JustCare

Category: Health insurance

  • Insurer provider directories misleadingly include physicians who are out of network

    Insurer provider directories misleadingly include physicians who are out of network

    Max Blau reports for Pro Publica on how the big insurers provide their enrollees with misleading directories of in-network providers, but nothing is done to fix the problem. We are in the age of tech, when accurate directories should be quick and easy. Insurers should be held accountable if they cannot keep an accurate provider directory, but neither the states nor the federal government is willing to hold the insurers accountable.

    Blau explains that insurers are not penalized for inaccurate directories and that it takes old fashioned cold-calling to figure out how misleading a provider directory is. Misleading directories are helpful to insurers since they encourage people to enroll; and, yet, the insurers won’t cover care from the providers they list who are not in-network.

    For more than ten years, the federal government has reported large inaccuracies in Medicare Advantage provider directories. Do not assume they are anywhere near accurate and up to date. Providers in the network today can leave the network at any time, and many have been leaving Medicare Advantage plans over the last few years.

    New York State government staff called health care providers listed in insurance company directories to determine whether they were actually seeing patients. They wanted to know two key things about the supposedly in-network providers: Do you accept insurance? And are you seeing new patients?

    But, the New York State staffers found that lots of physicians who were listed in the provider directories no longer accepted the insurance or were not taking new patients. Some of the time, staff didn’t even get a call back. As it turned out, insurers’ enrollees could not get treatment from more than eight in ten mental health providers listed in directories whom staff reached out to.

    The New York State law provides for penalties on insurers who do not keep accurate provider directories. But, New York State rarely penalizes insurers and, when it does, the penalty is tiny. When it comes to provider directories, New York State insurer behavior is no different from insurer behavior in other states. Misleading directories are the norm in most states, including Arizona, California and Massachusetts.

    The US Senate Finance Committee staff undertook an investigation a year ago of Medicare Advantage provider directories, and Senate Finance staff also found extremely misleading provider directories. As in the states, the federal government rarely holds the Medicare Advantage insurers accountable.

    The consequences of inaccurate directories can be dire for patients who cannot find providers to treat their conditions. For the insurers, it’s more money in their pockets. If their enrollees can’t get care, the insurers keep more money and grow profits.

    Here’s more from Just Care:

  • Why health insurers deny necessary care and get away with it

    Why health insurers deny necessary care and get away with it

    If you’re wondering why insurance companies deny necessary care and get away with it, it’s not only that the insurers are pulling all the strings and have become too big to fail. It’s that different doctors often have different opinions about what is medically necessary. A new report from the Center for Improving Value in Health Care focuses on the health care that people get that the Center says is not medically necessary, driving up health care spending, reports Markian Hawryluk for KFF Health News.

    The amount spent on unnecessary care or “low value” care in Colorado, as reported–$134 million in 2022–seems relatively small. The Center says it is the tip of the iceberg. But who is to judge what is low-value care? The health insurance companies should not be the judge when they profit from denying care.

    There is tremendous risk in turning authority over treatment decisions from physicians to insurance companies, as Medicare has done through the Medicare Advantage program. Where is the value in handing buckets of money to health insurance corporations who can deny coverage for low, medium and high value care without justification, in secret, largely with impunity, in order to maximize profits?

    And, we continue to hear horror stories of the health insurers denying needed care through AI algorithms and staff physicians who earn bonuses when they don’t refer patients for costly specialty care. Why would we trust the insurance companies and their staff to get coverage decisions right when they have no understanding of particular patient conditions and an incentive to deny care? Read this post on how UnitedHealth is using AI to deny rehab care to vulnerable older adults without regard to their particular conditions and weep.

    Of course, there is no perfect payment system. The Center for Improving Value in Health Care appears to like the idea of giving insurers buckets of money to cover care. But, rather than giving insurers the discretion over these treatments, isn’t the fix to have national policies, publicly vetted, about what is covered and not covered? If opiates, antipsychotics and screenings for Vitamin D deficiency are really unnecessary in most cases, why are insurers covering them?

    A capitated payment system–one in which the insurers are handed money upfront to “manage” care–simply changes the incentives, disregarding physician opinions, working against patients, and rewarding insurance companies for giving less care or for denying care inappropriately. And, corporate health insurers operate in a proprietary or secret system. Researchers can’t even learn whether what insurers are doing when they deny care is endangering people’s lives or helping them. How does that add value?

    What’s crystal clear is that if we are going to improve the health care system, we need to collect and review patient data. We need to know what is working and not working. We need to know in real-time what’s happening to protect people from insurance companies that put their profits first. And, we need to be doing what other wealthy nations do: Dictating all the terms of coverage, removing discretion over coverage decisions from insurance companies, so that people can count on getting the care they need without delay and are not forced to gamble with their health.

    Here’s more from Just Care:

  • As the US population ages, how will people afford long-term care?

    As the US population ages, how will people afford long-term care?

    Americans are finding it increasingly difficult to meet their and their loved ones’ long-term care needs. Congress continues to sit on its hands, while some states are taking action. Mark Miller writes for the New York Times about the need for Congress to step in on behalf of all Americans who could need long-term care and, in the meantime, what some states are doing to help their residents.

    The vast majority of Americans will need some kind of long-term care as they age, be it help with bathing, dressing and toiletting, other activities of daily living, or full-time home care or nursing home care. Only about one in five Americans will not need long-term care. For now, there’s no hope of Congressional action, as ensuring people’s long-term care needs are met costs money, and Republicans have taken raising taxes to cover additional healthcare costs off the table.

    The average cost for one year of nursing home care was nearly $110,000 two years ago. Yet, nearly seven in ten Americans have done little if any planning and saving to cover the costs of their long-term care needs. Not even one in six Americans believe they are prepared financially, if they need long-term care. Those who are unprepared will likely have to count on family and friends to volunteer their time to care for them, if they do not qualify for Medicaid.

    Medicaid does cover long-term care. It is an invaluable benefit. But, in order to get Medicaid, your income and assets need to be extremely low. Thankfully, in many states, if your income and assets are above the eligibility level, your health care expenses can bring your income and assets down to the Medicaid eligibility level so you can qualify for Medicaid.

    Most people do not realize that Medicare does not cover long-term care. At best, people might qualify for 100 days of nursing home care, but that’s only if they’ve been hospitalized for at least three days in the 30 days prior to admission in a nursing home. And, people in Medicare Advantage plans rarely get coverage for more than a very short nursing home stay. People also might qualify for very limited Medicare-covered home care, and that’s only if they’re homebound and need either intermittent skilled nursing or therapy services.

    Washington State is the first state to launch its own publicly-administered long-term care program, the WA Cares Fund,  States such as California and Minnesota might do the same in time. The issue is that covering long-term care is not only expensive, but tricky to implement.

    In Washington State, long-term care benefits will be available to everyone beginning in 2026, and everyone will pay in for those benefits during their working lives through a 0.58 percent payroll contribution. The maximum benefit will only be $36,500, a fraction of the total amount most people will need to spend on home care. The Washing State benefit should help with a year of home care costs.

    Washington State might save on Medicaid expenses through this long-term care program. That’s what the state is hoping. Because of the program, some people will not need to spend down all their assets to qualify for Medicaid. But, nothing is clear at this point.

    Some questions still need to be answered. For example, what if people also have private long-term care insurance? And, will people who contribute to the program lose their right to benefits if they move out of Washington state?

    All this said, Washington State is doing its residents a major service. Private long-term care insurance has always been a gamble, with “level” annual premiums able to double out of nowhere; it becomes increasingly unaffordable over time and offers benefits that are generally more limited than people realize.

    Here’s more from Just Care:

  • Can we fix our broken health care system without reining in costs?

    Can we fix our broken health care system without reining in costs?

    Aaron Carroll writes for the New York Times about how to fix our broken health care system.

    Notwithstanding all the ways the Covid-19 pandemic exposed fissures in our health care system, bringing with it more than one million deaths, Congress is doing precious little to address uninsurance and underinsurance and their consequences for our health and well-being.  Carroll studied health systems in five other wealthy countries to appreciate differences between them and the US. Carroll suggests that universal health care is the solution to our broken system, whatever it looks like; he doesn’t see health care costs in the US as a stumbling block.

    We spend more per person on health care than any other country, and health outcomes are generally significantly worse than in every other wealthy country, including life expectancy. So, what does the United Kingdom, France, Australia and New Zealand do differently? They all guarantee health care coverage to their citizens.

    Carroll posits that in every other significant way these other wealthy countries are different from one another. But, these countries not only share guaranteed universal coverage. They all have a sets price for most health care goods and services. It’s that combination, along with significant restrictions on insurance company profits, that make health care affordable for their citizens.

    Australia, New Zealand and Canada all offer government-provided coverage,  sometimes called single-payer.  Australia and New Zealand’s single-payer systems allow people to buy private insurance to improve their access to care. Canada does not allow that.  Australia’s system requires people to contribute significantly to the cost of their care.

    Carroll says France’s system is not quite single-payer because people get their coverage through different systems. But, it is primarily with government funding, either through their jobs or some other means, and with significant government rules and regulations. France requires people to pay upfront for their outpatient care and then reimburses them for the cost.

    Britain likely offers the most robust coverage of all these countries. Most services come with no out-of-pocket costs. Britain’s system is different from single payer because it is not insurance-based. Rather, the government employs physicians and owns hospitals and covers people’s care directly.  The British system is socialized medicine. While people can have private insurance for enhanced benefits, almost no one does.

    Singapore offers everyone only catastrophic coverage for high-cost services. People can buy private insurance to supplement the public coverage, but few do.

    Carroll acknowledges that public hospital systems in all these countries make a huge difference in improving access to care, eliminating competition for profits. It seems hard to imagine how the US moves to that system to reduce costs and improve access, given the very limited number of public hospitals here. Is there any way to open up the Veterans Administration hospitals to all Americans? And, even if there were, would that give people living in remote areas adequate access to care?

    Carroll points up that housing, food and education also contribute significantly to better health. Other countries invest in these “social determinants of health.” The US does not, but we could.

    Carroll suggests that if we allocated some of our health care budget to the social determinants of health, we would likely see far better health outcomes. But, we are currently on the reverse trajectory, cutting this discretionary spending, such as food stamps. With all the money we invest in health care, Carroll has hope of realigning these investments. He thinks it’s simply a matter of political will.

    Here’s more from Just Care:

  • Don’t rely on Mark Cuban’s Cost Plus Drugs for the lowest prices

    Don’t rely on Mark Cuban’s Cost Plus Drugs for the lowest prices

    I promoted Mark Cuban’s Cost Plus Drugs a while back as a way to get low-cost generics. As it turns out, Darius Tahir reports for Kaiser Health News that Cost Plus Drugs does not always offer the lowest prices. Bottom line, if you have Medicare Part D, you should shop around if you want the lowest prices on your drugs.

    Cost Plus Drugs now offers more than 1,000 prescription drugs. But, it does not manufacture them. So, your local pharmacy could offer the drugs you need at lower prices. You can also check PharmacyChecker.com for low-cost drugs around the world.

    Cost Plus Pharmacy negotiates prices. And, then it is charging you a 15 percent markup from the manufacturer’s price, plus $3.00 for labor for each medicine and then a flat $5 fee to ship as many drugs as you order.

    In a cost comparison of drugs beginning with the letter A, Kaiser Health News (KHN) found Cost Plus Pharmacy did not offer the lowest drug prices for residents of Washington DC most of the time. But, sometimes it offered massive savings. One expensive drug, aprepitant, an anti-nausea medicine, was nearly $1,000 less through Cost Plus Drugs than through GoodRx, $4,815.30 v. $5,740.

    Cost Plus Drugs is really taking out a lot of the PBM (Pharmacy Benefit Manager) and pharmacy markups, since it replaces the PBM as the middleman. Amazon and Walmart are also offering a bunch of low-cost generic drugs.

    Cost Plus Drugs is not a pharmacy but uses Truepill, a mail-order pharmacy.

    Bottom line, you Part D drug coverage should offer you some savings on some drugs, particularly brand-name drugs. But, don’t count on it to give you the lowest out-of-pocket costs. The copays can be higher than the total cost of your drugs through Costco or Cost Plus Drugs, at least for now.

    The good news, if you take a lot of drugs, is that beginning in 2026, you will not pay more than $2,000 in total for your prescription drugs on formulary through your Part D drug plan. That is one of the big benefits of the Inflation Reduction Act passed in 2022.

    Here’s more from Just Care:

  • When will Congress address surprise ambulance bills?

    When will Congress address surprise ambulance bills?

    Surprise medical bills are all too common, leaving millions of Americans with health care costs they did not expect to pay. A couple of years ago, Congress passed legislation to end surprise medical bills for some services, but the ambulance industry was able to keep Congress from protecting Americans from surprise ambulance bills. Fortunately, people with Medicare have protections and generally do not have to worry.

    Congress was resistant to addressing surprise ambulance bills allegedly in deference to municipalities that generate substantial revenue from running ambulance services. Congress also claimed not to have a good handle on the appropriate cost of ambulance services.

    A new report from US PIRG describes the toll that surprise medical bills takes on Americans needing ambulance services. Even in the 10 states that go farther than federal law to protect their insured residents from surprise ambulance bills, anyone working for a large employer with a self-funded ERISA health plan—a very large cohort—does not have protection from their state laws.

    The problem of surprise ambulance bills needs addressing for multiple reasons. For one, we are talking about a large cohort of the population. Some three million Americans with private insurance use ambulance services each year. Who knows how many do not seek critical care for fear of the cost, endangering themselves.

    Second, when people call 911, they have no control over whether the ambulance that comes for them is in their health care provider network. About half the time the ambulances are out of network. Every ambulance affiliated with 911 should be in the insurers’ networks.

    Today, working Americans with health insurance are scared to call 911 in an emergency, for fear of an ambulance arriving that is out of network and receiving a surprise bill that they cannot afford to pay or do not want to add to their list of expenses. The typical out-of-pocket cost is $450, but in some states it is more than $1,000. Millions of Americans at risk.

    What you can do: Talk to your members of Congress about the urgent need to end surprise ambulance bills. In the meantime, find out which ambulance services are in your health plan’s network, and put their numbers in your phone contact list and/or on a list of important contacts in your home. Share it with your loved ones and  health care proxy.

    Here’s more from Just Care:

  • HCA hospital system is charged with overtreating patients to maximize its profits

    HCA hospital system is charged with overtreating patients to maximize its profits

    Last week, I wrote about a hospital that incorrectly charged a patient for a costly service it did not render and only corrected the charge a year later, as a result of intensive efforts on the part of the patient’s wife. Now, Kaiser Health News reports on HCA, a for-profit hospital system that is charged with overtreating and overcharging patients and insurers. The government needs to hold hospitals accountable for inappropriate bills and other bad acts.

    Kaiser Health News reports on a patient with Covid-19 who went to a hospital emergency room to get checked out at her PCP’s direction. Instead of sending her home after seeing her, the hospital admitted her as an inpatient for three days and charged her $40,000. Of that amount, her insurer charged her $6,000. In this case, the hospital was HCA, the largest hospital system in the country.

    In this case, the patient’s PCP did not believe his patient should have been admitted to the hospital. But, hospitals control these decisions. To maximize their profits, some hospitals might provide incentives for their doctors to refer ER patients for an inpatient stay, even when not medically necessary, according to some experts.

    Congressman Bill Pascrell of New Jersey is hoping for the government to investigate HCA to determine whether it is engaged in Medicare fraud. The claim is that HCA requires its doctors to meet hospital admission targets and admit patients even when patients don’t need to be admitted. The result is both financial harm and potential health risks for patients.

    The Service Employees International Union (SEIU) released a report earlier this year documenting the issues particular to HCA. SEIU argues that overcharges to Medicare over the last ten years amount to nearly $2 billion. But, HCA is not the only culpable hospital according to SEIU. SEIU has made similar claims against Community Health Systems and Health Management Associations. Both hospitals systems settled, for $98 million and $262 million respectively.

    It’s not easy to prove that a patient was overtreated and did not receive appropriate care. You need the doctor to speak out, as one doctor did against an HCA hospital in Miami. This doctor claims that HCA told him that he would lose his job if he did not move more ER patients into the inpatient unit of the hospital. The government refused to investigate and to speak to a reporter about why it refused.

    HCA profits were nearly $7 billion in 2021.

    Here’s more from Just Care:

  • How to ensure your hospital bill is correct

    How to ensure your hospital bill is correct

    Most of us do not check our health care bills too carefully. We do as we are told by the doctors and hospitals and pay our insurance deductibles and copays largely without questioning the bills. It can be difficult to make sense of the bills, let alone to figure out if a health care bill is correct.

    Bram Sable-Smith reports for Kaiser Health News on a billing expert who saved her family a lot of money by questioning her husband, Dr. Bhavin Shah’s, medical bill. The hospital charged Shah more than $3,000 out of pocket. It took more than a year for the hospital to recognize that the procedure it claimed to have performed had never been performed and correct its bill. It could afford to delay as it pays no penalty for billing errors. During the hospital’s extended bill review time, Shah’s bill was sent to debt collections.

    Here’s what you can do to ensure you are not overpaying for your medical care in hospital 

    1. When you receive a bill, immediately call the hospital and ask for an explanation of all the charges. Make sure that the bill is itemized, with standardized billing codes.
    2. Focus on the services with the biggest charges and compare the charges for those billing codes with charges for the same billing codes at other hospitals in your area. All hospitals are required to disclose this information. You can visit fairhealthconsumer.org for information on typical hospital charges in your area. You can also check Medicare’s online tool. You should be able to see whether your bill is comparable to bills at other hospitals or completely out of line.
    3. If your hospital charges a lot more than other hospitals, contact the hospital and challenge its charges. Also, complain to your health insurer. Or, if that doesn’t work, complain to your state attorney general’s office.
    4. Ask for your medical records. You might find that the medical records do not show evidence of services for which you were billed.
    5. To protect your credit score and avoid more hassle, ask the hospital to hold off sending the bill to a debt collector while it is being disputed.

    And, if your income is low, keep in mind that non-profit hospitals are required to offer some charity care.

    Here’s more from Just Care:

  • 2022: Health care costs threaten the well-being of many Americans

    2022: Health care costs threaten the well-being of many Americans

    Fewer Americans are uninsured than ever–almost half the number before the Affordable Care Act took effect. But, rates of underinsurance are high, with millions of people having gaps in their coverage, millions skipping care and millions falling into medical debt because they cannot pay their health care bills. The Commonwealth Fund surveyed Americans and found that, too often, health care costs threaten their well-being.

    The big takeaways:

    • More than four in ten adults under 65 (43 percent) did not have adequate health insurance. People without insurance, people with gaps in insurance coverage during the year, and people who could not afford their care are included in this group.
    • Nearly three in ten people with employer coverage (29 percent) and more than four in ten people with coverage they bought in the individual market (44 percent) were underinsured.
    • Close to half of all people (46 percent) said that they had not gotten care or delayed getting care because of the cost. More than four in ten (42 percent) struggled to pay medical bills or were in medical debt.
    • Half of people surveyed (49 percent) said they could not afford to pay an unexpected medical bill of $1, 000 within 30 days, primarily people with low incomes (68 percent), Black adults (69 percent), and Latin/Hispanic adults (63 percent).

    Large numbers believe health care costs should be a top priority for the Biden administration and Congress. Democrats (68 percent), Independents (55 percent), and Republicans (46 percent).

    “Underinsured” is defined for people living above twice the federal poverty level as out-of-pocket health care costs over 12 months, excluding premiums, representing at least 10 percent of household income and for people living under twice the federal poverty level, representing at least 5 percent of household income ($27,180 for an individual and $55,500 for a family of four in 2022). Or, people whose health care deductible represented at least five percent of household income.

    People who lacked health insurance for at least a year tended to be young, poor, with one or more chronic conditions, living in the South, Latin/Hispanic. Undocumented individuals are not able to get affordable coverage.

    Because the US lacks a national health insurance program or even a national health insurance enrollment program, a lot of people who might be eligible for coverage based on their age, income and needs, go without coverage. More than half the people surveyed (56 percent) who had employer coverage but had been uninsured at some point during the year did not know that they were eligible to enroll in their state health insurance exchange plans because they lost their coverage.

    Americans likely would pay a lot less for their health care if the government set rates for all health care providers, as it does for people with Medicare. Because the US does not set provider rates–as all other wealthy countries do–these high rates drive high cost-sharing. Physician and hospital prices in the US are higher than anywhere else in the world.

    Close to one in four people with chronic conditions, such as diabetes, are not filling their prescriptions regularly because of the out-of-pocket cost.

    Of note, nearly one in four people with bills in collection said the bills stemmed from a mistake in billing. More than half of people with medical debt (56 percent) owed at least $2,000.

    Medical bills from out-of-network doctors at in-network hospitals represented almost half of all cost issues. These surprise bills are no longer permissible under the No Surprises Act, which took effect January 2022. But, the survey included a timeframe before then.

    When the public health emergency is declared over, likely in 2023, states will lose their improved federal matching funds. Inevitably, with less money, they will reconsider Medicaid eligibility and restrict coverage.

    Here’s more from Just Care:

  • Warning: An air ambulance ride could cost $489,000

    Warning: An air ambulance ride could cost $489,000

    How much could you be charged if you take an air ambulance? For sure, many times what it actually costs. Julie Appleby reports for Kaiser Health News on a man who was charged $489,000 for his air ambulance ride. How do you protect yourself from such insane charges?

    Medicare and other health insurers should cover air ambulances when medically necessary. The question becomes what is medically necessary. Because they cost so much, it is in the corporate insurers’ financial interest to claim that air ambulance rides are not medically necessary.

    Appleby’s story profiles a 32-year old man, Sean Deines, who fell gravely ill while in rural Wyoming. He had a low white blood cell count, which turns out to be acute lymphoblastic leukemia. He needed emergency care, for which he was airlifted to the University of Colorado hospital. His insurer, Blue Cross Blue Shield of North Carolina, through his state health insurance exchange, covered that trip.

    After Deines is stabilized, he and his wife decided to get care at Duke University Medical Center, his in-network hospital in North Carolina, where his family resides. The air ambulance company they contacted, Angel MedFlight, said it would accept payment from his insurer, and he would have no responsibility for the cost.

    Notwithstanding representations from the air ambulance company to the contrary, Deines received a bill for $489,000, About $70,000 of the bill was for ground ambulance services in Denver and Raleigh-Durham. But, Deines’ insurer claimed this transport was medically unnecessary; he could have remained in Denver for 28 days of treatment to put his cancer in remission.

    The air ambulance company tried to get prior authorization from Deines’ Blue Cross plan, but it transported Deines before it had approval. After Blue Cross denied the service, Angel MedFlight appealed, which resulted in a check to Deines from Blue Cross for $72,000, covering a small portion of his services, which Deines forwarded to Angel MedFlight.

    Three months later, Blue Cross demanded its money back, saying it had paid the $72,000 in error. It ended up sending the debt to a collection agency. Angel MedFlight appealed again to an outside independent evaluator who ruled for Blue Cross, claiming that Deines could have stayed at the Colorado hospital.

    What can you do to protect yourself from an air ambulance and ground ambulance bill of this magnitude? Shop around. Recently, I helped a family member get from a hospital in Arkansas to a hospital in New York. The total charge for the air ambulance and the ground ambulances from and to the hospitals was under $20,000, a far cry from $489,000. It’s also a good idea to call your insurer to understand its coverage policy. But, it’s not likely you would know ahead of time whether the insurer would pay for the service or deny coverage on medical necessity grounds.

    NB: As of January 1, 2022, air ambulances must tell you the cost of their services ahead of time. The federal No Surprises Act should protect you from being charged anything more than what your insurance pays a network provider; it should also ensure you are told what your costs might be if your care is denied.

    Here’s more from Just Care: