Anthem and UnitedHealthcare Falling Billions Behind in Payments

Jul 30, 2024 | Uncategorized

Anthem and UnitedHealthcare are among the major insurers lagging billions of dollars in payments to hospitals and doctors. New reimbursement rules, computer problems, and mishandled claims have led to these delays. Continue reading below to learn more!

Anthem Blue Cross, the country’s second-largest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors due to onerous new reimbursement rules, computer issues, and mishandled claims, according to hospital officials in multiple states. Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute “egregious” policies that harm patients and strain hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of, ‘Everyone’s distracted. We can get this through,’” she said.

Hospitals are also facing a spike in retroactive claims denials by UnitedHealthcare, the largest health insurer, for emergency department care, the AHA reports. Disputes between insurers and hospitals are nothing new, but this situation puts more patients in the middle, worried they’ll have to pay unresolved claims. Hospitals say this is hurting their finances as they cope with COVID-19 surges, even after receiving tens of billions of dollars in federal emergency assistance.

“We recognize there have been some challenges” to prompt payments caused by claims-processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”

Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, which operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are over 90 days old, VCU said. For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators. Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks, and the system is straining to finance the personnel and supplies” needed to fight COVID-19.

Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN. Substantial payment delays can be seen on Anthem’s books. On June 30, 2019, before the pandemic, 43% of the insurer’s medical bills for that quarter were unpaid, according to regulatory filings. Two years later, that figure had risen to 53% – a difference of $2.5 billion. Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.

‘It’s a game they’re playing’

Alexis Thurber, who lives near Seattle, was insured by Anthem when she received an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer. Anthem deemed the treatments “experimental” and “not medically necessary,” according to Thurber. She spent much of the summer trying to get the insurer to pay up – making two dozen phone calls, spending hours on hold, sending multiple emails, and enduring immense stress and worry. It finally covered the claim months later. “It’s so egregious. It’s a game they’re playing,” said Thurber, 51, whose cancer was diagnosed in November. “Trying to get true help was impossible.” Privacy rules prevent Anthem from commenting on Thurber’s case, said Anthem spokesperson Colin Manning.

When insurers fail to promptly pay medical bills, patients are left in a bind. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn’t pay. Hospitals point to various Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures, and requirements that doctors themselves – not support staffers – speak to insurance gatekeepers. “This requires providers to literally leave the patient’s bedside to get on the phone with Anthem,” AHA said in its letter. Anthem often hinders coverage for outpatient surgery, specialty pharmacy, and other services in health systems listed as in-network, amounting to a “bait and switch” on Anthem members, AHA officials said. “Demanding that patients be treated outside of the hospital setting, against the advice of the patient’s in-network treating physician, appears to be motivated by a desire to drive up Empire’s profits,” the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.

Anthem officials pushed back in a recent letter to the AHA, saying the insurer’s changing rules are partly intended to control excessive prices charged by hospitals for specialty drugs and non-emergency surgery, screening, and diagnostic procedures. Severe problems with Anthem’s new claims management system surfaced months ago and “persist without meaningful improvement,” AHA said in its letter. Claims have gotten lost in Anthem’s computers, and in some cases, VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes “an unmanageable disruption that threatens to undermine our financial footing,” VCU said.

An ‘incredibly aggravating’ response

United denied $31,557 in claims for Emily Long’s care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for “medical necessity” – an “incredibly aggravating” response on top of the distress of the accident, Long said. The Brooklyn hospital that treated Long was “paid appropriately under her plan and within the required time frame,” said United spokesperson Maria Gordon Shydlo. “The facility has the right to appeal the decision.” United’s unpaid claims stood at 54% as of June 30, about the same level as two years previously.

When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer’s entire prior-authorization database had gone down for weeks, said Conlisk, who lives in California. “There was a brief issue with our prior authorization process in mid-July, which was resolved quickly,” Gordon Shydlo said.

When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis. “Really a ton of uncertainty associated with this environment,” John Gallina, the company’s chief financial officer, said on a conference call in July. “We’ve tried to be extremely prudent and conservative in our approach.”

‘A deep fear of talking on the record’

During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem, and other insurers accelerated billions in hospital reimbursements. The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled. Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds “have been a lifeline, but they don’t make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience,” Pollack said.

Several health systems declined to comment about claims-payment delays or didn’t respond to a reporter’s queries. Among individual hospitals, “there is a deep fear of talking on the record about your largest business partner,” AHA’s Smith said.

Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she’s not confident her Anthem policy will do a better job next time of covering the cost of her care. “It makes me not want to go to the doctor anymore,” she said. “I’m scared to get another mammogram because you can’t rely on it.”

Original article published on usatoday.com

AMGA Opposes Proposed Medicare Advantage Coding Changes

Jul 29, 2024 | Uncategorized

The Centers for Medicare & Medicaid Services (CMS) has introduced new medical coding changes for Medicare, raising concerns among healthcare providers about the potential negative impact on patient care quality. To learn more about these proposed coding changes, continue reading. AMGA has requested that CMS not finalize the coding changes included in the 2024 Medicare Advantage Advance Notice, which would revise diagnoses and condition categories in the hierarchical condition categories (HCC) model. According to AMGA, the proposed changes to the risk adjustment model would negatively impact healthcare providers involved in value-based care contracts.

CMS has proposed transitioning from the ICD-9 coding system to ICD-10. While AMGA supports this shift, it has raised concerns about the revised HCC model, which includes fewer ICD-10-CM codes mapped to an HCC for payment purposes. Specifically, CMS has proposed removing over 2,000 unique codes from the HCC model that cover a variety of conditions, including depressive disorder, vascular disease, rheumatoid arthritis, and diabetes with chronic conditions. AMGA’s letter to CMS noted the limited timeframe for providers to review these changes, which could affect those in value-based contracts. Participation in value-based programs already presents challenges such as investing in analytics and hiring care managers. Adding more uncertainty could discourage provider participation.

Past changes to the risk adjustment model have been phased in, allowing plans and providers to adjust their systems and anticipate potential effects. If the proposals in the Advance Notice are finalized, Medicare Advantage plans must submit bids based on the new model by June 5, 2023, just four months after CMS released the proposal. AMGA urged CMS to extend the timeline for implementing the risk adjustment changes to allow adequate time for providers and plans to consider the effects and provide feedback. AMGA also expressed concerns about the minimal information CMS has provided to stakeholders and the unclear impact of the model changes.

Specifically, the proposed changes would standardize coefficient values for the diabetes group in the HCC model, regardless of complication status. This means that diabetes with severe acute complications, chronic complications, and unspecified or no complications will all have the same weight in the risk score, despite significant differences in care needs. CMS proposed a similar change for congestive heart failure. “By proposing to collapse these HCCs into a single risk score, CMS is discounting the importance of risk adjustment in the MA program,” the letter stated. “AMGA members in any value-based care arrangement, MA or otherwise, understand how critical accurate risk adjustment is for any population health-based model.”

AMGA said removing codes from the HCC model that represent conditions common among disadvantaged populations is “in stark contrast with CMS’ commitment to advance health equity throughout our public health system.” The changes will likely reduce payments to Medicare Advantage plans, impacting provider reimbursement and patient care access. AMGA suggested that CMS not finalize the proposed changes to the HCC model and instead work with stakeholders to help providers and plans understand the proposal’s effects.

While AMGA opposed the changes to the HCC model, the organization supported CMS’ proposal to align quality measures across Medicare. The Universal Foundation measurement is similar to an AMGA 2018 initiative that created a streamlined set of quality measures to simplify the reporting process and reduce provider burden.

AMGA is not the only provider group that has voiced opposition to the removal of diagnostic codes from the HCC model. America’s Physician Groups (APG) expressed similar concerns and called on CMS to delay the proposed modifications, explain its rationale for the specific coding changes, and acknowledge that the proposals could hinder health equity and value-based care advancements. APG also commissioned an ATI Advisory analysis which found that the changes would result in fewer patient visits that count toward risk adjustment. The share of visits contributing to risk adjustment would fall by one-third for patients with psychiatric conditions, 38 percent for those with musculoskeletal conditions, and 69 percent for patients with vascular conditions.

Original article published on revcycleintelligence.com

American Medical Association Unveils ‘Recovery Plan’ for Physicians

Jul 26, 2024 | Uncategorized

Due to the challenges physicians have faced in recent years, many are experiencing burnout and exhaustion. To address this, the American Medical Association (AMA) has developed a plan aimed at boosting morale. Continue reading to learn more about these developments.

The AMA has announced the AMA Recovery Plan for America’s Physicians to tackle the pressing challenges facing the nation’s doctors. Physician burnout was already a national concern before the coronavirus pandemic, and the pandemic has exacerbated this issue to crisis levels. The Association of American Medical Colleges projects a shortage of 37,800 to 124,000 physicians by 2034. AMA President Gerald Harmon, MD, emphasized the urgency of the situation, stating, “America’s doctors are a precious, irreplaceable resource. Physician shortages, already severe before COVID, have nearly become a public health emergency. If we don’t succeed with this Recovery Plan, attracting young talent to medicine and addressing the shortage will be even more difficult.”

The Recovery Plan focuses on five key areas:

• Supporting telehealth services, including insurance coverage
• Reforming Medicare payment for physician services
• Preventing “scope creep” that expands the practice scope of non-physicians, such as nurse practitioners
• Reforming prior authorization to reduce administrative burdens and avoid care delays
• Addressing physician burnout and reducing the stigma around mental health for physicians

Expanding Telehealth The pandemic led to unprecedented growth in telehealth, with 90% of physicians adopting it for patient care. Continuing telehealth services benefits both physicians and patients. Harmon noted, “The Centers for Medicare & Medicaid Services ensured that telehealth payment rates were equivalent to in-person services, even for audio-only visits. This has proven to be a viable option, offering safety, convenience, and time savings for patients. In rural areas, where geographic barriers pose significant travel challenges, digital health is invaluable.” Harmon stressed the importance of preserving telehealth advancements, saying, “Patients and physicians overwhelmingly support the continuation of telehealth post-pandemic. We are working to update laws and regulations to make this permanent.”

Reforming Medicare Physician Payment For years, Medicare reimbursement for physician services has been inadequate, creating financial uncertainty for physician practices. Harmon explained, “Medicare physician payments, the only healthcare delivery component subject to budget neutrality, have fallen 20% when adjusted for inflation since 2001. Legislative and regulatory changes during the COVID pandemic threatened a 10% cut in Medicare payments this past January. Thanks to the AMA and other medical organizations, Congress averted these cuts at the last minute—a major victory. However, we shouldn’t face this annual uncertainty. We need a permanent solution to ensure the economic viability of physician practices.”

Harmon underscored the need for payment reform, saying, “Predictable financial returns are essential for investing in costly infrastructure like new technologies and treatments. We are done with short-term fixes and looming cuts.”

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American Academy of Dermatology’s Guide to Sunscreen

Jun 5, 2024 | Uncategorized

Summer is here, and many people are spending more time outside, swimming, and taking vacations. It is crucial to wear sunscreen to protect yourself from the sun. Read below for more information from the American Academy of Dermatology about the importance of sunscreen!

With Memorial Day marking the unofficial start of summer and the reopening of many beloved outdoor activities after the COVID-19 shutdown, it’s more important than ever to remember your sunscreen—especially after many of us spent months indoors. The American Academy of Dermatology (AAD) offers a great two-minute video and five tips for proper sun protection.

So get outside, enjoy your favorite activities, and don’t forget to apply that sunscreen. It’s finally summer! Click here to read more about sunscreen from the AAD.

Amazon Is Already Reshaping Health Care

May 29, 2024 | Uncategorized

Amazon In The Healthcare Space

The mere threat of Amazon.com Inc. entering the health care market has already started transforming U.S. health care, and not necessarily for the better. This looming presence has accelerated consolidation, leading to potential consumer disadvantages.

The speculation about Amazon’s involvement prompted two of the largest pharmacy benefit managers, CVS Health Corp. and Express Scripts Holding Co., to merge with major insurers, Aetna Inc. and Cigna Corp. These mergers consolidate more of the U.S. health care system under fewer companies. While the merging companies claim this will reduce costs for consumers and the nation, the reality is likely to be more complex and less favorable.

About The Mergers

These mergers were made possible partly due to the Federal Trade Commission and the Department of Justice blocking the mergers of Anthem Inc. with Cigna and Aetna with Humana Inc. These mega-insurers would have been too preoccupied with their own integrations to pursue such vertical deals and would have been too large to be acquired by other insurers.

UnitedHealth Group Inc. has also played a significant role in motivating these mergers. It pioneered aggressive diversification by acquiring a large PBM in 2015 and through its Optum health-services unit. Its success in patient enrollment, revenue growth, and market valuation has set a benchmark, inspiring similar strategies among its peers. Additionally, profit pressures on PBMs likely made them more open to merging with insurers.

However, Amazon’s potential entry into the health care market is a significant factor driving these deals. Amazon’s technological capabilities, long-term investment approach, vast appetite for new ventures, and tolerance for thin margins have unsettled investors, especially those involved in the industry’s middleman roles. If these mergers are finalized, the result will be unprecedented market concentration, with the three largest U.S. PBMs tied to three of the largest insurers.

Effects On Prescriptions

CVS, Express Scripts, and UnitedHealth currently process over 70% of all U.S. prescriptions. Post-merger, three companies will manage the insurance of over 90 million people, process more than 3.5 billion prescription claims, and generate over $500 billion in revenue. While not every American will have both their medical and drug benefits managed by the same company, many more will in the future.

These integrated companies will have more comprehensive information about their customers and a greater ability and incentive to manage total health spending. UnitedHealth is already deeply integrated, with investments in ambulatory surgery centers and physician groups. The merger of CVS and Aetna, which adds retail pharmacies and primary care clinics to the mix, could significantly impact patient lives.

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