Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients

By Susan Jaffe - Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home. Read Full Article…

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1. Alleged Algorithmic Oversight and Coverage Discrepancies: Patients, providers, and patient advocates in various states have raised concerns regarding UnitedHealthcare’s nH Predict tool, claiming it often prematurely estimates patients’ discharge dates, which coincidentally align with the termination of their coverage. Critics argue that these algorithmically generated decisions do not fully accommodate the patients' unique health needs, resulting in inadequate care and potential health risks. This is exemplified in the case of Sullivan, a 76-year-old patient who still required considerable medical assistance but experienced a cutoff in her nursing home coverage. Instances like Sullivan’s highlight the reported mismatch between algorithmic predictions and individual patient needs, necessitating a call for human intervention to ensure appropriate and empathetic healthcare decisions.

2. Medicare Advantage Plans Under Scrutiny: Medicare Advantage plans, operated by private firms including UnitedHealthcare, offer an alternative to government-run Medicare with additional benefits but have been criticized for potential service denial to maximize profits. Reports indicate that services like nursing home care, which would likely be covered under original Medicare, are frequently denied by these private plans. With the federal government planning to enforce restrictions on the use of predictive technology in Medicare Advantage plans in the coming year, these companies will be under increased scrutiny to ensure that their decision-making processes are transparent, fair, and patient-centered.

3. Regulation and Compliance Challenges: Despite forthcoming federal rules designed to curb the use of algorithms in making coverage decisions, concerns persist about the enforcement and compliance of these regulations. The new rules mandate that insurance plans should base medical necessity determinations on individual circumstances rather than solely relying on algorithms. However, without specific penalties outlined for violations and ambiguity in the review process of coverage denials, there is uncertainty about the efficacy of these regulatory changes in guaranteeing fair coverage decisions and protecting patient rights. Advocacy groups and healthcare providers are urging for stringent enforcement measures to ensure that patients receive the necessary care without unwarranted financial burdens.

"Under the law he had no remedy." How Dr. Dan Hurley's legacy could lead to health insurance prior authorization reform

By Wendell Potter - Even in death, Dr. Dan Hurley’s fight against insurance companies and their often baffling and infuriating decisions on whether to pay – or not – for costly but essential medical care is far from over. Read Full Article…

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1. Disputed Insurance Claim Following a Doctor’s Death: The article highlights a disheartening scenario where the insurance company denied paying $80,000 for the final, experimental chemotherapy treatments of a Phoenix-area Ear, Nose, and Throat (ENT) doctor who succumbed to a rare form of cancer, chondrosarcoma. The insurers refused the payment despite preliminary approval, later arguing that the initial treatment was unapproved and the subsequent one was medically unnecessary – claims strongly disputed by the deceased doctor’s wife, Traci Hurley, who is now appealing the decision.

2. The Battle for Reforming Prior Authorization Practices: The late Dr. Hurley, in addition to his valiant fight against cancer, spent his final months challenging the existing health insurance practices, especially focusing on prior authorization. He envisioned forming an advocacy group and potentially initiating a class-action lawsuit aimed at reforming the system. Hurley, who had also enrolled in law school to better equip himself for this battle, had begun consulting experts in the field, like attorney Brian Hufford, to explore possible legal actions and other avenues for instigating change.

3. Persistent Issues with Insurance Claims and Prior Authorization: The story sheds light on the wider and deeply systemic issues related to insurance claim denials and prior authorization practices, illustrating a grim reality for many American patients. With approximately one in seven claims being denied by private insurers – often under the pretense of a treatment being unnecessary or overly experimental – the story underscores the urgent need for reform. Dr. Hurley’s relentless fight against such denials, for both his son and himself, exemplifies the enormous challenges and frustrations patients face when navigating through a complex and often non-transparent health insurance system.

McLaren Health Care confirms ransomware attack, investigates hackers' threats to release data online

By Dave Muoio - A 14-hospital system in Michigan said it is investigating reports that millions of its patients’ data “may be available on the dark web” following a security breach that reportedly affected its computer systems early last month. Read Full Article…

VBA Article Summary

1. Major Data Breach at McLaren Health Care: Late last week, a ransomware group claimed to have successfully extracted over six terabytes of data from McLaren Health Care, one of Michigan’s largest healthcare companies. Through online statements, the group threatened to release the sensitive information, alleging it pertains to 2.5 million patients, if their demands are not met. McLaren Health Care has since acknowledged the cyberattack, confirming the detection of suspicious activities on its networks, which led to a ransomware event.

2. Proactive Measures and Investigation Underway: In response to the cyber breach, McLaren has launched a comprehensive investigation into the matter and engaged global cybersecurity specialists to assist in the process. The healthcare provider has also been in communication with law enforcement. Subsequent to the breach, the organization has implemented additional security measures to enhance its cybersecurity defenses and mitigate potential disruptions to its services. McLaren's representatives are currently investigating reports suggesting that some of the stolen data might be circulating on the dark web.

3. Heightened Cybersecurity Risks in Healthcare Sector: The incident at McLaren Health Care is not isolated, as 2023 has already witnessed several high-profile data breaches affecting healthcare providers. These cybersecurity lapses not only risk the sensitive data of millions of patients but also impose significant financial burdens on the affected institutions. In 2022, healthcare organizations experienced an average loss of $10.1 million per cybersecurity incident, marking a 9.4% increase from the previous year. These figures underscore the escalating cybersecurity challenges within the healthcare sector and the imperative for robust protective measures.

5 ways brokers can help demystify health insurance

By Jasper Purvis - The adage “there are no stupid questions” is quite apt when it comes to navigating the complexities of the American health care industry, especially health insurance. Yet, many employees get incredibly stuck just trying to figure out where to start selecting health insurance that makes the most sense for them and their families, let alone understanding how to use their benefits to save themselves and their companies money. Read Full Article…

VBA Article Summary

1. Demystifying Health Insurance Concepts:

   Facilitate Inquisitiveness - Brokers need to destigmatize the process of asking questions. They should serve as accessible points of contact for employees, simplifying complex insurance concepts into digestible information through examples, scenarios, and simplified terminology. This approach empowers employees with enough understanding to pose informed questions and navigate their options confidently.

   Year-Round Communication - It’s vital for brokers to provide regular updates on changes to insurance policies, plans, rules, and regulations. This proactive communication strategy keeps both leaders and employees informed, helping them anticipate and adjust to changes effectively.

   Educational Resources - Offering resources like educational videos, FAQs, and consistent documentation on health plan operations, preventive health benefits, and insurance terminology can significantly support employees' understanding. Brokers can further enhance understanding by leading or sharing employee lunch-and-learns, workshops, and webinars, potentially offering one-on-one consultations.

2. Enhancing Employee Engagement:

   Regular Surveys - Brokers can facilitate year-round surveys to collect feedback on benefits processes, employee sentiments regarding their benefits, and other relevant aspects of health insurance. This strategy not only provides valuable data for internal strategy improvement but also fosters a sense of value and acknowledgement among employees, enhancing their engagement.

   Pre-Enrollment Surveys - These surveys can identify areas of confusion and concern among employees ahead of open enrollment periods. Brokers can utilize this data to tailor communication strategies, fostering clarity and engagement while building trust and confidence among employees.

3. Decision Support During Open Enrollment:

   Decision Support Tools - Implementing these tools during open enrollment can simplify the process for employees. These platforms elucidate available coverage options, explain complex terms, and delineate the benefits and limitations of each plan, empowering employees to make informed choices aligned with their needs and preferences. Furthermore, these tools streamline the decision-making process during open enrollment, saving employees time and helping them identify cost-saving opportunities.

Medicare Advantage plan slashes drug co-pays ahead of negotiations

By Maya Goldman - Medicare Advantage insurer SCAN is getting ahead of the program's planned drug price negotiations by offering seniors free or $11 monthly co-pays for 13 name-brand drugs, the carrier told Axios first. Read Full Article…

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1. Proactive Cost Reduction: The nonprofit SCAN is actively taking measures to mitigate the costs of vital drugs for their beneficiaries ahead of governmental negotiations set for 2024. Sharon Jhawar, SCAN's chief pharmacy officer, emphasized that the organization isn’t relying solely on government efforts but is proactively seeking ways to lower drug costs for patients. This initiative primarily targets expensive cardiovascular and diabetes drugs with no generic alternatives, like Eliquis, Xarelto, and Jardiance, making them more accessible to patients in need.

2. Beneficial Changes for Eligible Consumers: To alleviate the financial burden on patients, SCAN is implementing a zero co-pay policy for individuals eligible for both Medicare and Medicaid, as well as those enrolled in plans for diabetes and heart failure patients. For other consumers, the out-of-pocket cost will be a mere $11. Importantly, these changes mean that beneficiaries will see a significant reduction in co-pays, from the current range of $30 to $50 down to zero or $11. These adjustments are made possible by reallocating funds that would have otherwise been counted as profits, without necessitating cuts to other benefits offered by SCAN.

3. Uncoupling from Legal Uncertainties: Regardless of the uncertainties surrounding the Medicare drug price negotiation process in the courts, SCAN's new policy will proceed as planned. This decision underlines the organization’s commitment to facilitating better access to essential medications for older adults, independent of the ongoing legal and political debates. The broader impact of this policy will also be closely monitored, as SCAN intends to analyze changes in total care costs and patient outcomes when medications are made more financially accessible. With over 20% of American seniors reportedly skipping medications due to cost concerns, the policy is expected to not only improve individual health outcomes but also potentially lower SCAN's overall expenses by ensuring consistent medication adherence among beneficiaries.

Denials management is ripe for automation investment

By Jay Asser - If your healthcare organization isn't already automating denials management, it should consider moving away from manual processes to alleviate expenses. Denials management is one area of revenue cycle management that is especially susceptible to inefficiencies, which is why hospital leaders need to explore investment in AI, whether that's a standalone or an end-to-end solution. Read Full Article…

VBA Article Summary

1. Underutilization of Automation in Denials Management: A recent survey reveals that only 38% of hospitals and health systems currently automate any part of their denials management process, although there is an evident shift towards automation in the near future. Out of the CFOs and revenue cycle leaders surveyed, 44% plan to implement automation by the end of the year, and an additional 32% intend to do so in 2024. The growing interest in automation highlights the pressing need to streamline the denials management process in healthcare institutions to alleviate the stress and financial burden it places on executives and revenue cycle leaders.

2. Significant Financial Losses Due to Denied Claims: Healthcare providers face a substantial financial challenge due to denied claims, with over 40% reporting annual revenue losses exceeding half a million dollars and 18% losing more than a million. The data underscore the critical nature of efficient denials management in sustaining the financial health of healthcare providers. Investing in technology and expertise to mitigate these losses is becoming a priority, as indicated by the survey responses.

3. AI and RPA Showing Promising Results: Despite cautious investment attitudes due to tight margins, AI and robotic process automation (RPA) are demonstrating their worth in the healthcare revenue cycle, particularly in denials management. Approximately 20% of respondents using these technologies reported improved efficiency in claim filing, while 30% acknowledged experiencing faster cash flows and collections. Nicole Clawson from Pennsylvania Mountains Healthcare Alliance shared an insightful case of successfully implementing an end-to-end solution to optimize the revenue cycle, emphasizing the importance of data integration, quality, and analysis in preventing future denials and payment issues. These technological advancements not only enhance the efficiency of denials management but also contribute significantly to loss prevention and revenue protection.

An Integrative Medicine Approach to ADHD

By Dr. Kate Henry ND - Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder in childhood – impacting an estimated 15% of kids – and affects more than 8% of adults. ADHD impairs an individual's ability to pay attention, inhibits words and actions, and makes it hard to manage movement and activity throughout the day. It can also make things like long-term planning and task completion incredibly difficult. These symptoms impact almost every aspect of life, including interpersonal relationships, academic and professional performance, self-esteem, etc. Read Full Article…

VBA Article Summary

1. Understanding and Identifying ADHD: ADHD (Attention-Deficit/Hyperactivity Disorder) is a neurological disorder characterized by persistent patterns of inattention, impulsivity, and hyperactivity. It manifests in three primary types: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, and Combined Type ADHD, each presenting with distinct symptoms. Individuals with ADHD often struggle with organizing tasks, focusing on details, controlling behavior, and managing hyperactivity. Diagnosing this disorder necessitates a comprehensive approach including medical and psychiatric examinations to rule out other possible conditions and quantify the severity of ADHD symptoms. The origin of ADHD is multifactorial, encompassing genetic predispositions, neurological differences, environmental exposures, nutrient deficiencies, and early life stress or trauma.

2. Addressing ADHD through Integrative Medicine: An integrative medicine approach to ADHD considers various strategies tailored to the individual's unique needs, working to ameliorate symptoms and improve the quality of life. This approach involves comprehensive testing to uncover potential nutrient deficiencies, heavy metal toxicity, hormone imbalances, and food sensitivities, all of which may exacerbate ADHD symptoms. Nutrition plays a pivotal role, with an emphasis on anti-inflammatory diets, adequate nutrient intake, and elimination of allergenic foods. The incorporation of appropriate supplements, ranging from multivitamins to specific minerals, and herbal medicines like Ginseng, Pycnogenol, Saffron, and Bacopa Monnieri, may offer additional support in managing ADHD symptoms effectively.

3. Holistic Treatment and Lifestyle Modifications for ADHD: Implementing a combination of conventional and functional medicine treatments can provide a holistic approach to managing ADHD. Conventional treatments may include medications, cognitive-behavioral therapy (CBT), and combined treatment plans addressing both biological and behavioral aspects of the disorder. Lifestyle modifications and support strategies are integral for individuals with ADHD. Mind-body therapies like yoga and meditation, regular exercise, and engaging in sports can aid in symptom management. Hormone optimization, through lifestyle changes, nutrient therapy, and potentially medication, is another facet of comprehensive ADHD treatment. Overall, an integrative approach to ADHD, embracing therapy, nutrition, herbal medicine, supplements, pharmaceuticals, and lifestyle changes, provides a robust framework for individuals to not only manage but thrive with ADHD.

4 strategies employers are using to create attractive benefits

By John Feeney - In today’s hot labor market, employer-sponsored benefits continue to be a non-negotiable piece of the employee value proposition. But many factors, including inflation, economic instability and increased health care utilization as a result of the pandemic are driving up healthcare costs. Read Full Article…

VBA Article Summary

1. Embrace Voluntary Benefits: In an era of financial instability, voluntary benefits offer a viable solution for employers looking to enhance their benefits package without significantly increasing costs. Voluntary benefits, including disability (short-term and long-term), vision, dental, and life insurance, are typically employee-funded, allowing employers to offer an extensive benefits package at a lower organizational cost. This approach not only supports talent acquisition and retention but also provides employees with crucial financial protection. Employers can potentially leverage tax deductions related to these benefits, further alleviating financial strain. Offering these benefits on a pre-tax basis can additionally lower taxable income for employees and reduce payroll taxes for employers, creating a financially favorable scenario for both parties. For smaller businesses, voluntary benefits facilitate competition with larger corporations by allowing them to present attractive benefits packages that would otherwise be unaffordable.

2. Align Offerings with Employee Preferences: Recent surveys illustrate a growing employee preference for benefits that provide income protection, with heightened interest in life and disability insurance. Employers need to acknowledge and align with these shifting priorities by offering core voluntary benefits, addressing employees’ needs for income protection and financial security. Additionally, enhancing these benefits with supplementary options, like student loan repayment features or daily living activities coverage, can provide additional financial safeguards. Other value-added services like travel assistance and identity theft resolution can further contribute to employees’ and their families’ financial well-being during tumultuous times.

3. Invest in Long-Term Health and Wellness: To navigate through an unstable economy, companies might consider minimizing employee perks. However, investing in benefits promoting long-term health can be strategically cost-effective. Benefits like preventive dental and eye exams can identify early indicators of chronic diseases, enabling early intervention and preventing expensive future medical claims. With growing awareness and concern about mental health, providing support in this domain is essential. Employers are integrating more mental health support structures, such as Employee Assistance Programs (EAPs), which offer crucial support for employees contending with various challenges, ranging from mental health to financial and career-related issues.

4. Prioritize and Enhance Communication: Effective communication of benefits is fundamental to ensure employees are fully aware and can leverage the available offerings. Employers should establish a consistent, multi-channel communication strategy elucidating how the available benefits can address the needs of employees at different life stages. Understanding and appreciating the benefits will maximize the value derived from these programs for both the employee and the employer.

Obamacare Fine Gives IRS Bankruptcy Priority, Sixth Circuit Says

By Yun Park - The Affordable Care Act’s penalty for individuals who don’t have health insurance is a tax that the Internal Revenue Service can collect ahead of other creditors in a bankruptcy, the Sixth Circuit ruled. Read Full Article…

VBA Article Summary

1. Court Ruling on Shared Responsibility Payment: The US Court of Appeals for the Sixth Circuit determined that the Shared Responsibility Payment, a levy imposed from 2014 to 2018 on Americans who did not purchase health insurance as mandated by the ACA, exhibits several tax-like qualities. The court’s decision aligns with prior rulings from the Third and Fourth Circuits, clarifying that the payment is tied to household income, a factor influencing the amount owed by taxpayers.

2. Implications for IRS Collections: This clarification is crucial for the Internal Revenue Service (IRS), as it influences the agency’s priority in collecting Shared Responsibility Payments in bankruptcy cases. According to US bankruptcy law, unsecured claims by governmental units for income-based taxes are given collection priority. If the Shared Responsibility Payment is recognized as a tax rather than a penalty, the IRS would, therefore, have a preferential claim over other creditors in bankruptcy proceedings.

3. Case Background: The controversy originates from the bankruptcy case of Howard D. Juntoff, who in 2018 opted not to participate in a health plan and consequently did not pay the Shared Responsibility Payment. Upon Juntoff's bankruptcy declaration, the IRS sought to collect the unpaid levy and filed for priority status in the bankruptcy court. The court initially rejected the IRS’s claim, as the payment was not unequivocally income-based. The recent ruling, however, supports the IRS's position, potentially enabling it to prioritize the collection of similar levies in future bankruptcy cases.