The Affordable Care Act on Trial Again in King v. Burwell

bcbs lawsuitBy: Jackie Bain

The Affordable Care Act is heading back to the Supreme Court this Spring.  The issue presented to the Supreme Court on this occasion is whether the IRS is authorized promulgate regulations to extend tax credit subsidies for coverage purchased through Federal Government’s Health Care Exchange.

The Affordable Care Act allows individuals who purchased health coverage through State-established Health Care Exchanges to subsidize a portion of that coverage through the form of refundable tax credits.  The United States treasury directly pays each eligible taxpayer to offset the cost of the taxpayer’s insurance premium.  However, a majority of States (including Florida) have elected not to establish their own Health Care Exchanges.  In order to provide coverage to persons in these States, the Federal Government set up its own Health Care Exchange marketplace. Continue reading

Balance Billing Revisited

bonus calculationBy: Karina Gonzalez

Balance billing happens when a provider collects from a patient the difference between the provider’s total billed charge for the service and  the allowed amount  paid by an HMO or insurer for the service.  A provider’s collection of  a deductible, co-payment or co-insurance from a patient is not considered balance billing.

When an HMO pays a provider’s service it is generally  paying the amount it is required to pay pursuant to its contract with a member. Reimbursement  is not generally based on the provider’s billed charge.  HMO and insurers calculate the allowed amount based on what they consider to be a usual, customary and reasonable charge for the particular service. Continue reading