2015 could cause certain problems downstream.

Smart Business spoke with Haegele about what this delay means for business owners and their employees.

What was delayed until January 2015?

The Obama administration announced a one-year delay of the requirement that insurance companies and employers report certain information about health insurance coverage offered to individuals and employees, as well as the employer mandate.

It doesn’t change anything relating to the community rating rules, the individual mandate, the $8 billion sector tax, etc. These provisions are causing employers to explore self-funding, and all are still in play for January.

In what scenario does waiting to follow the employer mandate in 2015 create problems?

Large employers — those with 50 or more employees, according to the legislation — with employees who work 30 to 39 hours who don’t receive insurance face a unique situation. These employers were expecting to either pay a penalty or the need to offer some form of coverage. Many contemplated offering minimum essential coverage plans, or skinny bones plans, that just cover prevention and wellness — no hospitalization.

Let’s say an employer has 300 employees who work 30 to 39 hours and receive no benefits, and with the delay the company doesn’t plan to offer any until 2015. These employees still must have insurance coverage to meet next year’s individual mandate.

Many also are eligible for sliding-scale subsidies on the new health care exchanges — those with an income level 400 percent or lower than the federal poverty level. In 2013, that qualifies any family of four with an annual income of less than $94,200, or $45,960 for an individual.

Fast forward to 2015, a portion of the 300 employees have gone on the exchange and gotten insurance with subsidies. Now, you want to provide pared-down benefits to avoid the employer mandate penalties, which basically strips the employees of their subsidy, possibly increasing their insurance costs and/or decreasing their coverage. This might make it worthwhile to price out minimum essential benefit plans for 2014. Otherwise, employees may believe you did this to them, causing retention problems.

What other concerns does the delay raise?

More Americans will be accessing federal subsidies for health insurance, but the Internal Revenue Service (IRS) won’t be collecting employer mandate penalty revenue, as originally projected. With less money coming in and more going out, it may impact the ACA’s sustainability.

Originally, the ACA required insurance companies and employers to send an informational return to, for example, the IRS. This was meant to help enforce the individual mandate by offering a secondary source about whether individuals are covered by health insurance. With the delay until 2015, there is no way to match up the employer informational returns with the individual tax returns, which may make the individual mandate more difficult to enforce.

So, what are some next steps for business owners?

In addition to considering whether it’s worth offering coverage even though the penalties won’t start until 2015, you still need to implement complicated procedures that measure how many hours variable employees work on average. Companies need to work on their approach even in 2013, as transitional relief going into 2015 is more unlikely after a one-year delay. You’ll want to get it right the first time.

Mark Haegele is director of sales and account management at HealthLink. Reach him at (314) 753-2100 or [email protected]

Website: Visit to learn more about transparency and other key health care business trends.

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How the Affordable Care Act changes will affect employers

Marty Hauser, CEO, SummaCare, Inc.

Marty Hauser, CEO, SummaCare, Inc.

With so many provisions and mandates under the Affordable Care Act (ACA), it is not surprising some things have changed or been delayed along the way.

In fact, on July 5 the Obama administration released a 606-page document with final regulations on some of the ACA’s key provisions and mandates. In addition to providing new details about how the health insurance marketplaces will operate beginning Oct. 1, the document included changes that will impact the way employers shop for insurance.

Separately, on July 2, the U.S. Treasury issued guidance delaying the penalties to be imposed on large employers that fail to provide coverage to full-time workers and also reporting requirements applicable to insurers and self-insured businesses.

“When you are looking at changes impacting the health care delivery system in this country — including the way health insurance companies do business — delays and changes are expected,” says Marty Hauser, CEO of SummaCare, Inc. “The best thing employers and individuals can do is to stay informed and make the best decisions possible when it comes time to shop for a benefit plan.”

Smart Business spoke to Hauser about some of these changes and delays and what they mean for employers.

What are some ACA mandates that have been delayed that directly affect employers?

Components of the employer mandate have been delayed until 2015 to give employers more time to prepare for changes and requirements. The mandate, often referred to as ‘pay or play,’ requires employers with 51 or more employees to offer health insurance or risk paying a penalty. The delay of the mandate’s penalty portion gives employers an additional year to consider their options for offering insurance.

While some people argue that the delay in penalties effectively delays the entire mandate, it’s important to note that the mandate for large group employers to offer insurance still exists, but with no penalty for not complying. It is in the employer’s best interest to work with their broker, benefits consultant or insurer in an effort to comply with the law and figure out the best solution next year and in preparation for 2015.

At the time of this printing, this delay in the employer mandate does not change the individual mandate, effective Jan. 1, 2014.

A delay impacting small employers (with up to 50 employees) has also occurred related to the Small Business Health Options Program (SHOP). The functionality enabling employers to offer employees a variety of qualified health plans (QHPs) from different carriers has been delayed until 2015. This means that in 2014, small group employers may only offer one QHP to their employees shopping through the marketplace in an effort to give the exchange additional time to prepare.

It’s also important to mention that the SHOP is available to employers with up to 50 employees in 2014 and 2015, and expands to include employers with up to 100 employees in 2016.

What should employers keep in mind as they see marketing campaigns about the changes that become effective next year?

First and foremost, employers should work with their broker, benefits consultant, or insurer to help determine what mandates and provisions of the ACA apply in 2014 and beyond, in order to make the best benefits decisions for their employees and budget. They should also be prepared to receive and answer questions from employees regarding coverage in the coming year.

Additionally, since marketplaces open Oct. 1, 2013, for 2014 effective dates and employers are required to notify employees of the availability of the health insurance marketplace by the same date (Oct. 1), employees will likely be looking to their employer for guidance on coverage options and want to know what their employer plans to do by way of offering benefits.  Employers should be ready to educate their employees on how the new laws will or will not affect them and their benefits.

It’s also important to remember that although the penalty portion of the employer mandate has been delayed, there are ACA requirements employers must still meet, including reporting and payments, marketplace notification, distribution of Summary Benefits and Coverage documents upon renewal or enrollment, and distribution of rebates, when applicable.

Marty Hauser is CEO at SummaCare, Inc. Reach him at [email protected]

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Insights Health Care is brought to you by SummaCare, Inc.