Labor Department Sues UnitedHealth Group Over ‘Thousands’ of Claims Denials

By Katie Adams - The Labor Department recently sued UnitedHealth Group subsidiary UMR, alleging that it wrongfully denied claims for emergency room services and urinary drug screenings since 2015. UMR did not determine the medical necessity of the claims, denying them “based solely on diagnosis codes and not applying a prudent layperson standard," according to the complaint. Read Full Article…

VBA Article Summary

1. Alleged Violation of Federal Law: The U.S. Department of Labor has filed a lawsuit against UMR, a subsidiary of UnitedHealth Group, claiming that UMR wrongfully denied claims for emergency room services and urinary drug screenings since 2015. UMR allegedly denied these claims based solely on diagnosis codes, without applying a "prudent layperson standard", thus violating the Employee Retirement Income Security Act (ERISA) and the Affordable Care Act (ACA). UMR, as a third-party administrator, is required by ERISA to act in the best interest of plan participants. The Labor Department asserts that the company failed in this duty by denying claims for thousands of patients without evaluating their medical necessity.

2. Lack of Adequate Explanation for Denials: When UMR denied emergency room claims, they provided explanations of benefits that were allegedly insufficient. The explanations did not specify why the claims were denied, whether it related to the prudent layperson standard, or if the denial stemmed from inadequate documentation. Similarly, explanations for denied urinary drug screening claims were lacking critical details, making it challenging for patients to understand the reasons behind the rejections. Furthermore, UMR allegedly failed to educate patients about the informal appeal process they could undertake for denied claims.

3. History and Context of Urinary Drug Screening Claims: UMR reportedly denied all urinary drug screening claims between August 2015 and August 2018 without determining their medical necessity. It was only in August 2018 that UMR started accepting claims for certain urine tests conducted in emergency rooms or urgent care centers. By 2019, the company altered its urine screening claims denial reasons from a "lack of medical necessity" to requesting more medical records from the patient's healthcare provider.

With this lawsuit, the Labor Department aims to ensure that UMR complies with federal laws concerning claim procedures and wants the company to reprocess all denied claims from 2015 onwards.

Hospital mergers led to diminished quality of care, Elevance study finds

By Susanna Vogel - This study analyzed hospital admissions data from Elevance-affiliated commercial health plans in 20 states between 2012 and 2018 to determine the impacts of mergers on quality and access to care. The analysis is one of many suggesting hospital consolidation raises prices, but is valuable because it relies on actual price data from health plans, instead of average prices from data reported to the federal government, according to Elevance’s Public Policy Institute, which authored the report. Read Full Article… 

VBA Article Summary

1. Effects of Hospital Acquisitions: When independent hospitals were acquired by health systems, there were significant repercussions for patients. These acquisitions led to an average of 6% reduction in operating costs, largely due to personnel reductions. However, this cost-saving came at the expense of patients, with inpatient prices for those commercially insured rising by 5%. Additionally, readmission rates for cardiac care patients saw an increase of up to 12% and this elevated rate persisted for three years following the acquisition.

2. Decline of Independent Hospitals and Rise in Consolidation: Over a two-decade span from 2000 to 2020, there has been a marked decline in independent hospitals, with the proportion of hospital beds under health systems rising from 58% to 81% nationwide. Some regions now lack even a single independent hospital. Despite a brief decline in merger and acquisition activity during the pandemic, the rate has rebounded, motivated largely by the desire for operational efficiency. Independent hospitals are often driven to merge with larger health systems to garner more resources, negotiate favorable terms with payers, and better manage administrative burdens.

3. Regulatory Scrutiny of Hospital Mergers: Hospital mergers are increasingly coming under scrutiny from both state and federal governments. Cases in point include the canceled acquisition in California due to state intervention and the creation of a law in Minnesota giving the attorney general oversight into healthcare mergers. On the national front, the FTC released new antitrust merger guidelines, providing regulators with more tools to examine and potentially challenge cross-market merger deals.

Aflac's CHRO talks tech, AI, and why employers still aren't listening to employees' benefits needs

By Stephanie Schomer - Is it possible to get employees to truly engage with benefits communication? Yes — but it takes a number of complementary strategies, plenty of employer listening, and an assist from technology. "We're really seeing a blended workforce from a technology-expectation perspective," says Matthew Owneby, CHRO at Aflac. Read Full Article… 

VBA Article Summary

1. Growing Demand for Online Benefits Management: A significant portion of the workforce, especially millennials, is increasingly expecting to manage their benefits online. Aflac's 2022-2023 Workforces Report indicates that 82% of employees consider online management of benefits as very or extremely important. However, there's a gap between employee expectations and employer offerings. Only 67% of employers provide a digital platform for benefit management, a decline from 79% in 2021.

2. The Challenge of Effective Communication and Integration: Even with advancements in technology and the integration of social media channels, there remains a consistent communication disconnect between employers and employees regarding benefits. Employers often believe they effectively communicate the value of their benefits, but a significant portion of employees feel they do not fully understand their benefits. Companies need to consolidate the variety of benefits apps into one accessible portal. While individual apps exist from various providers, a unified platform can enhance user experience and engagement.

3. Future of Work and Role of AI in Benefits: The shift to remote and hybrid work models is influencing the types of benefits employees value. To encourage in-office presence, companies like Aflac are offering attractive perks like on-site child care and healthcare. The potential of artificial intelligence (AI) and machine learning in benefits management is vast. In the future, AI can analyze patterns in healthcare usage among employees and adapt benefits offerings accordingly. Customization based on AI can optimize both employee experience and company resources.

CVS to lay off 5K employees amid cost pressures

By Rebecca Pifer - The job cuts come as CVS faces significant integration costs from recent M&A activity. The layoffs, first reported by the Wall Street Journal and confirmed to Healthcare Dive, represent under 2% of CVS’ workforce. CVS employed more than 300,000 workers as of the end of last year, roughly three-fourths of them full-time, according to a filing with the SEC. Read Full Article… 

VBA Article Summary

1. Major Job Cuts and Cost Savings: CVS is letting go of approximately 5,000 employees, mostly in corporate positions, as part of its ongoing cost-reduction efforts. The company is grappling with expenses from its recent large-scale acquisitions. In addition to job cuts, CVS is minimizing its use of consultants and vendors, and discontinuing certain business initiatives that don't align with their current strategy.

2. Recent Acquisitions and Financial Pressure: Despite a rise in revenue for the first quarter, CVS faces substantial costs from recent mergers and acquisitions. The company recently bought Oak Street Health for $10.6 billion and acquired home health provider Signify for $8 billion. CVS has had to reduce its earnings forecast for 2023 due to these significant integration costs and the challenge of focusing more on direct healthcare delivery. There are also additional challenges from drugmakers and the rapid decrease in COVID-19 contributions.

3. Company Adaptation and Employee Assistance: The layoffs are a part of CVS’s strategy to prioritize care delivery and technology, adjusting to market shifts and evolving consumer health needs. CVS has assured that employees affected by the layoffs will be provided with severance pay, benefits, and assistance in finding new roles. The company believes these decisions will pave the way for long-term success.

The article concludes with a note that CVS will be announcing its second-quarter earnings results the following Wednesday.

Aetna, MLB hit with ERISA suit over denied mental health coverage

By Riley Brennan - Aetna Health and Life Insurance Co. and Major League Baseball Players Benefit Plan were hit with an ERISA lawsuit, challenging mental health claims that were denied by his health insurance benefits. This complaint was first surfaced by Law.com Radar. Read Full Article… 

VBA Article Summary

1. Lawsuit Against Aetna: A court action was filed against Aetna by DL Law Group on behalf of Chris C. in the U.S. District Court for the Northern District of California. The lawsuit challenges Aetna's denial of insurance coverage for inpatient mental health treatment provided to Chris C.'s daughter. The complaint claims that the denial violated both California’s Mental Health Parity Act and the Federal Mental Health Parity and Addiction Equity Act of 2008.

2. Basis for Denial: Despite the daughter being diagnosed with several mental disorders and receiving a recommendation for inpatient treatment from her providers, Aetna denied the insurance claim. The denial was based on the reasons that the treatment center did not meet the plan definition of a 'physician' and that the treatment center is not recognized and approved by certain accreditation bodies. Furthermore, the lawsuit alleges that Aetna imposed unfair treatment limitations (NQTLs) on mental health benefits, which don't apply to medical/surgical treatments.

3. Relief and Requests: Chris C. seeks for Aetna to pay the due mental health benefits, award reasonable attorney fees and costs, and 9% compounded prejudgment interest. Additionally, the lawsuit calls for a court order to stop Aetna from imposing certain accreditation requirements and to change procedures to ensure a fair appeals process. The complaint also demands that Aetna be removed as a plan fiduciary and that Chris C.’s claims be reevaluated in accordance with relevant laws. Chris C.’s attorney emphasized that the denial based on technicalities is "unconscionable."

U.S. Department of Labor sues UnitedHealth Group over thousands of denied claims

By Christopher Snowbeck - The U.S. Department of Labor is suing a subsidiary of UnitedHealth Group over allegations that the company wrongly denied thousands of claims to pay health care providers for emergency room services and urinary drug screenings. Denial of the ER claims was based solely on diagnosis codes, the government alleges, rather than a "prudent layperson" standard that's required by health plan documents. Read Full Article… 

VBA Article Summary

1. Accusations Against UMR Inc., a UnitedHealth Group Division: The U.S. District Court for the Western District of Wisconsin has received a lawsuit this week that accuses UMR Inc., a Wausau-based division of UnitedHealth Group, of improperly denying claims. The suit alleges that UMR should have applied a medical necessity standard to claims for urinary drug screening but instead denied all the claims. Furthermore, UMR is accused of failing to provide required information for denial documents and implementing a "True Emergency" policy that led to the unjust denial of emergency room claims.

2. Response from UnitedHealth Group and Related Concerns: UnitedHealth Group maintains that the government's complaint deals with administrative processes no longer in use and that they have been in ongoing conversations with the Labor Department, vowing to defend their position vigorously. Dr. Christopher Kang, president of the American College of Emergency Physicians, sees the lawsuit's issues as part of a broader pattern of large insurance companies delaying or reducing payments for emergency care, calling for immediate action to hold insurers accountable.

3. Details of the Alleged Misconduct and Its Implications: The lawsuit details the period during which UMR denied all urinary drug screening claims (August 2015 through August 25, 2018) and the change to its denial policy in August 2018 after a high overturn rate on appeal. It emphasizes that UMR's methods for adjudicating emergency room claims did not consider the layperson's perspective, relying solely on a medical provider's diagnosis at the end of treatment. The lawsuit's allegations point to a systemic problem with the way UMR handled claims, potentially affecting thousands of participants and 371 health plans, reflecting a critical issue in self-insured health plans in the U.S.

Medicare Part B premiums may increase in 2024, prompted by a new Alzheimer’s treatment

By Lorie Konish - One of the costs retirees pay — Medicare Part B premiums — may be increasing in 2024, driven by a new Alzheimer’s treatment on the market. The Medicare trustees projected in March that the standard monthly Part B premium may increase to $174.80 in 2024, an almost $10 monthly increase from the $164.90 standard monthly premium beneficiaries are currently paying. Read Full Article… 

VBA Article Summary

1. Introduction of Leqembi and Its Impact on Medicare Part B: Leqembi, a treatment for early-stage Alzheimer's, has been approved by the FDA and is now covered by Medicare. It's estimated to become the third most expensive drug under Medicare Part B, which may lead to an increase in Part B premiums. The Senior Citizens League estimates that Leqembi might increase Part B premiums by about $5 per month, totaling $179.80 monthly. With other associated costs, beneficiaries might see their premiums rise nearly $15 per month.

2. History and Future Projections of Part B Premiums: Previously, the introduction of another Alzheimer’s treatment, Aduhelm, caused a significant 15% increase in Part B premiums from 2021 to 2022. In contrast, the premiums decreased by 3% in 2023 due to restrictions on Aduhelm coverage. Juliette Cubanski of KFF mentioned that final premium figures for 2024 would be available in a couple of months.

3. Implications for Social Security and Medicare Beneficiaries: Social Security's cost-of-living adjustment for 2024 is predicted to be 3%, much lower than the previous year's 8.7% increase. The real impact on Social Security checks will be determined by the new Part B premium, as these premiums are deducted directly from these checks. Fluctuations in both the cost-of-living adjustments and Part B premiums have historically led to stagnant monthly checks for some beneficiaries for several years, increasing their financial reliance on savings or incurring debt. Medicare will cover Leqembi for patients with certain conditions, but it's uncertain how many will opt for it. The cost for patients could exceed $5,000 annually, excluding additional related medical services. Another Alzheimer's treatment might be introduced by year-end, but its adoption may be slow due to potential side effects.

Dental Insurance Service Market to Witness Astonishing Growth by 2030 | AXA, Allianz, Aetna

By EIN Presswire - The 2023E-2030 Global Dental Insurance Service Market study with 132+ market data Tables, Pie charts & Figures is now released by HTF MI. The research assessment of the Market is designed to analyze futuristic trends, growth factors, industry opinions, and industry-validated market facts to forecast till 2029. The market Study is segmented by key a region that is accelerating the marketization. This section also provides the scope of different segments and applications that can potentially influence the market in the future. Read Full Article… 

VBA Article Summary

1. Overview of the Global Dental Insurance Service Market: The Dental Insurance Service Market was valued at USD 112,987 Million in 2023 and is expected to reach a value of USD 147,232 Million by 2029, growing at a Compound Annual Growth Rate (CAGR) of 4.51% from 2023 to 2029. The dental insurance service market provides coverage and related services for dental care and oral health expenses. Offerings in the market range from preventive care, basic treatments, to major procedures, with some even covering orthodontic procedures. Major players in the industry include Cigna, Aetna Inc., UnitedHealthcare Services, Inc., Delta Dental, MetLife Services and Solutions, LLC, Humana, AXA, Allianz, Aflac Incorporated, and Ameritas.

2. Market Dynamics:

   Trends: There's a growing awareness of oral health's impact on overall well-being, leading to increased demand for dental insurance. Technological advancements like tele-dentistry are making dental care more accessible. Also, consumers are now looking for dental insurance plans that are more flexible and tailored to their needs.

   Drivers: The increasing cost of dental treatments emphasizes the importance of dental insurance. Additionally, dental insurance remains a crucial part of employee benefits, pushing insurance providers to offer competitive packages. Government initiatives to improve oral health, especially for marginalized groups, further fuel the market demand.

   Opportunities: There's room for growth by introducing innovative and user-centric dental insurance plans and tapping into emerging markets where dental insurance has low penetration.

3. Challenges and Competitive Analysis:

   Challenges: Some dental insurance plans come with restrictions or waiting periods, especially for major procedures, making it hard for those needing immediate extensive dental work. Furthermore, certain regions or demographics might not be fully aware of dental insurance options, leading to reduced market participation.

   Competitive Analysis: It's essential for stakeholders to understand the current market landscape. This includes insights into consumer trends, segment analysis, market share analysis, and competitor revenue details. The analysis can shed light on competitors like Cigna, Aetna Inc., and UnitedHealthcare Services, Inc., and others, helping businesses identify potential threats and opportunities.