Anthem Blue Cross Drops Cedars-Sinai, UCLA From Health Plan
Bob Herman
Becker Hospital Review
September 24, 2012
Anthem Blue Cross in California is shutting out two of the largest healthcare providers in the Los Angeles area — Cedars-Sinai Medical Center and UCLA Health System — from one of its health plans because the health systems are "too expensive," according to a Los Angeles Times report.
All physicians affiliated with Cedars-Sinai and UCLA will be eliminated from Anthem's Select health plan, effective Jan. 1, which is offered to roughly 60,000 employees and dependents in Los Angeles. The city said Anthem's plan would save $7.6 million in annual premiums. It is expected that roughly 2,200 city employees and family members will lose in-network access to their physicians, according to the report.
In response to the move, the health systems said their high costs are associated with their medical research and innovative treatments that "benefit the entire community," according to the report. Cedars-Sinai and UCLA also said Anthem's maneuver will only shift costs onto those who still receive care at the facilities.
Showing posts with label Blue Cross health insurance. Show all posts
Showing posts with label Blue Cross health insurance. Show all posts
Monday, November 19, 2012
Friday, April 15, 2011
Insurer denied needed medical tests, Senate finds
Insurer denied needed medical tests, Senate finds
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16
“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”
“Alright, let me put you back on hold,” came the reply.
Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.
A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.
The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.
According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”
“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
Advertise | AdChoices
Advertise | AdChoices
Advertise | AdChoices
Michael Fields was one of those found to have been wrongly denied.
Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds
The next day Fields had an emergency quadruple heart bypass.
“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”
When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.
Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.
Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.
Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.
In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.
MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.
According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.
Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
Advertise | AdChoices
Advertise | AdChoices
Advertise | AdChoices
Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.
In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.
“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”
Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.
In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.
MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."
1.
Only on msnbc.com
1. Ryan budget plan passes House; only 4 GOP no votes
2. 'Creepy' new software is a stalker's dream
3. Cosmic Log: Is this the age of megaquakes?
4. Why watching 'The Office' makes us cringe
5. 10 deadly do-it-yourself gadgets
6. Americans moving near nuclear reactors
7. Wacky minds behind Taiwan's viral videos
Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)
Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.
“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”
He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16
“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”
“Alright, let me put you back on hold,” came the reply.
Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.
A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.
The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.
According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”
“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
Advertise | AdChoices
Advertise | AdChoices
Advertise | AdChoices
Michael Fields was one of those found to have been wrongly denied.
Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds
The next day Fields had an emergency quadruple heart bypass.
“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”
When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.
Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.
Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.
Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.
In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.
MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.
According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.
Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
Advertise | AdChoices
Advertise | AdChoices
Advertise | AdChoices
Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.
In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.
“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”
Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.
In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.
MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."
1.
Only on msnbc.com
1. Ryan budget plan passes House; only 4 GOP no votes
2. 'Creepy' new software is a stalker's dream
3. Cosmic Log: Is this the age of megaquakes?
4. Why watching 'The Office' makes us cringe
5. 10 deadly do-it-yourself gadgets
6. Americans moving near nuclear reactors
7. Wacky minds behind Taiwan's viral videos
Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)
Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.
“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”
He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”
Monday, February 8, 2010
Obama official 'very disturbed' by Anthem Blue Cross rate hikes
UPDATE: DEMOCRATS ACHIEVE A SMALL STEP TOWARD HEALTH CARE REFORM
Anthem Blue Cross backpedals on raising rates
Anthem to delay insurance rate hike amid criticism
By LINDA A. JOHNSON (AP)
Feb. 13, 2010
Health insurer Anthem Blue Cross will postpone its much-criticized plan to raise rates for some California residents who buy insurance on their own, after reaching a deal Saturday with state regulators.
Anthem's planned rate hike, which the state estimates would affect about 700,000 customers, averaged 25 percent and would have been as high as 39 percent for some.
Anthem Blue Cross of California, based in Thousand Oaks, agreed to postpone the increase from March 1 until May 1 so California could have outside experts review the company's complex and detailed plan filing, including data on the medical costs it expects to incur...
In this Feb. 4, 2010 file photo, Health and Human Services Secretary Kathleen Sebelius testifies on Capitol Hill in Washington. washingtonpost.com
Blue Cross is obviously feeling very powerful. I imagine it will spend the new revenues on campaign ads to defeat universal health care. Hmmm. I'm trying to think of a more arrogant and smug act of contempt for the people who pour their hard-earned money into Blue Cross.
Obama official 'very disturbed' by Anthem Blue Cross rate hikes
By Duke Helfand
LA Times
February 9, 2010
California insurance regulators asked Anthem Blue Cross to delay controversial rate increases of as much as 39% for individual policies, hikes that have triggered widespread criticism from subscribers and brokers -- and now from the federal government.
In a rare step, the Obama administration called on California's largest for-profit insurer to justify its rate hikes, saying the increases were alarming at a time when subscribers face skyrocketing healthcare costs...
HHS secretary asks insurer to justify rate hike
By SHAYA TAYEFE MOHAJER
The Associated Press
February 8, 2010
LOS ANGELES -- The Obama administration on Monday asked California's largest for-profit health insurer to justify plans to hike customers' premiums by as much as 39 percent, a move that could affect some 800,000 people.
In a letter to the president of Anthem Blue Cross, Health and Human Services Secretary Kathleen Sebelius said she was disturbed to learn of the planned increases, calling them "extraordinary."...
WellPoint sees profit grow eightfold in fourth quarter
The Los Angeles Times, January 28, 2010
CA Health Insurance Companies Pay Fine for Rescinding Health ...
21 Jan 2010 by admin
The recent legal ruling is a result of a lawsuit against health giant Anthem Blue Cross of California. Prosecutors argued that Anthem violated state law by selling health plan members the promise of health insurance, but then later ... “ This puts new cops on the beat,” said Bryan Liang, director of the Institute of Health Law Studies at California Western School of Law in San Diego. “Lots of stuff in the standard operating practices of health plans is going to be affected ...
chocobaby.luv.ph/
Patient Sues Anthem Blue Cross Over Liver Transplant - Consumer ...
7 Oct 2009
Ephram Nehme was gravely ill when Anthem Blue Cross of California agreed to pay for a liver transplant his physician said he needed to survive. Then, his condition went downhill fast. The news from his doctor was bad. ... tremendously important issue because most people aren't savvy enough about how to work this system, and it is totally stacked against them," said Bryan Liang, director of the Institute of Health Law Studies at California Western Law School in San Diego. ...
Consumer Watchdog Updates
Anthem Blue Cross backpedals on raising rates
Anthem to delay insurance rate hike amid criticism
By LINDA A. JOHNSON (AP)
Feb. 13, 2010
Health insurer Anthem Blue Cross will postpone its much-criticized plan to raise rates for some California residents who buy insurance on their own, after reaching a deal Saturday with state regulators.
Anthem's planned rate hike, which the state estimates would affect about 700,000 customers, averaged 25 percent and would have been as high as 39 percent for some.
Anthem Blue Cross of California, based in Thousand Oaks, agreed to postpone the increase from March 1 until May 1 so California could have outside experts review the company's complex and detailed plan filing, including data on the medical costs it expects to incur...
In this Feb. 4, 2010 file photo, Health and Human Services Secretary Kathleen Sebelius testifies on Capitol Hill in Washington. washingtonpost.com Blue Cross is obviously feeling very powerful. I imagine it will spend the new revenues on campaign ads to defeat universal health care. Hmmm. I'm trying to think of a more arrogant and smug act of contempt for the people who pour their hard-earned money into Blue Cross.
Obama official 'very disturbed' by Anthem Blue Cross rate hikes
By Duke Helfand
LA Times
February 9, 2010
California insurance regulators asked Anthem Blue Cross to delay controversial rate increases of as much as 39% for individual policies, hikes that have triggered widespread criticism from subscribers and brokers -- and now from the federal government.
In a rare step, the Obama administration called on California's largest for-profit insurer to justify its rate hikes, saying the increases were alarming at a time when subscribers face skyrocketing healthcare costs...
HHS secretary asks insurer to justify rate hike
By SHAYA TAYEFE MOHAJER
The Associated Press
February 8, 2010
LOS ANGELES -- The Obama administration on Monday asked California's largest for-profit health insurer to justify plans to hike customers' premiums by as much as 39 percent, a move that could affect some 800,000 people.
In a letter to the president of Anthem Blue Cross, Health and Human Services Secretary Kathleen Sebelius said she was disturbed to learn of the planned increases, calling them "extraordinary."...
WellPoint sees profit grow eightfold in fourth quarter
The Los Angeles Times, January 28, 2010
CA Health Insurance Companies Pay Fine for Rescinding Health ...
21 Jan 2010 by admin
The recent legal ruling is a result of a lawsuit against health giant Anthem Blue Cross of California. Prosecutors argued that Anthem violated state law by selling health plan members the promise of health insurance, but then later ... “ This puts new cops on the beat,” said Bryan Liang, director of the Institute of Health Law Studies at California Western School of Law in San Diego. “Lots of stuff in the standard operating practices of health plans is going to be affected ...
chocobaby.luv.ph/
Patient Sues Anthem Blue Cross Over Liver Transplant - Consumer ...
7 Oct 2009
Ephram Nehme was gravely ill when Anthem Blue Cross of California agreed to pay for a liver transplant his physician said he needed to survive. Then, his condition went downhill fast. The news from his doctor was bad. ... tremendously important issue because most people aren't savvy enough about how to work this system, and it is totally stacked against them," said Bryan Liang, director of the Institute of Health Law Studies at California Western Law School in San Diego. ...
Consumer Watchdog Updates
Subscribe to:
Posts (Atom)