Managed care

UnitedHealthCare has settled a series of Nebraska charges by paying the largest fine ever imposed by the state's insurance regulators. UHC agreed to pay the Nebraska Department of Insurance $650,000 to settle a barrage of complaints, largely related to its claims handling process. This follows a previous settlement in 2005, in which United paid a total of $62,500 to settle another series of complaints. Regulators had said that UHC had violated 18 Nebraska laws more than 800 times between …

A new Connecticut law which will make health plans define "medical necessity" in policies is headed to the state's governor for signature. In reality, the bill isn't much of a ground-breaker--insurers typically offer standard medical necessity in policies--but it comes as part of a more aggressive longer-term effort to make insurers defend their medical necessity decisions. Under the original bill, if a member appealed a rejection, the insurer would have had to demonstrate why a treatment …

Legislators in the U.S. House of Representatives have begun considering a bill that would fund research comparing the effectiveness of standard treatments for common medical conditions. The bill would be financed not only from CMS revenues, but also insurers and employers. The research would then be performed by HHS's Agency for Healthcare Research and Quality. Drug makers and medical device companies will not be asked to fund the research; the assumption is that if they pay in, they …

Aetna has changed its reimbursement procedures to make billing and payment  simpler for doctors. The insurer is expanding the ability of physicians to submit claims electronically, and more significantly, is setting up a program that allows plan members to pay out-of-pocket expenses automatically through their debit or credit card. (While this would apply to small co-pays, the real point is to make sure doctors don't end up with huge unpaid bills under high-deductible plans.) Aetna …

Hoping to fend off potential sanctions and additional regulations, health plans have unveiled a program designed to eliminate questionable Medicare enrollment marketing practices. The plans are responding to charges that independent sales reps, employed only during peak enrollment periods and often loosely trained, were not following the rules set forth by federal authorities. Seniors have complained that these reps show up without invitation and lie about plan details to force an …

As federal legislators debate bills that would create parity between mental health insurance benefits and traditional medical benefits, few have asked the question as to whether this approach has really expanded access in the past. However, if Connecticut's experience is any guide, parity of benefits may not close the mental health treatment gap completely. Connecticut, which has had a mental health parity law on the books since 2000, requires the state's insurers to pay for treatment of …

Blue Cross of California has settled a lawsuit challenging its policy-cancellation practices, agreeing to stop rescinding individual policies unless it can prove that a beneficiary intentionally lied on their application. The agreement brings the curtain down on a class-action lawsuit involving 6,000 policyholders, who argued that the health plan had improperly canceled their coverage in a manner violating state law. The managed care company had contended that they have the right to …

With hospital industry pricing policies under increasing pressure, the Wisconsin Hospital Association has taken the bull by the horns. The hospital trade group is now recommending that uninsured patients automatically receive fee discounts similar to those enjoyed by managed care plans. The group is also suggesting that members work harder to let the uninsured know about charity care and financial assistance options.

WHA's recommendations aren't being made in a vacuum. Not only do …

Managed care executives are understandably stressed by the cost of biologic drug treatments which, in extreme cases, can run as much as $100,000 per year. To address the problem, many plans are asking patients to pay larger percentages of the medications' cost. With some patients already spending hundreds of dollars a month, some are cutting back, and others can't afford to raise doses when necessary, physicians say. Other doctors have complained that health plans are using less-direct …

Apparently happy with its existing results, Aetna has set plans to include more providers in its pay-for-performance program, expanding it out to family practice and internal medicine physicians based in Washington state. It already offers the program in Cincinnati, Atlanta, Louisville, Ky., Maryland, Washington, DC and northern Virginia. Aetna's P4P program bases its standards on guidelines from the NCQA, American Diabetes Association, American Heart Association and American Stroke …