Showing posts with label denial by insurance company. Show all posts
Showing posts with label denial by insurance company. Show all posts
Tuesday, July 10, 2012
Taking A Risk To Secure Health Insurance
Taking A Risk To Secure Health Insurance
By Randy Dotinga
KaiserHealthNews.org
Henry J. Kaiser Family Foundation
JUN 12, 2012
When it comes to medicine, I usually do as I'm told.
Take a pill? Sure. Blood test? Absolutely. Surgery? If you think so, doc.
But I've been acting against medical advice since January, and I'll keep on ignoring it until July. Let me explain.
Last January, I cancelled my existing, very expensive individual coverage through California's state-run high risk plan and became insurance-free to gain eligibility for the federal alternative.
That means that if I get a cancer diagnosis tomorrow, I'll end up with huge medical bills. I did this because I want to take advantage of the federal government's efforts to help people like me who have pre-existing conditions and no access to a group plan.
Those two words -- pre-existing condition -- explain why I find myself in this circumstance.
Back in 1996, when I was 27, my heart started to beat funny. The diagnosis was lone atrial fibrillation, a kind of irregular heartbeat that appeared for no apparent reason and, in my case, couldn't be fixed. Even getting "cardioverted" didn't help.
A daily beta blocker keeps my heart from pumping too fast, and my risk of any complications is low. Even so, no one will insure me on the individual market.
And since I'm single and self-employed as a freelance writer, I don't have access to guaranteed group coverage, except for a plan for artists and writers that would cost me at least $31,226 a year.
That's why, for the last few years, I have made do with the state's high-risk insurance plan. California, where I live, is one of 35 states that offer health insurance to people with pre-existing conditions who otherwise wouldn't be able to get individual coverage.
But for me, access to California's high-risk plan is expensive -- the PPO plan would cost me $748 a month this year, close to $9,000 a year -- and the coverage is thin. The annual spending limit is just $75,000, hardly enough to cover a major health crisis. And the lifetime benefit limit is a paltry $750,000.
As a result of the 2010 federal health law, I now have another possibility: The federal high-risk plan would cost me just $265 a month -- $3,180 a year -- and offers unlimited annual and lifetime benefits.
That sounds like a great deal cost-wise, and the lack of coverage limits is much better for me in the long run if I get diagnosed with an expensive disease. But there's a rub: I'm not eligible for the federal plan unless I go six months without any coverage at all. That's just what I decided to do. To me, the prospect of affordable and unlimited coverage -- at least from July 2012-December 2013 -- is worth the risk of going without coverage for the allotted time.
"You're responding in an understandable way," said Harold Pollack, a University of Chicago professor who studies health care. "Any program that requires people to be actively uninsured creates a very paradoxical and painful set of incentives and encourages people to do what you're doing."
But I'm taking a major risk by going without insurance for so long. This would be the absolute wrong time to get hit by the proverbial bus. Or, as happened a few weeks ago, hear a dermatologist ask "Have you had that looked at?" while I lounge at a hotel pool. (Don't worry. I'd previously had it looked at, and it's nothing to worry about.)
My decision to go coverage-free did not go over well up in Sacramento when I mentioned it to staffers at the California Managed Risk Medical Insurance Board, which oversees the state and federal high-risk plans here.
A spokeswoman told me that the agency wouldn't cooperate with me on this story if I planned to embolden other people to make the same decision. Janette Casillas, the agency's executive director, put it this way: going without insurance in order to get insurance "is not something that we would encourage."
The federal government could change everything by getting rid of that six-months-without-coverage rule. But if it did, it would need to find another way to limit coverage for high-risk patients so it doesn't cost more than the budgeted amount, Pollack said. "They'd have to have some other rationing requirement that would also create problems, since it's such a small program for such a huge need," he said. "Almost every deficit of this program comes down to the fact that Congress has not appropriated enough money to meet the need that is there."
Even if I do land in the federal high-risk plan as of July 1 -- if space is available -- it's not a long-term fix for me or anyone else. The good news, for me at least: In 2014, the federal health law is scheduled to take full effect, including provisions that protect consumers who have pre-existing conditions from being denied coverage. The high-risk pool coverage won't be needed anymore.
Wednesday, July 4, 2012
California doctors sue Aetna for coverage denials
Is it possible that both the doctors and the insurance companies are ripping off patients? Doctors are apparently getting kickbacks for referring patients.
California doctors sue Aetna for coverage denials
Jul 3, 2012
By Toni Clarke
(Reuters)
Thousands of doctors in California are suing the health insurance company Aetna Inc claiming the company routinely denies patients access to out-of-network doctors even when the patient has purchased a policy giving them the right to choose providers.
The lawsuit, filed in the Los Angeles County Superior Court, accuses Aetna of threatening patients with denial of coverage if their members visit doctors outside the Aetna network of providers, and of threatening doctors with having their Aetna contracts terminated if they refer patients outside the network.
The lawsuit was brought by the Los Angeles County Medical Association, California Medical Association and a coalition of health care organizations and providers.
Aetna claims the suit is in retaliation for a suit filed by Aetna in February claiming several California providers, including Bay Area Surgical Management (BASM)and seven ancillary facilities, sent Aetna members to BASM without revealing that physicians had an ownership interest in the facility or were getting paid by BASM for their referrals.
"We have sued some of these same doctors and surgery centers named in the suit for their egregious billing practices in February of this year," Cynthia Michener, a spokeswoman for Aetna, said in an email. "This is a countersuit disguised as a class action lawsuit."
Michener said Aetna would "continue to pursue medical providers whose charges are so grossly out of line."
She cited as examples facilities and doctors who have charged $73,536 for a kidney stone fragmentation when an average in-network charge would be around $7,612. Or those that have charged $37,572 for a knee procedure that would cost about $10,500 with an in-network physician.
Michener was not immediately able to say what the average cost of these procedures would have been in out-of-network facilities that are not being sued by Aetna.
The lawsuit brought by the physicians accuses Aetna of false advertising, breach of contract, unfair business practices, and both intentional and negligent interference with healthcare providers.
The lawsuit seeks an end to the practices, an immediate injunction, compensation for patients and physicians and punitive damages.
"Despite making tens of millions of dollars selling policies with out-of-network benefits, Aetna has engaged in a campaign to retaliate against its members who attempt to use their out-of-network benefits, and the physicians who refer these members to out-of-network providers," the lawsuit states.
California doctors sue Aetna for coverage denials
Jul 3, 2012
By Toni Clarke
(Reuters)
Thousands of doctors in California are suing the health insurance company Aetna Inc claiming the company routinely denies patients access to out-of-network doctors even when the patient has purchased a policy giving them the right to choose providers.
The lawsuit, filed in the Los Angeles County Superior Court, accuses Aetna of threatening patients with denial of coverage if their members visit doctors outside the Aetna network of providers, and of threatening doctors with having their Aetna contracts terminated if they refer patients outside the network.
The lawsuit was brought by the Los Angeles County Medical Association, California Medical Association and a coalition of health care organizations and providers.
Aetna claims the suit is in retaliation for a suit filed by Aetna in February claiming several California providers, including Bay Area Surgical Management (BASM)and seven ancillary facilities, sent Aetna members to BASM without revealing that physicians had an ownership interest in the facility or were getting paid by BASM for their referrals.
"We have sued some of these same doctors and surgery centers named in the suit for their egregious billing practices in February of this year," Cynthia Michener, a spokeswoman for Aetna, said in an email. "This is a countersuit disguised as a class action lawsuit."
Michener said Aetna would "continue to pursue medical providers whose charges are so grossly out of line."
She cited as examples facilities and doctors who have charged $73,536 for a kidney stone fragmentation when an average in-network charge would be around $7,612. Or those that have charged $37,572 for a knee procedure that would cost about $10,500 with an in-network physician.
Michener was not immediately able to say what the average cost of these procedures would have been in out-of-network facilities that are not being sued by Aetna.
The lawsuit brought by the physicians accuses Aetna of false advertising, breach of contract, unfair business practices, and both intentional and negligent interference with healthcare providers.
The lawsuit seeks an end to the practices, an immediate injunction, compensation for patients and physicians and punitive damages.
"Despite making tens of millions of dollars selling policies with out-of-network benefits, Aetna has engaged in a campaign to retaliate against its members who attempt to use their out-of-network benefits, and the physicians who refer these members to out-of-network providers," the lawsuit states.
Friday, March 2, 2012
California orders Kaiser to stop denying physical, occupational and speech therapy to certain patients
California orders Kaiser to stop denying physical, occupational and speech therapy to certain patients
By Sandy Kleffman
Bay Area News Group
02/28/2012
State regulators on Monday ordered Kaiser Foundation Health Plan to stop denying physical, occupational and speech therapy to certain patients.
Kaiser has declined such therapy to members who lack a "physical condition," according to documents filed by the state Department of Managed Health Care.
That means that people who may stutter or lisp or who have developmental delays don't receive speech therapy, for example, said Anthony Manzanetti, chief of enforcement for the state agency.
It also excludes those who have mental illnesses.
A Kaiser executive, who said he was surprised and disappointed by the state action, disputed the agency's description of Kaiser policies.
"The department appears to have misunderstood or mischaracterized Kaiser Permanente's approach to providing speech, physical and occupational therapy to our members," said John Nelson, Kaiser vice president, in a written statement.
"These therapies are not limited only to patients with physical conditions," he said.
Nelson said Kaiser will continue discussions with the state agency with the goal of "reaching a shared understanding. In the interim, we will continue to cover medically necessary health care services."
Since 2009, more than 100 Kaiser members have filed complaints with the Department of Managed Health Care after being denied physical, occupational and speech therapy, the state agency reported.
Consumers can appeal a health plan's refusal to provide services. They also have the right to receive an independent medical review if they disagree with their plan's decision.
By Sandy Kleffman
Bay Area News Group
02/28/2012
State regulators on Monday ordered Kaiser Foundation Health Plan to stop denying physical, occupational and speech therapy to certain patients.
Kaiser has declined such therapy to members who lack a "physical condition," according to documents filed by the state Department of Managed Health Care.
That means that people who may stutter or lisp or who have developmental delays don't receive speech therapy, for example, said Anthony Manzanetti, chief of enforcement for the state agency.
It also excludes those who have mental illnesses.
A Kaiser executive, who said he was surprised and disappointed by the state action, disputed the agency's description of Kaiser policies.
"The department appears to have misunderstood or mischaracterized Kaiser Permanente's approach to providing speech, physical and occupational therapy to our members," said John Nelson, Kaiser vice president, in a written statement.
"These therapies are not limited only to patients with physical conditions," he said.
Nelson said Kaiser will continue discussions with the state agency with the goal of "reaching a shared understanding. In the interim, we will continue to cover medically necessary health care services."
Since 2009, more than 100 Kaiser members have filed complaints with the Department of Managed Health Care after being denied physical, occupational and speech therapy, the state agency reported.
Consumers can appeal a health plan's refusal to provide services. They also have the right to receive an independent medical review if they disagree with their plan's decision.
Sunday, February 19, 2012
Anna Rahm v. Kaiser: Kaiser refused to give an MRI for three months; aggressive cancer then found
Shamefully, the California Medical Association, California Hospital Association and California Dental Association supported Kaiser's denial of care to this patient. The Court of Appeal ruled on behalf of the patient.
Filed 2/15/12 CERTIFIED FOR PUBLICATION
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA. SECOND APPELLATE DISTRICT
KAISER FOUNDATION HEALTH
PLAN, INC., et al.,
Petitioners,
v.
THE SUPERIOR COURT OF LOS
ANGELES COUNTY,
Respondent.
ANNA RAHM et al., Real Parties in
Interest.
...Anna Rahm is a member of the Kaiser Permanente Traditional Plan (the plan),
which provides its members medically necessary health care in exchange for monthly
premiums. In August of 2008, Anna began experiencing back pain. Anna‟s parents,
Lynnette and James Rahm, took Anna to a chiropractor. After the treatments failed to
alleviate Anna‟s pain, the chiropractor recommended that Anna “consult with a medical
doctor because she was in need of an MRI.”
In March of 2009, Anna met with Charlene Huang, a primary care physician at
Kaiser. Lynnette accompanied Anna to the appointment and requested that her daughter
receive an MRI. Although Huang acknowledged that Anna‟s chiropractor had
determined that her back pain was “„severe,‟” Huang refused to order an MRI. Huang
referred Anna “to the physical medicine department at [Kaiser] and also prescribed pain medications and steroids, a much less expensive treatment than an MRI. . . .” Anna took the prescribed medications but her pain persisted.
Two weeks later, on March 24, 2009, Anna met with Ngan Vuong, a physical
medicine doctor at Kaiser. Lynnette accompanied Anna to the appointment and again
requested that Anna receive an MRI. Vuong, however, recommended that Anna receive
an epidural and suggested that her pain could be remedied through changes to her
nutrition and exercise habits. Lynnette told Vuong she did not want her daughter to
receive an epidural and renewed her request for an MRI. Voung refused to authorize an
MRI.
This factual summary is based on allegations in plaintiffs‟ complaint, which we
assume to be true for the purposes of reviewing the trial court‟s order denying
defendants‟ motion to strike. (See Turman v. Turning Point of Central California, Inc. (2010) 191 Cal.App.4th 53, 63 (Turman) [“„In passing on the correctness of a ruling on a motion to strike [punitive damages allegations], judges read allegations of a pleading subject to a motion to strike as a whole, all parts in their context, and assume their truth.‟
In April of 2009, Anna sought acupuncture treatment for her pain. The treatments
were unsuccessful annd the acupuncturist recommended that Anna request an MRI from
her doctor. Lynnette called Vuong and informed her that Anna‟s acupuncturist had
recommended an MRI. Vuong again declined an MRI and referred Anna to Kaiser‟s
physical therapy department.
In May and June of 2009, Anna continued her acupuncture treatments. Two
different acupuncturists concluded that Anna was in need of an MRI. Anna also attended several physical therapy sessions at Kaiser, but was forced to discontinue the treatments because they were too painful. Kaiser‟s physical therapy department “recommended that [Anna] receive an MRI.”
Lynette called Vuong again and explained that a chiropractor, two acupuncturists
and Kaiser‟s physical therapy department had all recommended an MRI. Vuong rejected
these recommendations because they were not made by medical doctors, but invited the
Rahms to seek a second opinion.
Lynnette elected to schedule a meeting with another doctor. Prior to the
appointment, Lynnette contacted Huang, Anna‟s primary care physician, “as a last ditch effort” to get an MRI. Lynnette summarized the treatments Anna had undergone since her initial visit with Huang. Huang finally agreed to authorize an MRI, which was performed on July 2, 2009.
Anna‟s MRI indicated that she had an “aggressive mass” in her pelvis. A biopsy
revealed that Anna was suffering from a “high grade” osteosarcoma, which is “one of the fastest growing types of osteosarcoma, meaning that [Kaiser‟s] three month delay in ordering [Anna‟s] MRI allowed the cancer to spread and ultimately substantially
contributed to [Anna‟s ] poor prognosis.” Anna underwent chemotherapy and had
numerous surgeries that resulted in the loss of her right leg and portions of her pelvis and spine...
Filed 2/15/12 CERTIFIED FOR PUBLICATION
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA. SECOND APPELLATE DISTRICT
KAISER FOUNDATION HEALTH
PLAN, INC., et al.,
Petitioners,
v.
THE SUPERIOR COURT OF LOS
ANGELES COUNTY,
Respondent.
ANNA RAHM et al., Real Parties in
Interest.
...Anna Rahm is a member of the Kaiser Permanente Traditional Plan (the plan),
which provides its members medically necessary health care in exchange for monthly
premiums. In August of 2008, Anna began experiencing back pain. Anna‟s parents,
Lynnette and James Rahm, took Anna to a chiropractor. After the treatments failed to
alleviate Anna‟s pain, the chiropractor recommended that Anna “consult with a medical
doctor because she was in need of an MRI.”
In March of 2009, Anna met with Charlene Huang, a primary care physician at
Kaiser. Lynnette accompanied Anna to the appointment and requested that her daughter
receive an MRI. Although Huang acknowledged that Anna‟s chiropractor had
determined that her back pain was “„severe,‟” Huang refused to order an MRI. Huang
referred Anna “to the physical medicine department at [Kaiser] and also prescribed pain medications and steroids, a much less expensive treatment than an MRI. . . .” Anna took the prescribed medications but her pain persisted.
Two weeks later, on March 24, 2009, Anna met with Ngan Vuong, a physical
medicine doctor at Kaiser. Lynnette accompanied Anna to the appointment and again
requested that Anna receive an MRI. Vuong, however, recommended that Anna receive
an epidural and suggested that her pain could be remedied through changes to her
nutrition and exercise habits. Lynnette told Vuong she did not want her daughter to
receive an epidural and renewed her request for an MRI. Voung refused to authorize an
MRI.
This factual summary is based on allegations in plaintiffs‟ complaint, which we
assume to be true for the purposes of reviewing the trial court‟s order denying
defendants‟ motion to strike. (See Turman v. Turning Point of Central California, Inc. (2010) 191 Cal.App.4th 53, 63 (Turman) [“„In passing on the correctness of a ruling on a motion to strike [punitive damages allegations], judges read allegations of a pleading subject to a motion to strike as a whole, all parts in their context, and assume their truth.‟
In April of 2009, Anna sought acupuncture treatment for her pain. The treatments
were unsuccessful annd the acupuncturist recommended that Anna request an MRI from
her doctor. Lynnette called Vuong and informed her that Anna‟s acupuncturist had
recommended an MRI. Vuong again declined an MRI and referred Anna to Kaiser‟s
physical therapy department.
In May and June of 2009, Anna continued her acupuncture treatments. Two
different acupuncturists concluded that Anna was in need of an MRI. Anna also attended several physical therapy sessions at Kaiser, but was forced to discontinue the treatments because they were too painful. Kaiser‟s physical therapy department “recommended that [Anna] receive an MRI.”
Lynette called Vuong again and explained that a chiropractor, two acupuncturists
and Kaiser‟s physical therapy department had all recommended an MRI. Vuong rejected
these recommendations because they were not made by medical doctors, but invited the
Rahms to seek a second opinion.
Lynnette elected to schedule a meeting with another doctor. Prior to the
appointment, Lynnette contacted Huang, Anna‟s primary care physician, “as a last ditch effort” to get an MRI. Lynnette summarized the treatments Anna had undergone since her initial visit with Huang. Huang finally agreed to authorize an MRI, which was performed on July 2, 2009.
Anna‟s MRI indicated that she had an “aggressive mass” in her pelvis. A biopsy
revealed that Anna was suffering from a “high grade” osteosarcoma, which is “one of the fastest growing types of osteosarcoma, meaning that [Kaiser‟s] three month delay in ordering [Anna‟s] MRI allowed the cancer to spread and ultimately substantially
contributed to [Anna‟s ] poor prognosis.” Anna underwent chemotherapy and had
numerous surgeries that resulted in the loss of her right leg and portions of her pelvis and spine...
Wednesday, January 4, 2012
Bad news: if your doctor won't stand up for you to your insurance company, you're in trouble
New Year, New Deals? Breaking Down Health Plan, Doctor Alliances
by Dan Diamond
California Healthline Contributing Editor
January 04, 2012
The Washington Post's annual In/Out List doesn't crossover much with "Road to Reform." (Possibly for good reason; the latest edition says "wonks" are officially out this year.)
But this column is nothing if not occasionally gimmicky. So here's a one-time, two-line trend-spotting bonus for 2012:
Out: Physicians and insurance companies as mortal enemies.
In: Health insurers and physicians ... as partners.
Regular California Healthline readers know that several big payer-doctor deals were struck in 2011, disproportionately in the Golden State. UnitedHealth's Optum division acquired a handful of physician groups, most notably 2,300-member Irvine-based Monarch HealthCare. Other health plans teamed up with independent practice associations to launch accountable care organizations.
Are these deals an industry blip or the beginning of a boom?
Check back at year-end. For now, it's too soon to know.
The high-profile deals are garnering plenty of buzz, however. And given the rumblings, many other doctor groups and plans are scrambling to evaluate whether similar partnerships make sense.
Changes Afoot for Everyone
It's old news that industry players are taking on new roles.
Hospitals in 2011 ramped up the pace of physician acquisition, seeking to integrate care and gain reimbursement. More employers added responsibilities for their employees' wellness, hoping to cut costs.
But the physician and insurer deals are particularly striking because of the sectors' oft-contentious relationship. If doctors and health insurance plans aren't fighting over reimbursement, they're battling over paperwork or even public scorecards. Outside of Kaiser Permanente, many efforts at vertically integrated systems with insurers running doctor groups have largely failed.
Even the CEO of Monarch HealthCare is surprised by his own partnership with UnitedHealth.
"Not 10 years ago I would not have thought of something like this," Bart Asner told Modern Healthcare's Rebecca Vesely. But when seeking a partner, "[UnitedHealth] showed up on our doorstep."
What's Driving the New Partnerships
UnitedHealth's pursuit of Monarch -- and by extension, other plans looking to partner with physicians -- isn't a shock.
Given ongoing industry efforts to coordinate care, lock up primary care providers and cut costs, physician groups have many suitors.
But Vesely concludes that the reasons for physicians to team up with health plans, rather than merge with other doctors' groups or join a hospital, are less cut-and-dry.
One driver may be that national plans have much more financial wherewithal to meet the sales price for large groups, as well as their strategic ambitions. UnitedHealth projected profits of more than $5 billion in 2011. The average hospital clears about one-1000th of that per year.
Alternately, IPAs and health plans may be pushed together as dance partners while hospitals bulk up. The growing "dominance" of hospital-led health systems means that physician groups are losing market power and the ability to recruit new doctors, health care consultant Penny Stroud told American Medical News late last year, making plan ownership more appealing.
California at the Epicenter
These drivers can all be seen in the unlikely Monarch-UnitedHealth deal, which Vesely neatly breaks down in Modern Healthcare.
What UnitedHealth gains: Access to physicians for its members and better positioning in a new market of integrated care delivery.
What Monarch gains: Deep pockets to invest in electronic health records, clinical programs and its growth strategy.
A good share of these new physician-payer deals are unfolding in California.
That's partly because the state's long history with managed care offers fertile ground for such partnerships. The entrenched HMOs, large multidisciplinary physician groups and concentrated market have set up an ideal laboratory for attempting this kind of coordination.
CMS' efforts to reward integrated care also are pushing California's strong IPAs to the forefront. No state had more organizations named as Pioneer ACOs last month than the Golden State's six, which includes Monarch.
Reaction and Reassessment
Modern Healthcare calls the new deals a "marriage of convenience" -- and there's certainly little romance and a lot of number-crunching to the proceedings.
Monarch also leaves behind a pair of jilted ex-partners.
Blue Shield of California will end its contract with Monarch in May, citing the IPA's new relationship with UnitedHealth. Anthem Blue Cross has pulled out of the physician group's planned ACO pilot.
That ACO effort may become an early litmus test for the UnitedHealth-Monarch relationship. Other payers are watching how smaller-scale initiatives, like regional insurers' efforts to acquire physician clinics, are unfolding.
If the partnerships prove successful, expect a flurry of activity across 2012 as more payers and physicians make sure they're dealt in -- and not left out.
Here's what else to watch as the new year begins.
In the States
CMS on Dec. 20, 2011, approved a new three-year, $26.75 billion Medicaid waiver for Massachusetts that allows its 2006 health insurance law to continue and provides hospitals with incentives to offer quality-focused and cost-efficient care. The waiver will expire in June 2014 (Baker, "Healthwatch," The Hill, 12/20/11). The waiver is vital to the state law's primary goal of ensuring that most residents have health insurance (Conaboy, "White Coat Notes," Boston Globe, 12/20/11).
Texas Democrats in a recent letter urged HHS Secretary Kathleen Sebelius to reject the state's request for a waiver from the medical-loss ratio regulations under the federal health reform law (Pecquet, "Healthwatch," The Hill, 12/22/11).
The advocacy group Progress VA recently filed a petition seeking to pressure state lawmakers to disassociate with the American Legislative Exchange Council, a conservative, pro-business group that authored the state's lawsuit against the federal health care reform law (Pecquet, "Healthwatch," The Hill, 12/28/11).
Challenges to Reform
After more than a year of vowing to "repeal and replace" the federal health reform law, Republicans still have not developed a plan to substitute for it. Republican presidential candidates have proposed new tax credits and allowing residents to purchase health insurance over state lines as an alternative to the reform law. However, some conservative experts said the ideas might not work as intended and even if they did, they would be only the beginning of a true replacement for the Affordable Care Act (Fahrenhold, Washington Post, 12/24/11). In related news, a Kaiser Family Foundation survey shows that among opponents of the current reform law, most want the ACA repealed, but not replaced (Kliff, "WonkBlog," Washington Post, 12/26/11).
Inside the Industry
Health insurers in 2012 will start paying the federal government a $1 fee for each insured person to go toward funding the Patient-Centered Outcomes Research Institute, which aims to determine which medications, medical procedures, tests and treatments work best. While the Treasury Department said the fee would not likely be collected this year, insurers will still owe the federal government the amount. The fee rises to $2 per insured person in 2013 and rises with inflation each year thereafter (Alonso-Zaldivar, AP/Washington Times, 12/27/11).
CMS on Tuesday announced the names of 73 health care experts who will participate in its Innovation Advisors Program, which will support individuals who seek to pilot and refine innovative payment and delivery models. After an orientation phase, advisers will work with the CMS Innovation Center -- established through the health reform law -- to pilot health care delivery models in their local communities and create partnerships that can foster and disseminate successful ideas. Each adviser's organization will receive up to $20,000 to support his or her activities during their participation (CMS release, 1/3). The Innovation Advisors Program will select up to 200 participants within its first year. The agency is expected to reopen applications in Spring 2012 and select remaining advisors by June (CMS fact sheet, 1/3)...
by Dan Diamond
California Healthline Contributing Editor
January 04, 2012
The Washington Post's annual In/Out List doesn't crossover much with "Road to Reform." (Possibly for good reason; the latest edition says "wonks" are officially out this year.)
But this column is nothing if not occasionally gimmicky. So here's a one-time, two-line trend-spotting bonus for 2012:
Out: Physicians and insurance companies as mortal enemies.
In: Health insurers and physicians ... as partners.
Regular California Healthline readers know that several big payer-doctor deals were struck in 2011, disproportionately in the Golden State. UnitedHealth's Optum division acquired a handful of physician groups, most notably 2,300-member Irvine-based Monarch HealthCare. Other health plans teamed up with independent practice associations to launch accountable care organizations.
Are these deals an industry blip or the beginning of a boom?
Check back at year-end. For now, it's too soon to know.
The high-profile deals are garnering plenty of buzz, however. And given the rumblings, many other doctor groups and plans are scrambling to evaluate whether similar partnerships make sense.
Changes Afoot for Everyone
It's old news that industry players are taking on new roles.
Hospitals in 2011 ramped up the pace of physician acquisition, seeking to integrate care and gain reimbursement. More employers added responsibilities for their employees' wellness, hoping to cut costs.
But the physician and insurer deals are particularly striking because of the sectors' oft-contentious relationship. If doctors and health insurance plans aren't fighting over reimbursement, they're battling over paperwork or even public scorecards. Outside of Kaiser Permanente, many efforts at vertically integrated systems with insurers running doctor groups have largely failed.
Even the CEO of Monarch HealthCare is surprised by his own partnership with UnitedHealth.
"Not 10 years ago I would not have thought of something like this," Bart Asner told Modern Healthcare's Rebecca Vesely. But when seeking a partner, "[UnitedHealth] showed up on our doorstep."
What's Driving the New Partnerships
UnitedHealth's pursuit of Monarch -- and by extension, other plans looking to partner with physicians -- isn't a shock.
Given ongoing industry efforts to coordinate care, lock up primary care providers and cut costs, physician groups have many suitors.
But Vesely concludes that the reasons for physicians to team up with health plans, rather than merge with other doctors' groups or join a hospital, are less cut-and-dry.
One driver may be that national plans have much more financial wherewithal to meet the sales price for large groups, as well as their strategic ambitions. UnitedHealth projected profits of more than $5 billion in 2011. The average hospital clears about one-1000th of that per year.
Alternately, IPAs and health plans may be pushed together as dance partners while hospitals bulk up. The growing "dominance" of hospital-led health systems means that physician groups are losing market power and the ability to recruit new doctors, health care consultant Penny Stroud told American Medical News late last year, making plan ownership more appealing.
California at the Epicenter
These drivers can all be seen in the unlikely Monarch-UnitedHealth deal, which Vesely neatly breaks down in Modern Healthcare.
What UnitedHealth gains: Access to physicians for its members and better positioning in a new market of integrated care delivery.
What Monarch gains: Deep pockets to invest in electronic health records, clinical programs and its growth strategy.
A good share of these new physician-payer deals are unfolding in California.
That's partly because the state's long history with managed care offers fertile ground for such partnerships. The entrenched HMOs, large multidisciplinary physician groups and concentrated market have set up an ideal laboratory for attempting this kind of coordination.
CMS' efforts to reward integrated care also are pushing California's strong IPAs to the forefront. No state had more organizations named as Pioneer ACOs last month than the Golden State's six, which includes Monarch.
Reaction and Reassessment
Modern Healthcare calls the new deals a "marriage of convenience" -- and there's certainly little romance and a lot of number-crunching to the proceedings.
Monarch also leaves behind a pair of jilted ex-partners.
Blue Shield of California will end its contract with Monarch in May, citing the IPA's new relationship with UnitedHealth. Anthem Blue Cross has pulled out of the physician group's planned ACO pilot.
That ACO effort may become an early litmus test for the UnitedHealth-Monarch relationship. Other payers are watching how smaller-scale initiatives, like regional insurers' efforts to acquire physician clinics, are unfolding.
If the partnerships prove successful, expect a flurry of activity across 2012 as more payers and physicians make sure they're dealt in -- and not left out.
Here's what else to watch as the new year begins.
In the States
CMS on Dec. 20, 2011, approved a new three-year, $26.75 billion Medicaid waiver for Massachusetts that allows its 2006 health insurance law to continue and provides hospitals with incentives to offer quality-focused and cost-efficient care. The waiver will expire in June 2014 (Baker, "Healthwatch," The Hill, 12/20/11). The waiver is vital to the state law's primary goal of ensuring that most residents have health insurance (Conaboy, "White Coat Notes," Boston Globe, 12/20/11).
Texas Democrats in a recent letter urged HHS Secretary Kathleen Sebelius to reject the state's request for a waiver from the medical-loss ratio regulations under the federal health reform law (Pecquet, "Healthwatch," The Hill, 12/22/11).
The advocacy group Progress VA recently filed a petition seeking to pressure state lawmakers to disassociate with the American Legislative Exchange Council, a conservative, pro-business group that authored the state's lawsuit against the federal health care reform law (Pecquet, "Healthwatch," The Hill, 12/28/11).
Challenges to Reform
After more than a year of vowing to "repeal and replace" the federal health reform law, Republicans still have not developed a plan to substitute for it. Republican presidential candidates have proposed new tax credits and allowing residents to purchase health insurance over state lines as an alternative to the reform law. However, some conservative experts said the ideas might not work as intended and even if they did, they would be only the beginning of a true replacement for the Affordable Care Act (Fahrenhold, Washington Post, 12/24/11). In related news, a Kaiser Family Foundation survey shows that among opponents of the current reform law, most want the ACA repealed, but not replaced (Kliff, "WonkBlog," Washington Post, 12/26/11).
Inside the Industry
Health insurers in 2012 will start paying the federal government a $1 fee for each insured person to go toward funding the Patient-Centered Outcomes Research Institute, which aims to determine which medications, medical procedures, tests and treatments work best. While the Treasury Department said the fee would not likely be collected this year, insurers will still owe the federal government the amount. The fee rises to $2 per insured person in 2013 and rises with inflation each year thereafter (Alonso-Zaldivar, AP/Washington Times, 12/27/11).
CMS on Tuesday announced the names of 73 health care experts who will participate in its Innovation Advisors Program, which will support individuals who seek to pilot and refine innovative payment and delivery models. After an orientation phase, advisers will work with the CMS Innovation Center -- established through the health reform law -- to pilot health care delivery models in their local communities and create partnerships that can foster and disseminate successful ideas. Each adviser's organization will receive up to $20,000 to support his or her activities during their participation (CMS release, 1/3). The Innovation Advisors Program will select up to 200 participants within its first year. The agency is expected to reopen applications in Spring 2012 and select remaining advisors by June (CMS fact sheet, 1/3)...
Tuesday, December 13, 2011
Jerry Sandusky vows "fight to the death" against boys he abused
Jerry Sandusky's attitude toward his victims is sadly common among human beings. Sandusky sees his victims as abusers because they made accusations against him. He feels they should leave him alone.
This attitude is actually startlingly common. Many people feel no remorse when they are called out for wrongdoing; instead, they attack their victims once again. They hire a lawyer that cares only about winning. Sadly, many insurance companies do this to the people that pay them for health insurance. I'm experiencing this same attitude from Kaiser Permanente. It's especially creepy when your doctor and your insurance company are one and the same, as in Kaiser Permanente. Then you end up with your doctor working to harm your health! At least with fee for service insurers, it isn't your doctor who's denying necessary care.
Vowing 'fight to the death,' Sandusky waives hearing in child sex-abuse case
Sandusky waives hearing, vows to fight charges
By MARK SCOLFORO and MARYCLAIRE DALE
Associated Press
Dec. 13, 2011
Former Penn State assistant football coach Jerry Sandusky opted against forcing his accusers to make their claims of child sex abuse in a packed courtroom Tuesday but then took his case to the courthouse steps as his lawyer assailed the credibility of the alleged victims and witnesses.
"There will be no plea negotiations," defense lawyer Joseph Amendola said. "This is a fight to the death."
Waiving such a preliminary hearing is not unusual but it was unexpected in this case: Amendola repeatedly had said his client was looking forward to facing his accusers. Afterward, he called the cancellation a "tactical decision" to prevent the men from reiterating the same claims they made to the grand jury.
Lawyers for the alleged victims said some were relieved they would not have to make their claims in public before a trial, but others said they had steeled themselves to face Sandusky and were left disappointed.
"It would have been apparent from watching those boys and their demeanor that they were telling the truth," said Howard Janet, a lawyer for a boy whose mother contacted police in 1998 after her son allegedly showered with Sandusky.
Sandusky has denied the allegations, which led to the departures of longtime Penn State football coach Joe Paterno and the university president. He is charged with more than 50 counts that accuse him of sexually abusing 10 boys over the span of 12 years...
This attitude is actually startlingly common. Many people feel no remorse when they are called out for wrongdoing; instead, they attack their victims once again. They hire a lawyer that cares only about winning. Sadly, many insurance companies do this to the people that pay them for health insurance. I'm experiencing this same attitude from Kaiser Permanente. It's especially creepy when your doctor and your insurance company are one and the same, as in Kaiser Permanente. Then you end up with your doctor working to harm your health! At least with fee for service insurers, it isn't your doctor who's denying necessary care.
Vowing 'fight to the death,' Sandusky waives hearing in child sex-abuse case
Sandusky waives hearing, vows to fight charges
By MARK SCOLFORO and MARYCLAIRE DALE
Associated Press
Dec. 13, 2011
Former Penn State assistant football coach Jerry Sandusky opted against forcing his accusers to make their claims of child sex abuse in a packed courtroom Tuesday but then took his case to the courthouse steps as his lawyer assailed the credibility of the alleged victims and witnesses.
"There will be no plea negotiations," defense lawyer Joseph Amendola said. "This is a fight to the death."
Waiving such a preliminary hearing is not unusual but it was unexpected in this case: Amendola repeatedly had said his client was looking forward to facing his accusers. Afterward, he called the cancellation a "tactical decision" to prevent the men from reiterating the same claims they made to the grand jury.
Lawyers for the alleged victims said some were relieved they would not have to make their claims in public before a trial, but others said they had steeled themselves to face Sandusky and were left disappointed.
"It would have been apparent from watching those boys and their demeanor that they were telling the truth," said Howard Janet, a lawyer for a boy whose mother contacted police in 1998 after her son allegedly showered with Sandusky.
Sandusky has denied the allegations, which led to the departures of longtime Penn State football coach Joe Paterno and the university president. He is charged with more than 50 counts that accuse him of sexually abusing 10 boys over the span of 12 years...
Friday, September 30, 2011
California looks into HMO medical claim denials; Kaiser Permanente and Anthem Blue Cross each rejected about 28 percent of their claims.
Kaiser Permanente and Anthem Blue Cross each rejected about 28 percent of their claims.
California looks into HMO medical claim denials
Victoria Colliver,
San Francisco Chronicle Staff Writer
September 4, 2009
The state attorney general has launched an investigation into how health maintenance organizations review and pay medical claims, the office announced Thursday.
The inquiry is based on an analysis by the California Nurses Association that found more than 1 in 5 requests for medical claims - 22 percent - were rejected by the state's six largest health insurers.
"These high denial rates suggest a system that is dysfunctional, and the public is entitled to know whether wrongful business practices are involved," said Attorney General Jerry Brown in a press statement.
The nurses union based its research on data reported to the state Department of Managed Health Care, which oversees HMOs.
In the first six months of this year, the group found denial rates ranged from 6.4 percent for Aetna to 39.6 percent for PacifiCare. According to the analysis, Cigna rejected 32.7 percent of medical claims, Health Net denied 30 percent of the time and Kaiser Permanente and Anthem Blue Cross each rejected about 28 percent of their claims.
The trade group representing the state's health insurers said the nurses' numbers fail to reflect the reasons behind the denials, which may include requests for more information, paperwork errors and duplicate claims, as well as claims submitted to the wrong health insurer.
"It appears that a good deal of the so-called denials are merely paperwork issues between providers and plans and have little financial impact on consumers or impact the care received," said Nicole Kasabian Evans, spokeswoman for the California Association of Health Plans.
California looks into HMO medical claim denials
Victoria Colliver,
San Francisco Chronicle Staff Writer
September 4, 2009
The state attorney general has launched an investigation into how health maintenance organizations review and pay medical claims, the office announced Thursday.
The inquiry is based on an analysis by the California Nurses Association that found more than 1 in 5 requests for medical claims - 22 percent - were rejected by the state's six largest health insurers.
"These high denial rates suggest a system that is dysfunctional, and the public is entitled to know whether wrongful business practices are involved," said Attorney General Jerry Brown in a press statement.
The nurses union based its research on data reported to the state Department of Managed Health Care, which oversees HMOs.
In the first six months of this year, the group found denial rates ranged from 6.4 percent for Aetna to 39.6 percent for PacifiCare. According to the analysis, Cigna rejected 32.7 percent of medical claims, Health Net denied 30 percent of the time and Kaiser Permanente and Anthem Blue Cross each rejected about 28 percent of their claims.
The trade group representing the state's health insurers said the nurses' numbers fail to reflect the reasons behind the denials, which may include requests for more information, paperwork errors and duplicate claims, as well as claims submitted to the wrong health insurer.
"It appears that a good deal of the so-called denials are merely paperwork issues between providers and plans and have little financial impact on consumers or impact the care received," said Nicole Kasabian Evans, spokeswoman for the California Association of Health Plans.
Thursday, September 15, 2011
Family struggles to get daughter's tumor removed
Family struggles to get daughter's tumor removed
KGET.com
9/13/2011
Fourteen-month-old Claire DeCant is a beautiful, happy baby despite the swelling hemangioma under her left eye. "It first started as a little scratch under her eye when she was 4 and a half weeks," says her mother Davina.
Doctors don't know what causes hemangiomas to form, but the vascular tumor - an abnormal build up of blood vessels - is common in premature Caucasian female babies. "She was born 6 weeks premature."
As Claire grows, so does the hemangioma. First-time parents, Ryan and Davina DeCant say they've asked doctors to remove the benign tumor, but their insurance provider, Kaiser Permanente told them they won't cover because it could make the situation worse. "They didn't want to leave a scar on her face. My husband and I said we don't care about that. We want her depth perception to be normal, we want her vision to be at full capacity."
Frustrated, the family contacted Gregory Levitin, a doctor based in New York City. "Well as a specialty interest there are several doctors who can treat simple legions. For the more complicated legions there's probably less than a dozen specialists like myself who treat this across the country."
The Decant's sent Dr. Levitin photos. "In this location specifically it can encroach into the orbit and cause compression of the eyes called astigmatism and this is where the eye cannot develop normal vision. Along the nose it actually collapses the nose. No different than if you or I put pressure on our nose. It blocks off the nasal airway."
On a trip he makes monthly to Los Angeles to meet with patients with conditions such as this, Dr. Levitin evaluated Claire, then sent this letter to Kaiser, describing her "significant and progressive vascular malformation of the left hemiface" and said the tumor "require(s) a surgical excision as it was "likely to potentially grow further."
"With Claire's situation this absolutely should be covered by insurance. Anyone who looks at a smiling picture of this child can tell there's a tumor in her face. This is not a cosmetic issue at all."
A month later, Kaiser responded to the Decant's request for an "out of plan referral." It was denied. The reason listed: "insufficient clinical information."
We had a load of specialists that did review the location and the effect on breathing and vision. Pediatric cardiology, pediatric optomology, plastic surgery, dermatology and pediatrics. The assessment was it was not affecting the vision and it was not affecting the breathing," says Dr. Michael Jorgensen, assistant medical director, LA medical center.
But the Decant's say Claire has had trouble breathing, walking and seeing properly because of the hemangioma. "These are all things we notice. We expressed concern with Kaiser and they just did not care," says DeCant.
Kaiser says the tumor may be removed surgically eventually if necessary. But their team of specialists thought it best to first treat the tumor medically by prescribing propranolol, a high blood pressure medicine typically given to adults, then reevaluate before possibly offering surgery down the road.
But the DeCants say as they watch their baby suffer, waiting is not an option. The DeCants have filed two complaints and four appeals against Kaiser, all unsuccessful. The family plans to switch from Kaiser, an HMO, to Blue Shield, a PPO in October so Claire can have her hemangioma removed by Dr. Levitin who says he will do the surgery.
KGET.com
9/13/2011
Fourteen-month-old Claire DeCant is a beautiful, happy baby despite the swelling hemangioma under her left eye. "It first started as a little scratch under her eye when she was 4 and a half weeks," says her mother Davina.
Doctors don't know what causes hemangiomas to form, but the vascular tumor - an abnormal build up of blood vessels - is common in premature Caucasian female babies. "She was born 6 weeks premature."
As Claire grows, so does the hemangioma. First-time parents, Ryan and Davina DeCant say they've asked doctors to remove the benign tumor, but their insurance provider, Kaiser Permanente told them they won't cover because it could make the situation worse. "They didn't want to leave a scar on her face. My husband and I said we don't care about that. We want her depth perception to be normal, we want her vision to be at full capacity."
Frustrated, the family contacted Gregory Levitin, a doctor based in New York City. "Well as a specialty interest there are several doctors who can treat simple legions. For the more complicated legions there's probably less than a dozen specialists like myself who treat this across the country."
The Decant's sent Dr. Levitin photos. "In this location specifically it can encroach into the orbit and cause compression of the eyes called astigmatism and this is where the eye cannot develop normal vision. Along the nose it actually collapses the nose. No different than if you or I put pressure on our nose. It blocks off the nasal airway."
On a trip he makes monthly to Los Angeles to meet with patients with conditions such as this, Dr. Levitin evaluated Claire, then sent this letter to Kaiser, describing her "significant and progressive vascular malformation of the left hemiface" and said the tumor "require(s) a surgical excision as it was "likely to potentially grow further."
"With Claire's situation this absolutely should be covered by insurance. Anyone who looks at a smiling picture of this child can tell there's a tumor in her face. This is not a cosmetic issue at all."
A month later, Kaiser responded to the Decant's request for an "out of plan referral." It was denied. The reason listed: "insufficient clinical information."
We had a load of specialists that did review the location and the effect on breathing and vision. Pediatric cardiology, pediatric optomology, plastic surgery, dermatology and pediatrics. The assessment was it was not affecting the vision and it was not affecting the breathing," says Dr. Michael Jorgensen, assistant medical director, LA medical center.
But the Decant's say Claire has had trouble breathing, walking and seeing properly because of the hemangioma. "These are all things we notice. We expressed concern with Kaiser and they just did not care," says DeCant.
Kaiser says the tumor may be removed surgically eventually if necessary. But their team of specialists thought it best to first treat the tumor medically by prescribing propranolol, a high blood pressure medicine typically given to adults, then reevaluate before possibly offering surgery down the road.
But the DeCants say as they watch their baby suffer, waiting is not an option. The DeCants have filed two complaints and four appeals against Kaiser, all unsuccessful. The family plans to switch from Kaiser, an HMO, to Blue Shield, a PPO in October so Claire can have her hemangioma removed by Dr. Levitin who says he will do the surgery.
Wednesday, September 14, 2011
Kaiser Permanente denies 47 per cent of applicants in Georgira
Study: Health Insurance Denial Rates Routinely Exceed 20%
By Rachel Fields
ASC Review
September 12, 2011
Health insurance denial rates routinely exceed 20 percent and are often much higher, according to a Kaiser Health News review of 20 of the most populous states and the District of Columbia.
According to data provided by insurers to the federal Department of Health and Human Services, denial rates can vary widely in individual states. In Georgia, Aetna's denial rate is 15 percent, compared with 47 percent for Kaiser Permanente and 67 percent for John Alden Life Insurance. Humana rejects 26-39 percent of applications in Kentucky, while UnitedHealthcare denies 38-43 percent.
The same insurer can deny customers at different rates in different states, according to the report. For example, Kaiser Permanente denied 32 percent of applications in Maryland, but only 17 percent in Colorado.
According to industry trade group America's Health Insurance Plans, 87 percent of people who apply nationally for individual coverage are offered a policy. However, that data includes people who are turned down for one policy but offered another more expensive option.
By Rachel Fields
ASC Review
September 12, 2011
Health insurance denial rates routinely exceed 20 percent and are often much higher, according to a Kaiser Health News review of 20 of the most populous states and the District of Columbia.
According to data provided by insurers to the federal Department of Health and Human Services, denial rates can vary widely in individual states. In Georgia, Aetna's denial rate is 15 percent, compared with 47 percent for Kaiser Permanente and 67 percent for John Alden Life Insurance. Humana rejects 26-39 percent of applications in Kentucky, while UnitedHealthcare denies 38-43 percent.
The same insurer can deny customers at different rates in different states, according to the report. For example, Kaiser Permanente denied 32 percent of applications in Maryland, but only 17 percent in Colorado.
According to industry trade group America's Health Insurance Plans, 87 percent of people who apply nationally for individual coverage are offered a policy. However, that data includes people who are turned down for one policy but offered another more expensive option.
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.”
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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.
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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."
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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.”
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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.
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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.”
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