beneficiaries

UnitedHealthcare to pay $250K fine in Ohio

Anne Zieger — Tue, 29 Jul 2008 10:53:30 -0400

Health plan UnitedHealthcare has agreed to pay a $250,000 fine to settle with the state's Department of Insurance over letters it sent to policyholders concerning a health system in its network. The health plan sent out letters in May informing some members that they would have to change providers, given that a central Ohio health system, OhioHealth, appeared to be on the verge of giving up its contract. The letters said that beneficiaries would need to find new providers as of June 10--making no mention of the fact that UnitedHealthcare was still in contract talks with the health system.

Ultimately, OhioHealth and UnitedHealthcare managed to seal a deal seven hours before their contract was set to expire. That meant that despite the letters, UnitedHealthcare's beneficiaries could continue to see their OhioHealth providers. Because of the letter, however, patients made scores of calls to physician practices and OhioHealth's three hospitals, seeking reassurance that they could still see their existing providers.

The Department of Insurance, which dubbed the letters "confusing" and "misleading," is requiring UnitedHealthcare to submit a plan describing how it will improve its communications with members. The fines it imposed include a $150,000 civil penalty and $100,000 in administrative costs.

To find out more about the investigation:
- read this Marion Star piece

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CMS makes Part D data available for patient-safety efforts

Fri, 23 May 2008 06:59:58 -0400

CMS has issued final regulations that will make Medicare Part D claims data available to the FDA and other agencies, as well as academic researchers, for use in patient-safety initiatives. The FDA has said that it will use the data to pilot-test its Sentinel Initiative, a new electronic system that will let the agency query a large number of health information databases in an effort to more effectively detect post-market adverse events resulting from use of approved drugs and medical devices. This program won't only detect the events, it will allow the agency to monitor the performance of drugs and devices in real time, said FDA and CMS officials. The Sentinel program links claims data from 25 million beneficiaries with prescription drug coverage to other Medicare claims information, including diagnoses, treatments, hospitalizations and physician services.

To learn more about this announcement:
- read this Modern Healthcare article (reg. req.)

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CIGNA launches site offering doctor, hospital rankings

Fri, 23 May 2008 06:59:57 -0400

CIGNA has launched a national website ranking doctors and hospitals by cost and quality measures, along with providing its beneficiaries with several additional tools to help them obtain care. Not only does the site rank providers, it also names hospitals in specific regions with the lowest death and complication rates. In addition, it offers lists of questions patients can ask their doctor in regards to specific conditions, and offers patients tools to help them locate nearby pharmacies with the lowest prices.

At least where New York physicians are concerned, Cigna's program will be under the scrutiny of a fierce watchdog. New York Attorney General Andrew Cuomo has investigated several of the state's health plans as they rolled out rating and ranking programs, and Cigna was one of the plans asked to sign an agreement detailing the practices it would adhere to in establishing ranking programs. Cigna has since hired the National Committee for Quality Assurance to oversee its ratings program for the entire U.S.

To learn more about CIGNA's rankings program:
- read this Atlanta Journal-Constitution article

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SPOTLIGHT: New rules would limit Medicare marketing

Fri, 09 May 2008 06:59:52 -0400

Federal regulators have proposed new rules that would set limits on the marketing of private Medicare health plans. The rules would ban unsolicited sales visits and phone calls to beneficiaries, regulate commissions to sales agents and increase insurer fines. Article

ALSO NOTED: WellPoint exposes patient data; ED visits go up when OR trims Medicaid rolls; and much more...

Fri, 25 Apr 2008 06:59:50 -0400

> Security pros are lambasting WellPoint, which may have inadvertently allowed Web users to access data on 130,000 of its beneficiaries. FierceHealthIT

> A new study has found that when Oregon dropped a large group of Medicaid enrollees, the state's ED traffic went up. FierceHealthFinance

> It seems that pharmaceutical companies are waaaay behind on the drug effectiveness and safety studies that they're supposed to do once the drugs are approved. Surprised? FiercePharma

> Harvard president Drew Faust argues that the government's system for funding biotech research is broken. FierceBiotech

And Finally... What's really entertaining about reading this drug ad parody is that for a minute or two, you don't realize you're being taken for a ride. (Warning: Don't be drinking or eating anything when you read the advisory for squirrels). Site

Medicare disease management pilot ending this year

Thu, 24 Apr 2008 06:59:56 -0400

Three years ago, CMS hired eight private disease management firms to set up chronic care improvement programs for beneficiaries. The programs, which reached as many as 150,000 seniors enrolled in Medicare, use trained nurses or health coaches to reach out to patients and make sure they were taking the right self-care steps. The idea was that by doing so, patients would have fewer hospitalizations and less trips to the emergency department, saving Medicare some money. During the run of the project, three of the eight firms actually dropped out, citing cost overruns--which is bad enough--but the worst was yet to come.

CMS now is closing the project down, having concluded that it hasn't lowered claims. The agency will end the pilot in at the end of the year unless the remaining five companies can cut Medicare claims by $600 to $800 per patient per month from now through December. Since that's unlikely, it seems the pilot is doomed, despite the fact that some physicians (and members of Congress) are lobbying to keep it alive for other reasons.

To learn more about the pilot's results:
- read this AMNews piece

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Los Angeles sues Anthem for individual policy cancellations

Thu, 17 Apr 2008 06:59:58 -0400

The Los Angeles city attorney has sued Anthem Blue Cross for allegedly canceling coverage of thousands of members after they filed large medical claims. In doing so, it's following the lead of the state's Department of Managed Health Care, which has conducted an ongoing campaign against such practices. City attorney Rocky Delgadillo contends that Anthem, its parent company WellPoint, and another subsidiary unlawfully revoked the policies of as many as 6,000 members. What's more, he argues that the plans' 500,000 individual policyholders have been defrauded, because their policies won't actually help them if they get sick. Delgadillo is seeking $2,500 per violation, or $5,000 if the victim is disabled or a senior--numbers that could amount to costs of more than $1 billion if the city wins its suit.

To learn more about the suit:
- read this Los Angeles Times piece

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Who pays for care when errors are made?

Fri, 04 Apr 2008 07:59:59 -0400

Increasingly, health plans are beginning to follow Medicare's lead and refuse payment for at least some care related to medical errors. The most recent to take this step is WellPoint, the nation's largest health plan as calculated by number of beneficiaries. The Blues are well on their way to taking a similar position.

All of this raises questions that I don't think have sufficiently been addressed. Who will pay for the care delivered to address these errors? Before you suggest that it's obvious that providers will, let me propose a few alternative scenarios:

The insurer refuses to pay, but the hospital disputes that the error was its fault. They bill the patient.
The patient sues over the error, collects, and then finds that the insurance company collects whatever they'd spent on it (which can happen due to provisions in some health plan contracts).
The hospital stands behind the high-admitting doctor who made the mistake, and allows him to balance-bill the patient for additional care. If the doctor is an ED doctor, particularly, he may not be on the hospital's managed care contract, which may make the balance-billing arrangement perfectly kosher.

Sure, I know that many state hospital associations already have vowed not to bill for care related to never events, but the associations vary in what they're accepting financial responsibility for. Meanwhile, insurers are developing their own lists of unacceptable errors, which may not overlap in each case.

All I'm saying is, that I see the makings of a mess here, and one that isn't really being discussed enough. Folks, things could get pretty nasty fast once enough insurers get tough with non-payment policies. It wouldn't hurt to take a hard look today at how you'll handle disputes that fall between the cracks. - Anne

MDs fight to keep Medicare pilot program

Fri, 28 Mar 2008 07:59:58 -0400

An article in The Tennessean reports that, according to Healthways, more than 300 doctors, group practices and health systems are fighting to continue a pilot program that provides support for chronically ill Medicare recipients in Maryland and Washington, D.C. According to some within the program, it has served "more than 75 percent of the 20,000 beneficiaries originally eligible." Healthways is based in Nashville and is one of five participants in the pilots. The program is in danger because the Centers for Medicare and Medicaid Services said the pilots "weren't meeting requirements for improving clinical quality and customer satisfaction and weren't hitting savings targets."

- read the article in The Tennessean

Blue Cross plans push wellness

Thu, 20 Mar 2008 07:59:56 -0400

The nation's fourth largest health insurance company has kicked off an initiative that focuses on using its resources more on patient wellness. Chicago-based Health Care Service Corp., whose subsidiaries include Blue Cross and Blue Shield of Illinois and BCBS plans in Texas, New Mexico and Oklahoma, has more than 12 million members. Health Care Service Corp. has added the word "wellness" to the mission statements of each of these plans, as well as launching initiatives like adding wellness programs to its basic health benefit plans. The health plans are also offering beneficiaries extra incentives to stay well by, for example, earning points for participating in such preventive measures as cholesterol screenings and wellness risk assessments.

Giving consumers--not just providers--direct incentives to stay well seems like a good idea. Let's see, however, if these programs mature into something that goes significantly beyond what U.S. health plans already are doing to meet wellness and preventive goals.

To learn more about the plans:
- read this Chicago Tribune piece

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