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"Insurance companies are denying more claims than before and for unusual reasons. Appeals are taking longer and the process is becoming increasingly complex.,, claims that once might have been paid immediately are instead quickly denied "  More at KFF Health News ➜

"When a stubborn pain in Nick van Terheyden’s bones would not subside, his doctor had a hunch what was wrong. Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis. A blood test in the fall of 2021 confirmed the doctor’s diagnosis, and van Terheyden expected his company’s insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not “medically necessary.”. ... Read more at ProPublica

"The insurance industry and Republicans are using the debt ceiling fight and President Biden’s vows not to cut Medicare to fend off changes to private Medicare Advantage plans, which are popular among the public but have faced criticism about their costs to the government."  More at Roll Call ➜

Many of the patients left in the lurch have life-threatening digestive disorders that render them unable to eat or drink. They depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins, and electrolytes are pumped, in most cases, through a specialized catheter directly into a large vein near the heart..... Read full article at KHN

"Caitlin Wells Salerno knew that some mammals — like the golden-mantled ground squirrels she studies in the Rocky Mountains — invest an insane amount of resources in their young. That didn’t prepare her for the resources the conservation biologist would owe after the birth of her second son." Read more 

The bill-signing ceremony, took place at the Truman Library in honor of former President Harry S. Truman, who had first proposed national health insurance in 1945. The former President was enrolled as Medicare’s first beneficiary and received the first Medicare card.
For 50 years, these programs have been protecting the health and well-being of millions of American families, saving lives, and improving the economic security of the nation.

AURORA, Colo. — Fatumo Osman, a 65-year-old Somali refugee who speaks limited English, was in a bind. She made too much money at a meal prep service job so she no longer qualified for Medicaid. But knee pain kept her from working, so her income had dropped. She could reapply for Medicaid, get her knee fixed and return to work, at which point she’d lose that safety-net health coverage. Her first step was getting a note from a doctor so she wouldn’t lose her job.

So, Osman came to Mango House, a clinic in this eastern suburb of Denver that caters primarily to refugees and turns no one away, regardless of their ability to pay. Dr. P.J. Parmar designed the clinic to survive on the Medicaid payments that many doctors across the U.S. reject as too low.

The clinic is just one part of a broader refugee ecosystem that Parmar has built. Mango House provides food and clothing assistance, after-school programs, English classes, legal help — and Parmar even leads a Boy Scout troop there. He leases space to nine stores and six restaurants, all owned and run by refugees. Mango House hosts a dozen religious groups, plus community meetings, weddings and other celebrations. When Parmar needs an interpreter for a patient from any of a dozen languages spoken in the building, he can easily grab one of his tenants.

“This is what I call a medical home,” Parmar said.

Although it’s not part of the formal U.S. refugee resettlement program, Mango House is in many ways emblematic of refugee health care in the U.S. It’s a less-than-lucrative field of medicine that often relies on individual physicians willing to eke out a living caring for an underserved and under-resourced population.

Parmar finds creative ways, often flouting norms or skirting rules, to fit his patients’ needs. As a result, Mango House looks nothing like the rest of the U.S. health care system and, at times, draws the ire of the medical establishment.

“How do you deliver the quality of care necessary, and that they deserve, while still keeping the lights on? It’s a struggle for sure,” said Jim Sutton, executive director of the Society of Refugee Healthcare Providers. “It’s these heroes, these champions out there, these cowboys that are taking this on.”

Osman brought her son, Jabarti Yussef, 33, to interpret for her. They have been coming to Mango House for 10 years and said that Parmar opens doors for them when they have trouble accessing care.

“If we ask for an appointment to get Medicaid, P.J. makes the call,” Yussef said. “If we call, we’re on hold for an hour, and then it hangs up. If we go to the ER, it’s a three-hour wait. Here, the majority of people walk in and sit for 30 minutes. It’s good for the community.”

As for Osman’s knee pain, Yussef asked Parmar, could they pay cash to get an MRI at the hospital?

“I can almost guarantee it’s arthritis,” Parmar replied. “You could do an X-ray. That will cost $100. An MRI will cost $500. And if it shows a bigger problem, what are you going to do? It will cost you $100,000.”

Parmar said he would connect them with someone who could help Osman enroll in Medicaid but that it’s an imperfect solution. “Most orthopedists don’t take Medicaid,” Parmar said. Older immigrants need to have worked the equivalent of 10 years in the U.S. to qualify for Medicare.

Medicaid, which covers low-income people, generally pays primary health care providers a third less than Medicare, which covers seniors and the disabled. And both pay even less than commercial insurance plans. Some doctors paint Medicaid patients as more difficult and less likely to follow instructions, show up on time or speak English.

Parmar said he realized back in medical school that few doctors were motivated to treat Medicaid patients. If he limited his practice to just Medicaid, he said dryly, he’d have guaranteed customers and no competition.

So how does he survive on Medicaid rates? By keeping his overhead low. There are no appointments, so no costs for a receptionist or scheduling software.

He said his patients often like that they can drop in anytime and be seen on a first-come, first-served basis, much like an urgent care clinic, and similar to the way things worked in their native countries.

Because he takes only Medicaid, he knows how to bill the program and doesn’t have to hire billing specialists to deal with 10 insurance companies.

It’s also more cost-efficient for the health system. Many of his patients would otherwise go to the emergency room, sometimes avoiding care altogether until their problems get much worse and more expensive to fix.

“Really none of our innovations are new or unique; we just put them together in a unique way to help low-income folks, while making money,” Parmar said. “And then, instead of taking that money home, I put it back into the refugee community.”

The son of Indian immigrants, Parmar, 46, was born in Canada but grew up in Chicago and moved to Colorado after college in 1999, where he did his medical training at the University of Colorado School of Medicine. He opened Mango House 10 years ago, buying a building and renting out space to refugees to cover the cost. Two years ago, he expanded into a vacant J.C. Penney building across the street.

“There’s a good three-, four-year dip in the red here, intentionally, as we move from there to here,” Parmar said. “But that red is going to go away soon.”

The covid pandemic has helped shore up his finances, as federal incentives and payment increases boosted revenue and allowed him to pay down his debt faster.

Parmar must navigate a host of obstacles while working to overcome financial and language barriers. A Muslim Somali woman needs dental care but is uncomfortable seeing a male dentist. A Nepalese woman needs a prescription refill, but she lives in Denver and so has been assigned by Medicaid to the safety-net hospital, Denver Health. Parmar won’t get paid but sees her anyway. Another patient brings paperwork showing he’s being sued by a local health system for a year-old emergency room bill he has no way to pay. A Nepalese man with psoriasis doesn’t want creams or ointments; good medicine, he believes, comes through a needle.

“A lot of this is, basically, geriatrics,” Parmar said. “You have to add 20 years to get their age in refugee years.”

When one patient turns away momentarily, Parmar discreetly throws away her bottle of meloxicam, a strong anti-inflammatory he said she shouldn’t be taking because of her kidney problems. He began stocking over-the-counter medications after realizing his patients got overwhelmed amid 200 varieties of cough and cold medicines at the drugstore. Some couldn’t find what he told them to get, even after he printed flyers showing pictures of the products.

Parmar’s creative solutions, however, often rub many in health care the wrong way. Some balk at his use of family members or others as informal interpreters. Best practices call for the use of trained interpreters who understand medicine and patient privacy rules. But billing for interpretation isn’t possible, so hospitals and clinics must pay interpreters themselves. And that’s beyond the capabilities of most refugee clinics, unless they’re affiliated with a larger health system that can absorb those costs.

“It’s a good thing to have the standards, but it’s another thing altogether to implement them,” said Dr. Pat Walker, an expert on refugee health at the University of Minnesota.

When Mango House began providing covid vaccines, residents of more affluent areas of town started showing up. Parmar tried to limit vaccinations only to those patients living in the immediate area, checking ZIP codes on their IDs. The state stepped in to say he could neither require IDs nor turn away any patients, regardless of his refugee-focused mission.

During a recent lull at the clinic, Parmar took stock of that day’s inventory of patients. Six were assigned to Denver Health, one patient’s Medicaid coverage had expired, and two had high-deductible commercial plans. Chances are he wouldn’t get paid for seeing any of them. Of the 25 patients he had seen that day, 14 had Medicaid coverage that Parmar could bill.

“We see the rest of them anyway,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Kyunghee Lee’s right hand hurts all the time.

She spent decades running a family dry cleaning store outside Cleveland after emigrating from South Korea 40 years ago. She still freelances as a seamstress, although work has slowed amid the covid-19 pandemic.

While Lee likes to treat her arthritis with home remedies, each year the pain in the knuckles of her right middle finger and ring finger increases until they hurt too much to touch. So about once a year she goes to see a rheumatologist, who administers a pain-relieving injection of a steroid in the joints of those fingers.

Her cost for each round of injections has been roughly $30 the past few years. And everything is easier, and less painful for a bit, after each steroid treatment.

So, in late summer she masked up and went in for her usual shots. She noticed her doctor’s office had moved up a floor in the medical building, but everything else seemed just the same as before — same injections, same doctor.

Then the bill came.

The Patient: Kyunghee Lee, a 72-year-old retiree with UnitedHealthcare AARP Medicare Advantage Walgreens insurance who lives in Mentor, Ohio

Medical Service: Steroid injections into arthritic finger joints

Service Provider: University Hospitals Mentor Health Center, part of the University Hospitals health system in northeastern Ohio

Total bill: $1,394, including a $1,262 facility fee listed as “operating room services.” The balance included a clinic charge and a pharmacy charge. Lee’s portion of the bill was $354.68.

What Gives: Lee owed more than 10 times what she had paid for the same procedure done before by the same physician, Dr. Elisabeth Roter.

Lee said it was the “same talking, same injection — same time.”

Lee and her family were outraged by the sudden price hike, considering she had gotten the same shots for the far lower price multiple times in the years before. Her daughter, Esther, said this was a substantial bill for her mother on her Social Security-supplemented income.

“This is a senior citizen for whom English is not her first language. She doesn’t have the resources to fight this,” Esther Lee said.

What had changed was how the hospital system classified the appointment for billing. Between 2019 and 2020, the hospital system “moved our infusion clinic from an office-based practice to a hospital-based setting,” University Hospitals spokesperson George Stamatis said in an emailed statement.

That was a change in definition for billing. The injection was given in the same medical office building, which is not a hospital. Lee did not need or get an infusion, which requires the insertion of an IV and some time spent allowing the medicine to flow into a vein.

Nonetheless, that change allowed the hospital system to bill what’s called a “facility fee,” laid out on Lee’s bill as “operating room services.” The increasingly controversial charge — basically a room rental fee — comes without warning, as hospitals are not required to inform patients of it ahead of time.

Hospitals say they charge the fee to cover their overhead for providing 24/7 care, when needed. Stamatis also noted the cost of additional regulatory requirements and services “that help drive quality improvement and assurance, but do increase costs.”

But facility fees are one reason hospital prices are rising faster than physician prices, according to a 2019 research article in Health Affairs.

“Facility fees are designed by hospitals in particular to grab more revenue from the weakest party in health care: namely, the individual patient,” said Alan Sager, a professor of health policy and management at the Boston University School of Public Health.

Lee’s insurance had changed to a Medicare Advantage plan in 2020. The overall cost for the appointment was nearly three times what it was in 2017 — before insurance even got involved.

The National Academy for State Health Policy has drafted model legislation for states to clamp down on the practice, which appears to have worsened, Executive Director Trish Riley said, as more private practices have been bought by hospitals and facility fees are tacked onto their charges.

“It’s the same physician office it was,” she said. “Operating in exactly the same way, doing exactly the same services — but the hospital chooses to attach a facility fee to it.”

New York, Oregon and Massachusetts are pursuing legislation to curtail this practice, she said. Connecticut has a facility fee transparency law on the books, and Ohio, where Lee lives, is considering legislation that would prohibit facility fees for telehealth services.

But Riley noted it’s difficult to fight powerful hospital lobbyists in a pandemic political climate, where hospitals are considered heroic.

The Centers for Medicare & Medicaid Services has attempted to curtail facility fees by introducing a site-neutral payment policy. The American Hospital Association sued over the move and plans to take the case to the Supreme Court.

Resolution: Lee’s daughter, Esther Lee, was furious with the hospital over the fee. Her mom, who is fiercely independent, finally brought her the bill after trying for weeks to get the billing office to change it.

“This is wrong,” Esther Lee said. “Even if it was a lot of money for services properly rendered, then of course she would pay it. But that’s not the case here.”

When Lee called her doctor’s office to complain, they told her to talk to the billing department of the hospital. So Lee, with Esther’s help, repeatedly called the billing department and filed a complaint with Medicare.

“I don’t want to lose my credit,” Kyunghee Lee said. “I always paid on time.”

But after receiving a “final notice” in February, and then being threatened with being sent to collections, the Lee family gave up the fight. Esther Lee paid the bill for her mother. But she’s worried her mom will delay getting the shots now, putting up with the pain longer, as she knows they are more expensive.

The Takeaway: When planning an outpatient procedure like an injection or biopsy, call ahead to ask if it will happen in a place that’s considered a “hospital setting” — even if you think you understand the office’s billing practices. Ask outright if there will be a facility fee — and how much — even if there’s not been one before. If it’s an elective procedure, you can search for a cheaper provider.

One easy place to scout for more affordable care is the office of a doctor whose practice has not been bought by a hospital. It is the hospital, not your longtime doctor, that is adding the fee, said Marni Jameson Carey, executive director of the Association of Independent Doctors.

“This is one of the terrible fallouts of consolidation,” Carey said.

Sources:

Stephanie O’Neill contributed to the audio version of this story.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

When it comes to health care, President Donald Trump has promised far more than he has delivered. But that doesn’t mean his administration has had no impact on health issues — including the operation of the Affordable Care Act, prescription drug prices and women’s access to reproductive health services............ Continue Reading

Physicians Premier ER charged Dr. Zachary Sussman’s insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.

When COVID-19 smacked the United States in March and April, health plans feared medical costs could skyrocket, jacking up premiums drastically in 2021, when millions of the newly unemployed might still be out of work.

But something else happened: Non-COVID care collapsed as hospitals emptied beds and shut down operating rooms to prepare for an expected onslaught of patients sickened by the coronavirus, while fear of contracting it kept people away from ERs, doctors’ offices and outpatient clinics. In many regions of the country, the onslaught did not come, and the billions of dollars lost by hospitals and physicians constituted huge savings for health plans, fattening their bottom lines.

But that doesn’t mean consumers will see lower premiums next year.

Numerous insurers across the country have announced plans to hike rates next year, though some have proposed cuts.

Peter Lee, executive director of Covered California, appeared skeptical about premium reductions in the state’s Affordable Care Act exchange, which is likely to announce 2021 health plan rates next week.

“Would we like zero increases? Absolutely. Would we like them negative? Yeah — but not if that means you’re going to increase premiums in a year by 20%,” Lee said in an interview with California Healthline this week. “We’ve been leaning on them to do what we always lean on them to do, and this is to have the lowest possible rates where you won’t be on a rate roller coaster. We want health plans to price right — not to price artificially low or artificially high.”

Covered California provides coverage for about 1.5 million residents who buy their own insurance.

If the insurance exchanges in other states offer any guidance for Covered California, it is in the direction of moderate premium increases for 2021, though there is wide variation.

A KFF analysis last week of proposed 2021 rates in the exchanges of 10 states and the District of Columbia showed a median increase of 2.4%, with changes ranging from a hike of 31.8% by a health plan in New Mexico to a cut of 12% in Maryland. (Kaiser Health News, which produces California Healthline, is an editorially independent program of KFF.)

Among the roughly one-third of filings that stated how much COVID-19 added to premiums, the median was 2%, with estimates ranging from minus 1.2% at a plan in Maine to 8.6% at one in Michigan.

The proposed premiums for ACA marketplace plans do not affect job-based coverage, but they may indicate how the pandemic is affecting premiums generally.

The consensus among industry experts is that COVID-19 has generated little pressure for rate rises, and health plans should err on the side of moderation. But some fear that many insurers will hold onto the reserves they’ve built up, citing the possibility of widespread vaccinations and concerns that the care forgone in 2020 could rebound with a vengeance next year.

“The tendency of health plans, when they are faced with any degree of uncertainty, is to be very conservative and price for the worst-case scenario,” said Michael Johnson, an industry observer and critic who worked as an executive at Blue Shield of California from 2003 to 2015. “Actuaries are less likely to get fired if the plan prices too high than if the plan prices too low. But I think regulators really need to push back hard on that.”

Lee said all 11 insurers participating in the exchange this year will remain in 2021, and no new ones will be added to the mix, though some of the current carriers will extend their coverage geographically. Ninety percent of consumers who buy their own health insurance get subsidies from the federal government or the state to help pay their premiums.

In January, California became the first state to offer subsidies to middle-income people who make too much money to qualify for federal subsidies. The lion’s share of the state subsidies is earmarked for those who earn between 400% and 600% of the federal poverty level, or $51,040 to $76,560 a year for an individual and $104,800 to $157,200 for a family of four.

The rate proposals expected to be unveiled next week will be subject to scrutiny by state regulators before they are finalized. Sign-ups for the plans start Nov. 1 and run through Jan. 31. This year, the average Covered California rate increase statewide was 0.8%, the lowest since the exchange started providing coverage in 2014.

The benefits reaped by health plans so far in the pandemic can be seen in strong second-quarter earnings and reduced spending on care. UnitedHealth Group, the nation’s largest health insurer, announced earlier this month that its net profit in the April-June quarter nearly doubled from the same period a year earlier. Its medical spending plummeted from 83.1% of premium revenue to 70.2% over that period.

Anthem, the parent company of Blue Cross of California, reported Wednesday that its net profit in the second quarter doubled from the same period in 2019, also on the back of plunging medical expenses.

Anthem said it offered one-month premium credits ranging from 10% to 50% to enrollees in individual, employer and group dental policies — including its Blue Cross plans in California.

UnitedHealth said it has provided $1.5 billion worth of financial support to consumers so far, including premium credits and cost-sharing waivers, and expects to pay out $1 billion in rebates.

But UnitedHealth, which does not participate in Covered California, is seeking a rate increase of 13.8% in the New York exchange. Anthem, which covers about 80,000 people in Covered California, is planning rate hikes of 16.6% in Kentucky and 9.9% in Connecticut.

On the other hand, Kaiser Permanente, which covers more than one-third of Covered California enrollees, plans rate cuts in other states, ranging from 1% in Hawaii to 11% in Maryland. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Lee downplayed the notion of a financial boon for California health plans, saying that, partly because of the use of telehealth, primary care has rebounded and the plans are paying for it. “So we don’t see this as being at this point a bonanza year for health plans,” he said. “Rather, it’s a year in which there are lessons learned for how we can deliver care in a pandemic.”

Still, the health plans are in a far stronger position than they had feared earlier this year.

In March, Covered California released a study showing that COVID-19’s impact on 2021 premiums for individuals and employers could range from an increase of 4% to more than 40%. But less than three months later, projections commissioned by the industry’s national advocacy group, America’s Health Insurance Plans, showed that even in the worst-case scenario of a 60% COVID infection rate — far above where it stands now — the pandemic would increase medical costs in 2020 and 2021 by 6% at most, and could even decrease them.

That moderate effect is largely attributable to what Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, called “a kind of yin and yang: If you have a lot of COVID, you don’t have a lot of other health care spending.”

Independent of the course the pandemic takes, emergency room and outpatient visits still lag behind pre-COVID levels and will probably continue to do so next year, to the continued benefit of insurers, predicted Glenn Melnick, a professor of health care finance at the University of Southern California’s Sol Price School of Public Policy. That could be good news for consumers, he said, potentially leading to lower premium increases or even reductions next year.

On the other hand, hospitals and doctors have lost money, and the ones whose contracts with health plans are up for renewal will be looking to make up those losses, Melnick said.

“Providers could be asking for 20-25% increases next year,” he said, “and if they’ve got market power, they can make it stick.”

July 31, 2020