Healthcare

We have a crisis in American Healthcare.  The most critical component is the Primary Care Physician.  Decades of cuts to physician internship training hit an all-time low about 20 years ago, and have never recovered.  The economy was booming and Congress felt primary care doctors would find a way. 

Primary Care in Health Care

We have a crisis in American Healthcare. The most critical component is the Primary Care Physician. Decades of cuts to physician internship and resident training hit an all-time low about 20 years ago, and have never recovered. The economy was booming and Congress felt primary care doctors would find a way.
Healthcare recognized this shortage starting in the late 1960s after we won the space race. However, surveys have indicated about 25% of first line professionals, such as nurses, left the occupation due to management practices. Large hospital lobbying groups pressured Congress to allow more imported doctors and nurses under a revised State Department visa program called H-1B.

Countries that have severe healthcare personnel shortages are being depleted and necessitating higher levels of aide when a health crisis arises. Because countries do not have comparable schools, many of these H-1B doctors and nurses have to go through additional training and certification to practice in the U.S.A. Because we have many that also obtain citizenship and have pledged allegiance to their new country, they are to be congratulated.

As an educator and counselor, too many talented natural born and naturalized citizens have not fully enjoyed the American Dream because of non-investment. Medical school is expensive and these same colleges limit enrollment. Additionally, many graduating doctors cannot find hospitals for residency training. Some private alternative schools are less expensive and have been contracted by the few state grants to help offset the PCP shortages. 

There are many American candidates that have the attributes to become physicians and lack resources.

1) Ascending Career Solutions Group, Inc. believes in partnerships, without politics, and paying it forward.

2) Graduates would have to complete all requirements of becoming a licensed physician.

3) Doctors would have to dedicate themselves to Primary Care for at least 10 years.

4) Candidates would have scholarships paid in exchange for contractual service.

5) A percent of income back to the organization to help others in the pipeline. 

6) All graduating doctors would have residences.

7) The same holds true for nurses. Education for these critical direct care professionals are also in need. Many of whom are referenced in the above leaving statistic.

8) It is not unusual to have $250K in training for traditional medical schools. An Arizona grant of $7million about 2004 was to train 55 primary care doctors. The State’s only medical university said that was enough for one year. A private school accepted it for four years of medical school.


Hospitals in Healthcare

Hospitals have a tremendous responsibility in our communities. Hospitals have regulations in place because YOUR life depends on the quality of care offered at the institution that is caring for you.

Unfortunately, many hospitals comply but have outbreaks of disease that can be controlled by better practices. Because doctor training is not considered a major drive, it is often discounted by major chains.

For the difference that the ACS Group was in line to receive in loans in 2006, and the penalty a major bank paid for its practices, a hospital can be built that employs best practices and training our critically needed primary care physicians.

Good practices are not always found in large entrenched operations. There are smaller facilities that can be brought up to scale with a clean slate. Practices that reduce recurring admissions are not always practiced by large organizations.


Healthcare & Insurance FAQ

The following is a guide to different health insurance products and generally what they cover.
It is not comprehensive by any means and meant as a guide to answer most of the commonly
asked questions about health insurance.


For about the past 20 years, more and more plans have been customized for employers.
There are several hundred plans on the market and it is highly recommended each person ask
their respective employers’ benefits department, insurance company representative or agent
for what is and is not covered. This is especially true of upcoming tests and procedures.


Your relative that worked under a union health plan that paid everything, is not going to be
the same as your plan working for a private or public agency employer. Most organizations
are moving toward more individual responsibility with higher premiums, higher co-insurance
and or deductibles and higher annual caps.


The ideal insurance would be integrated within a healthcare system that alleviated the need to
constantly call about services and payments. There have been experiments in this area but as
yet not an integrated system.

a. Health Insurance is an assignment of your healthcare financial liability to another party.
b. In this case, you are paying a premium for an insurance company to assume part of the financial risk for your healthcare.

a. This is the percent of financial liability for medical expenses the insurance company will pay and what you, the patient, will pay.
b. In the example: The Insurance company has signed a contract that says they will pay up to 70% of the negotiated fees with healthcare providers and facilities (hospitals, labs, imaging, therapy, etc.)
c. In the example: The patient is responsible for 30% of the negotiated fees for their healthcare. This is called Co-insurance.
d. Traditional plans had an 80/20 split.
e. This is no longer the case as the divisions can be from 60/40 to 90/10.
f. Co-insurance is the fixed percentage amount the patient is responsible for during the benefit year. A benefit year usually begins January 1 and ends December 31.
g. The co-insurance maximum can be up to the deductible or annual cap each benefit year.
h. Are Co-insurance and Deductible the same thing? No. b

a. Insurance companies set fees for services, tests and supplies covering:

i. Primary Care Providers (PCP)

ii. Specialists (Cardiologists, Podiatrists, Optometric/Ophthalmic, Gastroenterologists, Epidemiologists, etc.)
iii. Lab facilities
iv. Imaging Facilities (X-ray, MRI, CT, Sonograms)
v. Pharmaceuticals
vi. Therapy (Physical Therapies, Occupational Therapies, etc.)
vii. May include other services such as Chiropractic and Acupuncture.
viii. Eyewear for frames, lenses, contacts.
ix. Hearing aids
x. Mental Health
xi. Durable Medical Equipment (Oxygen tanks or concentrators, special shoes,
prosthetics – that include specific replacement devices for joints.)
xii. These are the most common items found. As healthcare is a complex area, there
are many items that may or may not be covered.

a. A deductible is a minimum that a patient needs to pay before the insurance company starts to pay.
b. Co-payments can count toward the annual deductible amount.
c. A deductible can also be a cap on annual expenses that limits the liability of the patient. Be sure it is understood whether the deductible is different than an annual cap.
d. A plan may have a $500 deductible and a $5000 annual cap. This means you will have at least $500 outlay for co-pays at the doctor, pharmacy and other services until the insurance pays the prescribed insurance percent (the 70 in 70/30, 80 in 80/20, etc.) Then there is a $5000 cap on the amount the patient is responsible in the plan. However, there can be exclusions that can exceed this annual cap. Always check with your benefits administrator, healthcare company or other information person to see the limits of the plan.
e. A doctor visit for your primary care could be $0 to $30. This is a co-insurance payment. This is often referred to as co-pay.
f. A doctor visit to a specialist could be $50 to $75. This is also a co-insurance payment. This is also referred to as co-pay.
g. An annual deductible can include all services that are covered under the plan.
h. Deductibles are on an annual basis. Typically they reset each January 1 and end on December 31 of each year.

a. HSA stands for Health Savings Account. It is usually a fixed amount the insurance company or employer puts allows for health services each year.
b. Some plans have a rollover provision. Check with your Benefits Section or Agent on what is and is not covered.
c. There are some plans that allow patients to add or subtract amounts to their plans.
d. Some health plans have traditional Insurance/Co-Insurance rates and HSAs also.

e. Does it cover everything for my health? It will cover most areas of your healthcare up to the limits of the Account. There may not be the same negotiated pricing for services than a traditional healthcare plan.

a. In Network means the insurance company has negotiated more favorable rates with the medical providers, labs and other facilities.
b. You will pay no more than the contract co-pay or co-insurance specified in the contract.
c. Out-of-Network means you are allowed to see the provider or facility but will have to pay a higher rate above the Co-Insurance and or Co-pay listed in your contact.

Note:
Even if going to an In-Network provider or facility, it is always a good idea to put on the new patient paperwork: In-Network ONLY.

It is standard for providers and facilities to have a financial liability section that says you are responsible for any charges the insurance company may not cover.

Many providers and facilities use labs or contractors that are not covered (such as surgical specialists in hospitals and surgical centers) that are considered Out-Of-Network.

Even if not In-Network, they may be paid the standard Medicare rate and this payment may be sent to the patient. However, as many are contractors, they may be difficult to track down to pay. The facility, that services were provided within, will not take any responsibility for helping you find the person or their billing agent. This places the patient with a possible delinquent bill if the provider’s billing agent cannot be found before a delinquent period exists. 

Find a way to put In-Network ONLY on the record, even if putting it above your signature on an Electronic Pad. 

This can save you hundreds, if not thousands of dollars. 

It gives you leverage with the insurance company to advocate and contest your charges with this In-Network notation in place, as it puts the provider or facility on notice to use services, personnel and labs covered on your health plan.

a. The above plans mentioned are what are called commercial plans.
b. An employee of a commercial plan does not receive an individual policy but a certificate of coverage from the company. The contract is between the employer and the insurance carrier.
c. Commercial plans are usually contracted through major healthcare providers. There are traditionally the “Big 5” (United, Aetna, Cigna, Humana, BCBS) and as well as an employee owned and a mutual company. Mutual of Omaha is also entering the market.
d. The company can pay an insurance carrier a fee based on the coverages desired, to match their company’s demographics.

    i. Demographics are the employee profiles in relation to health needs. An example              would be a female population out of prime child bearing years would not need                    obstetrics as much.
    ii. Needs not in a general demand would probably be available as a Rider                                (an additional charge added to the period health insurance payment.)

        e. A company may also be self-insured and have an insurance company administer            the plan.
        f. There are also insurance companies that have TPAs (Third Part Administrators –               often part of an insurance company) to Administer a plan that has been contracted             with a company.
        g. This also applies to HSAs or HMAs.

a. The above plans mentioned are what are called commercial plans.
b. An employee of a commercial plan does not receive an individual policy but a certificate of coverage from the company. The contract is between the employer and the insurance carrier.
c. Commercial plans are usually contracted through major healthcare providers. There are traditionally the “Big 5” (United, Aetna, Cigna, Humana, BCBS) and as well as an employee owned and a mutual company. Mutual of Omaha is also entering the market.
d. The company can pay an insurance carrier a fee based on the coverages desired, to match their company’s demographics.

    i. Demographics are the employee profiles in relation to health needs. An example              would be a female population out of prime child bearing years would not need                    obstetrics as much.
    ii. Needs not in a general demand would probably be available as a Rider                                (an additional charge added to the period health insurance payment.)

        e. A company may also be self-insured and have an insurance company administer            the plan.
        f. There are also insurance companies that have TPAs (Third Part Administrators –               often part of an insurance company) to Administer a plan that has been contracted             with a company.
        g. This also applies to HSAs or HMAs.

a. The official title – Patient Protection and Affordable Care Act is found in P.L. 111–148, Approved March 23, 2010 (124 Stat. 782) – Also referred to as the PPACA
b. Its original intent was to make a “Medicare for all plan” that was to be patterned after the healthcare plan for seniors that are 65 or older.
    i. One of Medicare’s features is people with pre-existing conditions cannot be denied
    coverage.
    ii. The only medical question that has to be answered is whether a person as ESRD (End Stage Renal Disease). This condition, as well as others that can appear over the course of a person’s health, have special plans that are specific to the condition.
    iii. Preexisting conditions do matter for persons on Medicare that purchase a
    Medigap Supplement. After the initial six (6) month no-questions-allowed period, an
    new insurer has the right to have the patient go through underwriting to be accepted
    for a Medigap policy for the new company.

c. The ACA eliminated any exclusions and any underwriting for coverage.
d. Medicare and Medicaid come under the regulation of the CMS (Centers for Medicare and Medicaid Services) and is part of the HHS (Health and Human Services). HHS is also a Cabinet position.
e. ACA is part of the Social Security Act and a part of Medicaid
    i. Medicaid is the state and federal program medical insurance for low income and
    indigent populations.
    ii. States have an option to use the Federal guidelines or make an equivalent system            that meets the Federal Requirements.
    iii. States can also call the program something other than Medicaid. Examples:
        1. Arizona calls it AHCCCS (Arizona Health Care Cost Containment System)
        2. California calls it MediCal
    iv. ACA required states to expand Medicaid to be eligible
    v. Eighteen States (18) did not elect the expansion
 f. It’s payment structure is based on the FPL (Federal Poverty Level) See them here at:
 https://aspe.hhs.gov/poverty-guidelines
 g. Signing up is through the Healthcare.gov website or through a licensed agent                 that has passed all the required HHS (Health and Human Services) certifications.

    h. Healthcare Navigators or Advocates are not allowed to assist you directly in                       signing up as only state licensed agent has that authority. The Agent must enter                 their license or broker number.

             i. Different states can have different procedures covered. Example: One state may                 cover a surgery that is considered elective that another state does not consider                     elective.
       j. Many people have had any and all increases in pay going directly to healthcare                   premiums, as it bumped their income into a higher pay FPL bracket.
      k. It allowed employers to discharge spouses from their health plans if they were                  working at another company or had healthcare through their own employer.
          i. Many hundreds of thousands of spouses lost coverage under this provision
          ii. UPS alone discharged over 33,000 spouses from its health plans.
          iii. Many education districts and colleges reduced their healthcare expenses by                     hundreds and thousands through reclassification of positions to part-time.
      l. There were penalties for employers and individuals for not having insurance.
     m. These penalties have recently been lifted.
     n. The ACA was dropped by many providers as it paid only about one-third (33.3%) of           the commercial rate. This is the same rate as Medicaid reimburses.
     o. Medicare pays about 50% of the commercial rate.
     p. The PPACA impacted the individual healthcare market by eliminating about two-           thirds of the brokers that sold individual plans.
     q. In the first quarter of 2017, all providers removed information about individual plans.
    Insurance companies still offering individual plans did not offer any information and          needed specific information, that only existing agents or brokers writing these plans          had knowledge.
    r. Commissions for individual health policies ceased to be paid in February of 2016.
    s. Agents that are HHS certified for the ACA only receive about $12/month for each              person signed to manage the account and answer questions. Often, the agents are            better informed than the call centers that a person has to use if they signed up by                themselves online.
    t. Agents only receive the fee for the weeks that enrollment is allowed.
    u. After the annual enrollment period, for which no fee is now authorized, a person              may be asked to pay a small fee for assistance from an agent.

a. Large errors are being addressed here, that usually are in the many hundreds or thousands of dollars.
b. It is recommended that a line by line explanation be given by the provider.
c. If the provider, such as a surgeon, does not provide an explanation, then the insurance
company can provide interpretation of the charges, as they relate to the services rendered and the coverage in your policy.
d. It is sometimes a 50/50 toss up on whether a charge is authorized.
    i. An insurance representative may say no, so as to save the company money.
    ii. When later challenged, after speaking to the billing representative of the provider,          the insurance company may then change their mind and say the charge is authorized      and patient has to pay the co-insurance.

    iii. Conflicts are usually the result of interpretation of the terms of the policy or benefits      package.

e. If hospital charges are the concern, you have the right to have an administrator go over the bill line-by-line in layman terms. This may take an appointment to do so at their location.
f. It is suggested that your insurance company be contacted and you ask for an advocate to review your bill. As your insurance company is paying the biggest part of the bill, it is in their interest to see they are paying only what is authorized. They are also the “experts” for the terminology and coverage authorized.
g. What if you disagree with what you hear from the insurance company or they do not assist you?
    i. Contact your state’s Department of Insurance. Your state may call it an Insurance              Commission.
    ii. Address your concern in writing to the Department of Insurance.
    iii. There are usually very few investigators and can only act upon written complaints.
    iv. Companies have their rating affected by how many complaints that are placed
    with your State’s Insurance Department. It is an accountability area that is used to set
    rates, as well as issuing how many stars a company gets as a whole and on specific
    plans.
    v. Be specific on what the complaint regards. Billing, Services, Advocacy, etc.
    vi. Have dates and who you talked to for the problem encountered.
    vii. Writing your complaint enables the Insurance Investigator to take action. A
    phone call most often does not.
    viii. Writing your complaint starts resolution timelines for both the Insurance
    Investigator and the Insurance Carrier. (Many states have similar timelines for utilities,
    and the governing agency, that is usually a Corporation Commission.)
    ix. You may also have an avenue of complaint through your state’s AG office
    (Attorney General). It is your state’s highest law enforcement body.

a. Gap Insurance is a separate policy, and premium, that can take many forms:
    i. Gap Insurance can pay for the co-pays and deductibles of the main insurance.
    ii. Gap Insurance can also pick up part of the co-insurance, up to the specified dollar
    amount.
    iii. Gap Insurance can act like a disability policy and cover monthly expenses
    through a predetermined cash amount.
    iv. Gap Insurance can help with hospital expense deductibles and co-insurance of a
    fixed daily amount.
    v. Gap Insurance can also be used for emergency transportation (ambulance).
        b. As aforementioned, this insurance has a separate premium that must be paid.
        c. Some individuals that have high deductible plans find Gap Insurance economical            in to offset the high deductibles and or co-insurance payments.

a. Many pharmacies and labs have cash payment options that may be less than paying the deductibles of the insurance plan. Ask first before using your insurance.
b. Why would you pay $15 with co-pay for a prescription that is $9.50 cash?
c. There are plans online that may save you money, such as GoodRx, Drugs.com, EasyDrugCard, and other discount plans. These prices for respective medications often change, therefore, it is usually best to have the latest coupon or phone app pricing for the pharmacy. Labs also have cash pay pricing that is often less. Many doctor offices now advise of cash pay labs when patients have limited or no insurance for needed tests. Major labs now have cash pricing to avoid losing business to the dedicated cash labs.
d. Be aware of the tiered system that many companies use for prescription drugs.
    i. Tier I – Preferred Generic (The most favorably priced and negotiated.)
    ii. Tier II – Generic – Not name brand but may be recently released generics from name
    brands that are only slightly lower than the previous branded products.
    iii. Tier III – Preferred Name Brands – Sometimes there is not any generics for a
    prescription treatment and only the Name Brand is available. Here, the most favorable
    pricing is chosen for among the name brands.
    iv. Specialty Drugs – These are the most expensive and typically used when other
    lower tier drugs do not work.
    v. Your doctor is the primary source for drug treatment therapies.
e. Eyeglass coverage is another area. You may use your vision coverage for the regular glasses and frames, but use a cash special for your sunglasses.

a. Under IRS Regulations they are deductible if the expenses exceed 7.5% of your Adjusted Gross Income (AGI).
b. Deductions are entered on Form 1040, Schedule A.
c. Medical deductions can be found in IRS Publication 502 below:
d. https://www.irs.gov/forms-pubs/about-publication-502
e. With the new tax law raising the annual personal deductions, this may alter the allowable healthcare deductions.
f. Consult your tax professional.
g. Choosing a tax professional is an important decision.
    i. Make sure you know the qualifications and availability of who is preparing your taxes.
    ii. There have been surveys that reveal tax professionals that do taxes year-round have
    less errors and usually less expensive overall than seasonal preparers.
    iii. Here is a link below that can help in the process.
    iv. https://www.irs.gov/tax-professionals/choosing-a-tax-professional

Learn more about our organization

Get Involved

Contact Us

ACS Group, Inc.
2747 E. University Dr. #2487 Mesa, AZ 85214
(480) 830-0306 P
(480) 830-0600 F
info@acsgroupinc.org