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Tag Archives: Insurance

United "FraudCare"

According to MSNBC, United HealthCare just paid $50 million to settle New York Attorney General Andrew Cuomo’s claims that United HealthCare manipulated its own proprietary pricing database to set an unreasonably low “fair market value” for medical care. By doing so, it is alleged that UHC forced its insureds to pay more out of pocket costs when using “out of network” providers – to the tune of tens of millions of dollars. No criminal actions have been filed, but class action lawsuits are reportedly already in the works. Other insurers are in the sights of several state Attorneys General. A New York Times article about the suit and the basis behind the suit is here. Also some interesting discussion going on at Newsvine.com. The question I have is … with a company that has revenues of $45 billion, is a $50 million settlement enough to dissuade similar actions in the future? That’s like a person who makes $100,000 per year agreeing to pay a fine of $100 – not exactly a big hit in the pocketbook. Instead, why not disgorge all of UHC’s revenues for a couple of years? How about a fine of $50 billion instead of $50 million? I can’t think of a better example of a corporate “never event” – can you? If providers shouldn’t be paid for things that should “never” occur, neither should the insurers.

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Medicaid Modus Operandi – Limit Access, Save Money

Forget the fact that Medicaid payments to physicians amount to less than the cost of a lunch at McDonalds in some states. According to an article published in the Dec 8 edition of AM News, bureaucratic hassles and delays in payments are also causing significant limitations to the number of physicians that are willing to provide care for Medicaid patients. What good is health insurance if you’re prevented from using the benefits? Pennsylvania and New York take an average of almost 4 months to pay a Medicaid claim. Some claims take even longer to be paid in those states. To put this in perspective, imagine starting work at a new job, then waiting an average of 4 months to get your paycheck (if you’re lucky you’ll get paid in 2-3 months, but if you’re unlucky, you might wait 6 months). Is that somewhere you could afford to work? How would you pay for your mortgage, your car payment, or your groceries? By delaying payments for services, states are forcing some physicians to close up shop. Not only do Pennsylvania and New York withhold payments, those states also happen to be two of the states that pay the least for Medicaid services in the US. New York pays $20 for a one hour consultation on a new patient. Hell, my babysitter makes almost that much – and she doesn’t have to purchase a $1 million malpractice insurance policy. Now New York is going to cut Medicaid payments further? (h/t to Kevin for the link) By encouraging hassles and purposefully delaying payments, states are limiting access to medical care. If you can’t get in to see a doctor, then the states don’t have to pay the doctor. Great way for states to minimize budget shortfalls – receive a portion of the 15.4% taken from every working person’s paycheck, pay a pittance for the services … and delay payment for the services, piss off enough medical providers so that very few people provide the services, and then keep most of the money. If I had a business that accepted money for services and then provided half-assed results, I’d be sued and probably charged with a crime. The state Attorney General may even come after me. Sure don’t see the Attorney General stepping in and going after states to make them pay the money they owe to medical providers. Strange how things work sometimes. Picture credit here Full AM News article below for those who don’t have access to the AM News site

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Mandated Employer-Paid Health Insurance

Among many “changes” advocated by President-Elect Obama is a plan for mandated employer-based health insurance. I can’t find a clear description on exactly how the plan is going to work (the plan is outlined on Obama’s site here, and there is a NEJOM summary here), but there are many opinions out there on what the effects of the plan will be. See posts at Hot Air Blog, The Health Care Insurance Reform Blog, The Cato Institute, and John Goodman’s Health Policy Blog I’m all for changing the current system, and I’m committed to giving Obama a chance to turn things around, but is mandating that employers pay for insurance going to improve healthcare in this country? I admit that I haven’t taken an in-depth review into the pros and cons, but in principle, I think it’s a bad idea. Reminds me too much of the “Hats” post I put up last year. If you’re an employer whose bottom line is hit by a tough economy and you’re now forced to spend additional money to either “pay” a percentage of your payroll into a national plan or to “play” by purchasing “health insurance” for your workers, what are you going to do? You’re going to find the cheapest way out. If I were an employer faced with this directive, I’d probably do one or more of several things: 1. I’d have to fire some of my employees to cut the amount of money I was required to spend on insurance. Now think about the repercussions of employers having to decrease the number of employees. Those former employees will have difficulty finding another job because most companies are downsizing because of the poor economy and to avoid paying extra for insurance for their employees. The former employees then end up sucking money out of the system by applying another mandated insurance plan called “unemployment insurance.” Instead of maintaining productive employees who contribute to the economy, mandated insurance will create out of work employees who take out of the economy. 2. I would purchase the cheapest insurance I can find. As in “Yeah, I’ll take that $100,000 deductible plan right there.” Hey – the mandate says you have to purchase insurance, it doesn’t say what kind of insurance you have to purchase. Exclusions for pre-existing conditions? So? Five thousand dollar policy limit? Big deal. Only pays providers three cents on the dollar so no provider will accept patients who have that type of insurance? Who cares? According to the mandate, insurance is insurance … right? 3. I would consider whether or not to cut my remaining employees’ wages to offset the cost of the insurance I am forced to buy. Depends on how far my company is in the black. If I’m having trouble making payroll and the economy is bad, where do you think the money is going to come from? Now consider the real-world impact. Employees who haven’t been fired will effectively receive less income so that employers can pay for the least expensive insurance they can find. In essence, the mandate is forcing the employees to pay for crappy insurance. Who wins? Not the States. They’re going to lose out with all the extra people using programs for the indigent because they are unemployed. Bigger drain on the system and I don’t know too many States that want to throw more money into social programs – most are trying to figure ways to cut back. Not the employers. They’re losing money by being forced to purchase insurance for the employees. Not the employees. The ones who haven’t been let go ...

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Medical Tourism

The Chicago Tribune has an AP story about how WellPoint is going to start a pilot program of medical tourism where it will send some non-emergent patients to India for surgeries in order to save money. A knee or hip replacement costs between $65,000 and $80,000 in the U.S., but only costs between $8,000 and $10,0000 in India. As a carrot to get patients interested, insurers will pay for travel, lodging, and the medical procedure for a patient AND will pay travel costs and lodging for a companion. I think medical tourism is a good idea. I especially like the concept because it cuts out the middle man. Patient pays for care, doctor and hospital provide care. Maybe patient and provider haggle over price. Maybe patient calls around to different hospitals and comparison shops – not unlike reading through the Sunday paper and comparing grocery ads. It concerns me that now a “middle man” wants to get involved. I also foresee all kinds of new issues popping up once American insurance companies actively engage in sending people to other countries to have medical procedures performed. Right now (and this is pure conjecture on my part), unless there is a catastrophic injury I believe that medical tourists effectively give up their right to sue a foreign doctor for malpractice. The patient will have to submit to another country’s malpractice laws. Doubt that the payouts would be anywhere near as big as they are in the US (although the docs might get jail time and 1500 lashes with a whip). To get started, the patient would have to retain an attorney (or attorneys) experienced in both malpractice and in international law.  Think you’ll be able to get some of those on contingency? Will the insurance company be liable in the US if there is malpractice in another country and the insurance company “brokered the deal”? Maybe you can’t sue the insurer for medical malpractice, but can you sue the insurer for negligent contracting? Will the ERISA shield apply to these types of lawsuits against insurers? What happens if there are surgical complications? In the US, the price for surgery includes a certain amount of follow-up care (30-90 days?). With foreign surgeries, does the patient stay in India until the complications are resolved? Will the insurance company pay for that care as well? What if there is a complication and family wants to visit? Who picks up the travel and lodging tab? What if the patient is OK when leaving India, then returns and develops a surgical complication? Surgeons in the US are often hesitant to “become involved in someone else’s screw up” (as I have heard more than one surgeon put it). A “screw up” is already more likely to end up in court. If a US surgeon tries to fix an Indian surgeon’s screw up and the patient doesn’t get better, then the US surgeon may be stuck holding the bag in the event of a lawsuit. If there is a “screw up” do the patient and a companion get shipped back to India to make good on the care? What happens if, during the trip, the patient has another medical problem? What happens if the surgery has to be canceled? Free trip for two to India? Aaaaack! What happens if there is a “never event”? Free care?? Or do those never event thingees only happen in American hospitals? The most pressing question of all is: Who gets to keep the frequent flyer miles? The Chief Medical Officer interviewed for the article hinted that insurers are trying to use medical tourism ...

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More On Medicare Never Events

I have to stop reading Kevin’s blog. Lately, every time I read through his posts, I get all riled up over something. The most recent thing to get my blood boiling was Kevin’s link to a nice rant on Buckeye Surgeon’s blog about these looming Medicare “Never Events.” There’s a journalist in Cleveland named Diane Suchetka who published a “blind leading the blind” article about “never events” in the Health News section of Cleveland.com. I know that I’ve beaten this whole “never event” horse before, but the whole concept is just so remarkably brain dead that I had to get my whip out again. The thing that concerns me the most about the “never event” concept right now is that many members of the general public are jumping on this bandwagon. Like foie gras ducks being force-fed corn, the citizens of this country are being force fed the notion of “never events” by the government and insurance agencies. Even more disconcerting is that the feeble minded among us actually believe that all of these “never events” should never happen. Just look at the comments to Ms. Suchetka’s article. After reading the article and the comments, I added my own comment: It is unfortunate that someone so misinformed about the effects of “never events” on the practice and accessibility to medical care is allowed to publish an article like this. It is even more unfortunate that so many of the members of the general public support Ms. Suchetka’s ramblings. First of all, look at the contradictions contained within this article itself. She quotes someone from “SHIC” as saying that “If hospitals were to set up efforts to follow these longstanding practices, the vast majority of these medical errors and infections could be prevented.” Wait a second. “Vast majority?” I thought that these were “never events.” Shouldn’t Captain Obvious have stated that the events would “never” happen if the policies were followed? Medicare calls the “errors” “reasonably preventable.” If they are “never events,” shouldn’t they be called “entirely preventable”? If they are “never events” then I want to see the people who came up with that term treat patients for a year and show me their results in preventing them. There are other misstatements. Realitynurse states that “C. diff is a medical mistake.” Uninformed and untrue statement. C. diff is an organism that lives and grows just like every other organism on this planet. Antibiotic use may increase the prevalence of C. diff, but antibiotic use does not “cause” C. diff. Your statement is akin to saying “mosquitoes are a mistake” or “uninformed nurses are a mistake.” Why has C. difficile become so ominous? Up to 20% of people prescribed clindamycin can develop C. difficile. What exactly should we do to make sure that not one single patient ever develops a C. difficile infection? Go on. I want all you smart people to tell me. Stop prescribing all antibiotics? Sounds like a plan. Then Medicare will deem all the other infections as “never events,” too. If any of the people reading this column want to avoid never events, here’s how to do it: Don’t go to doctors and stay away from hospitals. That’s right. Boycott us. If you want to create a manual on how to provide perfect medical care while you’re treating yourself for a ruptured appendix, I’d be happy to read it. Ms. Suchetka is right that these Medicare rules will affect all of us, but she has the wrong reasoning. They will affect all of you that develop these conditions because physicians and hospitals will avoid you like the ...

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Rating the Insurers

Sick of getting rated by the insurers? Physicians Practice magazine had an article in June that rated the insurers. The link to the article online is here. A print version of the article is here -> Examining Payer Performance. To summarize, UnitedHealth Group was the worst of the national insurers, rating lowest in patient opinion polls at 65 out of 100 and also ranking worst in hospital reputation with only 8% positive/91% negative scores. Aetna had a 66 out of 100 point score for patient opinion and had the highest reputation with hospitals at 57% positive/37% negative scores. A score of 57% is considered the “best”? In terms of regional payers, Medicaid was consistently rated as one of the worst. The Medicaid system in New York was by far the worst of the worst, taking more than three times as long to pay as the best Medicaid system and approving only 57% of the charges on the “first pass” compared to 92% of the charges on “first pass” paid by the best Medicaid system. New York Medicaid also had the highest denial rate, the lowest denial “transparency” and the highest noncompliance with national coding standards (more than 100 times greater than the best ranking state). So is it just a coincidence that a hospital New York was in the news for some bad patient outcome not too long ago? UPDATE AUGUST 14, 2008 Just found this 2008 AMA National Insurer Report Card. CIGNA and Humana are at the bottom of the list in timeliness. CIGNA and Health Net are at the bottom of the list in Accuracy. CIGNA and United Health reduce the most number of claims to $0 by edits. Notice a pattern?

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