USC hospital sues Kaiser over nonpayment of bill; Kaiser also has contracts with UCLA

USC hospital sues Kaiser over nonpayment of bill
'It's usually the patient fighting to get transferred' from Kaiser, said attorney Scott Glovsky
USC says Kaiser didn't disclose that its patient had exhausted a $75,000 annual cap on insurance benefits
Stuart Pfeifer, Chad Terhune
Los Angeles Times
May 23, 2014

Two medical giants in Southern California are heading for a potentially bruising legal battle.

Keck Hospital of USC has sued Kaiser Permanente, accusing California's largest HMO of sending one of its patients to Keck for open-heart surgery and then refusing to pay the $544,000 hospital bill.

USC contends that Kaiser didn't disclose that its patient had already exhausted a $75,000 annual cap on insurance benefits when it asked Keck Hospital to perform the October 2013 surgery. Kaiser could have handled the procedure with its own surgeons but opted to transfer the patient to save money, Keck Hospital said in the lawsuit.

Kaiser declined to comment except to insist that USC knew about the limitations of the patient's insurance.

This legal battle between healthcare heavyweights highlights Kaiser's long-standing practice of using outside hospitals to see some patients who require more specialized care. It also provides a rare glimpse into the sometimes bitter disputes between health insurers and providers that are often handled behind closed doors.

Kaiser is both an insurer collecting premiums from customers and a medical provider treating them at Kaiser-run hospitals and physician offices. In some instances, Kaiser transfers patients to outside facilities for specialty care such as transplants, then covers the costs as any other insurer would.

In this case, Kaiser transferred the patient from the intensive care unit at its Los Angeles Medical Center to Keck Hospital knowing it would not cover the costs, USC said in the lawsuit, filed May 15 in Los Angeles County Superior Court.

The Kaiser representative who called Keck to arrange the surgery said the patient had active health coverage through Kaiser, the lawsuit said. With that assurance, USC authorized the surgery and treated the patient for 13 days at its hospital.

In December, Kaiser denied Keck Hospital's bill for the treatment, saying for the first time that the patient had exceeded the $75,000 cap on annual coverage, USC said. Those coverage limits were set by a state program Kaiser participates in for people who were denied coverage because of preexisting conditions.

Kaiser declined to discuss details of the lawsuit, but said in a statement, "We are confident that Keck's allegation that it was not informed about coverage limits is not accurate."

The lawsuit could tarnish a lengthy relationship between the healthcare giants. Keck, then known as USC University Hospital, and Kaiser first entered into an agreement in 1994 for the hospital to treat some Kaiser patients, with Kaiser paying the tab, USC said in the lawsuit.

Kaiser, a nonprofit based in Oakland, is California's largest HMO and one of the largest healthcare providers in the country. It reported $53.1 billion of operating revenue last year and $2.7 billion in net income.

Mark V. Pauly, a professor of healthcare management at the University of Pennsylvania's Wharton School, said a lack of communication about the patient's coverage appears to be at the center of the disagreement.

"It seems like somebody forgot to ask or somebody forgot to tell, which may be a sign of dysfunction in our healthcare system," Pauly said.

Scott Glovsky, a Pasadena attorney who represents other Kaiser patients suing the HMO over access to appropriate and timely care, said this latest hospital dispute is unusual in several ways.

Glovsky said Kaiser typically goes to extreme lengths to keep patients at its own facilities as part of its unique HMO model.

"It's usually the patient fighting to get transferred," he said. "If Kaiser authorized the treatment, they can't reverse course and later deny payment. It is not fair to a hospital to essentially dupe them into taking the patient."

Neither Kaiser nor USC would identify the patient, citing rules on medical privacy. Kaiser said the only coverage it offers with a $75,000 cap on annual benefits is part of California's high-risk pool, known as the Major Risk Medical Insurance Program.

For years, it has provided coverage to people with serious health problems who were previously rejected by insurers. There is a $750,000 cap on lifetime benefits in addition to the $75,000 annual limit.

New federal rules lifting most coverage limits don't apply to the state program.

Enrollment in the state high-risk pool has fallen by half to about 3,000 people since insurers are no longer permitted to reject applicants under the Affordable Care Act, according to Morgan Staines, chief counsel for the state program. The governor's latest budget proposal calls for closing the state program by the end of this year, Staines said.

For most consumers, the federal health law prevents insurers from setting lifetime coverage limits, and annual limits were phased out for most health plans starting this year. Health insurance policies in place before March 2010, when the health law was passed, are grandfathered and don't have to comply with rules on annual limits.

Keck Hospital is one of several medical centers with which Kaiser partners to supplement its care. For instance, it has sent patients to City of Hope for bone marrow transplants and used UCLA Medical Center for kidney transplants.

This 32-Year-Old Florida Woman Is Dead Because Her State Refused To Expand Medicai

Charlene Dill died because Florida Republicans refused to expand Medicaid that would have paid for her heart health care CREDIT: GoFundMe

This 32-Year-Old Florida Woman Is Dead Because Her State Refused To Expand Medicaid
By Tara Culp-Ressler
Think Progress
April 9, 2014

Charlene Dill, a 32-year-old mother of three, collapsed and died on a stranger’s floor at the end of March. She was at an appointment to try to sell a vacuum cleaner, one of the three part-time jobs that she worked to try to make ends meet for her family. Her death was a result of a documented heart condition — and it could have been prevented.

Dill was uninsured, and she went years without the care she needed to address her chronic conditions because she couldn’t afford it.

Under the health reform law, which seeks to expand coverage to millions of low-income Americans, Dill wasn’t supposed to lack insurance. She was supposed to have access to a public health plan through the law’s expansion of the Medicaid program. But Dill, a Florida resident, is one of the millions of Americans living in a state that has refused to accept Obamacare’s Medicaid expansion after the Supreme Court ruled this provision to be optional. Those low-income people have been left in a coverage gap, making too much income to qualify for a public Medicaid plan but too little income to qualify for the federal subsidies to buy a plan on Obamacare’s private exchanges.

Florida has one of the highest uninsurance rates in the nation, and is home to a disproportionately large number of residents who struggle to afford health services. Nonetheless, lawmakers have continued to resist accepting generous federal funds to expand Medicaid to an estimated 750,000 low-income Floridians like Dill.

Although Florida Gov. Rick Scott (R) initially indicated that he was in favor of accepting the funds for expansion, he’s since walked back that position. Meanwhile, Republicans in the legislature don’t even plan to schedule a vote to address Medicaid expansion during their current session, suggesting that the federal government won’t actually come through with the funding to support the policy.

Dill made about $9,000 annually by babysitting, cleaning houses, and selling vacuum cleaners. As the Orlando Weekly reports, she was optimistic about her coverage options under President Obama’s administration. She tried to sign up for Obamacare using the online calculator on HealthCare.gov, but quickly found out she fell within the coverage gap.

In the absence of health coverage, Dill’s best friend, Kathleen Voss Woolrich, occasionally turned to crowdfunding sites on the internet to raise the money Dill needed to pay for her heart medication. Last month, Woolrich crowdfunded to pay for Dill’s funeral.

In an emotional blog post published on the site Women on the Move at the end of last month, Woolrich blamed Florida politicians for her friend’s early death.

“You see the main argument Republicans use is that it’s some lazy person who needs Medicaid expansion. That those of us living without healthcare or dental care are lazy. But my friend, a single beautiful mother, worked three jobs,” Woolrich wrote. “I am burying my best friend because of the policies of the Republican Party. I am burying my best friend because had Medicaid expanded, her needs would have been met.”

And Dill won’t be the only one. A recent study conducted by Harvard researchers estimated that as many as 17,000 people will die directly as a result of their states refusing to expand Medicaid. In Florida, that translates to about six deaths like Dill’s every single day. This issue is exacerbated by the fact that the low-income residents in states that have resisted Medicaid expansion tend to have more health problems than the residents in other states.

Democratic officials in Florida have responded strongly to Woolrich’s story. Rep. Alan Grayson (D) — who told the Orlando Weekly that his colleaugues’ resistance to Medicaid expansion “has put the GOP’s appalling disregard for human life on full display” — entered Woolrich’s blog post into the Congressional record.

“I memorialized Charlene’s life and death in the Congressional Record, because the Republicans want to pretend that none of this is happening. That Charlene didn’t die as a result of their callous neglect — that no Floridians will die as a result of their willful refusal to expand Medicaid at no cost,” Grayson explained. “But I’m not going to let them forget. I’m not going to let them pretend. This is not a game; this is very real. This is life and death.”

Experts Reshape Treatment Guide for Cholesterol

Experts Reshape Treatment Guide for Cholesterol
By GINA KOLATA
New York Times
November 12, 2013

The nation’s leading heart organizations released new guidelines on Tuesday that will fundamentally reshape the use of cholesterol-lowering statin medicines, which are now prescribed for a quarter of Americans over 40. Patients on statins will no longer need to lower their cholesterol levels to specific numerical targets monitored by regular blood tests, as has been recommended for decades. Simply taking the right dose of a statin will be sufficient, the guidelines say.

The new approach divides people needing treatment into two broad risk categories. Those at high risk because, for example, they have diabetes or have had a heart attack should take a statin except in rare cases. People with extremely high levels of the harmful cholesterol known as LDL — 190 or higher — should also be prescribed statins. In the past, people in these categories would also have been told to get their LDL down to 70, something no longer required.

Everyone else should be considered for a statin if his or her risk of a heart attack or stroke in the next 10 years is at least 7.5 percent. Doctors are advised to use a new risk calculator that factors in blood pressure, age and total cholesterol levels, among other things.

“Now one in four Americans over 40 will be saying, ‘Should I be taking this anymore?' ” said Dr. Harlan M. Krumholz, a cardiologist and professor of medicine at Yale who was not on the guidelines committee...