North Carolina AG gets 116 complaints about Mission Health

A concerning number,' Attorney General describes recent Mission Health  complaints filed | WLOS

The North Carolina attorney general’s office received 116 complaints about Asheville, N.C.-based Mission Health over a 12-month period, WLOS reported June 8. 

WLOS reported that most of the complaints were related to billing issues, 23 percent were concerns over quality of care, 16 percent were related to cost of service, 7 percent were from employees or former employees of Mission Health and 5 percent were related to charity care requirements.

“It’s a concerning number, 116 over a year,” Attorney General Josh Stein told WLOS. “That’s a lot, so we’re sharing our serious concerns with the management of the health system and we are going to be on top of this to the extent we possibly can.”

Mr. Stein told the publication that his office recently dedicated one of his employees to keeping track of all the complaints about Mission Health.

Mission Health was acquired by Nashville, Tenn.-based HCA Healthcare in 2019. HCA agreed to certain commitments as part of the deal, including keeping major Mission Health facilities open and continuing to provide certain services.

Since the acquisition, there have been a number of physician exits from the health system, and an independent monitor is looking into the reason behind the exits.

Mission Health shared the following statement with WLOS:

“Since January of 2021, we are aware of 15 complaints made to the Attorney General’s office, nine of which were related to billing and all of which have been resolved. We address every issue the Attorney General’s office brings to our attention promptly—both with them and the patient. Our patient care is our first priority. We strongly encourage everyone to contact us directly any time there is a concern so we can address it with them immediately and personally.

Going back to 2020, the majority of billing concerns were made shortly after acquisition of Mission and primarily regarded questions around changes to medical practice operations and a variety of billing issues all of which were resolved. Any patient or guarantor with billing questions or concerns should contact 833-323-0834 and we are happy to discuss, answer any questions you may have, and seek resolution where needed. Further, we have an email address, contactmission@hcahealthcare.com, where people can reach out to us on any matter.”

UnitedHealthcare to crack down on ER visits, potentially exposing patients to bigger bills

TeeMichelle on Twitter: "UnitedHealthcare to crack down on ER visits, potentially  exposing patients to bigger bills | Healthcare Dive https://t.co/bLNYAczNjB  #SmartNews"

Dive Brief:

  • The nation’s largest commercial insurer is taking a closer look at whether visits to the emergency room by some of its members are necessary. Starting July 1, UnitedHealthcare will evaluate ER claims using a number of factors to determine if the visit was truly an emergency for its fully insured commercial members across many states, according to a provider bulletin
  • If UnitedHealthcare finds the visit was a non-emergency, the visit will be “subject to no coverage or limited coverage,” the provider alert states.
  • However, a statement provided to Healthcare Dive said the insurer will reimburse for non-emergency care according to the member’s benefit plan. In other words, the amount paid by UnitedHealthcare may be less if deemed a non-emergency.    

Dive Insight:

Patients seeking out the pricey ER setting for minor illnesses that could have been treated elsewhere has been a perennial issue for the healthcare industry. Misuse of the nation’s emergency departments for minor ailments costs the nation’s healthcare system $32 billion a year, according to a previous report from UnitedHealth Group, the parent firm of UnitedHealthcare.

Providers worry such policies will lead to a chilling effect, causing patients to hesitate even in a true emergency such as a heart attack or stroke. Some of those concerns about the effects on patients were aired on Twitter this week after the provider bulletin became public. 

UnitedHealthcare’s policy contains exclusions, including observation stays, visits by children under the age of two and admissions from the ER.  It’s not clear precisely how many patients will be impacted but UnitedHealthcare had a total of 26.2 million commercial members at the end of 2020.

The insurer said this is an attempt to ensure healthcare is more affordable. To curb costs, they want patients to seek out treatment in a more “appropriate setting” like an urgent care facility. 

Other major insurers have enacted similar policies in the past and faced pushback from the public and providers.

Anthem in recent years has also enacted policies that put patients on the hook for the ER bill if they sought care that didn’t warrant a trip to the ER. The policy also attracted scrutiny from then Senator Claire McCaskill, a Missouri Democrat, who requested Anthem turn over internal documents over the policy and the Blues player ultimately scaled back some of its policies amid pushback from doctors and others.

Providers have argued these policies collide with federal law that require emergency rooms to treat any patient that shows up, regardless of their ability to pay.

UnitedHealthcare does have a process in place for those to contest a visit that was deemed a non-emergency.

1 in 3 Americans skip care due to cost concerns, survey shows

Americans most likely to skip health care due to cost: survey

In the past year, cost was a bigger factor driving Americans to skip recommended healthcare than fear of contracting COVID-19, according to a report released June 1 by Patientco, a revenue cycle management company focusing on patient payment technology.

Patientco surveyed 3,116 patients and 46 healthcare providers, finding 34 percent of female patients and 30 percent of male patients have avoided care in the past year citing concerns about out-of-pocket costs.

Below are three more notable findings from the report:

  1. Healthcare affordability is not an issue that affects only Americans with low incomes, as 85 percent of patients with household incomes greater than $175,000 are less likely to defer care when flexible payment options are offered.
  2. Across all ages, income levels and education levels, most patients said they struggled to understand their medical bills and what they owed. Nearly two-thirds of patients said they did not understand their explanation of benefits, did not know what they should do with the information in their explanation of benefits, or waited too long to obtain their explanation of benefits.
  3. Forty-five percent of patients said they would need financial assistance for medical bills that exceed $500, and 66 percent of patients said the same for medical bills that exceed $1,000.

Another kind of surprise medical bills

Kaiser Health News’ latest edition of its “Bill of the Month” series features a patient who was charged a “facility fee,” which drove up what she owed to more than 10 times higher than what she’d previously paid for the same care.

Why it matters: Facility fees — which are essentially room rental fees, as KHN puts it — are becoming increasingly controversial, and patients often receive the bill without warning.

  • Hospitals aren’t required to inform patients ahead of time about facility fees.
  • Hospitals say they need the revenue to help cover the cost of providing 24/7 care.

What they’re saying: “Facility fees are designed by hospitals in particular to grab more revenue from the weakest party in health care: namely, the individual patient,” Alan Sager, a professor at the Boston University School of Public Health, told KHN.

  • The practice is becoming more popular as more private provider practices are bought by hospitals.
  • “It’s the same physician office it was,” said Trish Riley, executive director of the National Academy for State Health Policy. “Operating in exactly the same way, doing exactly the same services — but the hospital chooses to attach a facility fee to it.”

From insurer to diversified services business

https://mailchi.mp/3e9af44fcab8/the-weekly-gist-march-26-2021?e=d1e747d2d8

Large health insurers no longer just provide coverage, but are instead repositioning themselves as vertically integrated healthcare organizations that span the care continuum.

The graphic above shows five-year total revenue growth by segment for the top five health insurance companies.

Some, like Anthem and Humana, are still in the early stages of revenue diversification, leveraging partnerships and investments to fill service gaps—in Humana’s case, these are mainly centered on the Medicare Advantage population.

On the other hand, the insurance revenue of Cigna and CVS Health is already dwarfed by pharmacy benefit management (PBM) revenue (as well as retail clinic revenue for CVS).

UnitedHealth Group (UHG) is clearly leading the pack, with a robust revenue diversification and vertical integration strategy. 

Its Optum subsidiary grew 62 percent over the last five years, nearly double the rate of its UnitedHealthcare insurance business. Already the largest employer of physicians in the country, Optum recently announced plans to acquire Massachusetts-based 715-physician group, Atrius Health. It also announced its intent to acquire Change Healthcare, one of the largest providers of revenue and payment cycle management solutions.

Given the outsized role of the Optum division in driving UHG’s growth and profitability, it may soon face a dilemma that other publicly traded, diversified companies have had to confront: shareholder demands to unlock value by spinning off the business into a separate company.

Central to fending off that kind of activism by shareholders: demonstrable steps to integrate the myriad businesses the company has acquired into a functional whole. Just as Amazon’s hugely profitable Web Services business has become a target of spin-off demands, so too, eventually, may UHG’s Optum.

Michigan healthcare CEO gets 15 years in prison for $150M fraud

IIG trade finance fund caught in alleged Ponzi scheme | Global Trade Review  (GTR)

The CEO of a chain of medical clinics in Michigan and Ohio was sentenced March 3 to 15 years in prison and ordered to pay $51 million in restitution for his role in a $150 million healthcare fraud scheme, according to the U.S. Justice Department

Mashiyat Rashid was sentenced after pleading guilty in 2018 to money laundering and conspiracy to commit healthcare fraud and wire fraud. Twenty other defendants, including 12 physicians, have been convicted for their involvement in the scheme. 

Mr. Rashid, who served as CEO of Tri-County Wellness Group from 2008 to 2016, developed and approved a corporate policy to administer unnecessary back injections to patients in exchange for prescriptions of over 6.6 million doses of medically unnecessary opioids, according to the Justice Department. 

Many patients experienced pain from the unnecessary injections, and some developed adverse conditions, including open holes in their backs, according to testimony at Mr. Rashid’s trial. Physicians at the clinics denied patients, including those addicted to opioids, medication until they agreed to get the injections, according to court documents. 

According to evidence presented at trial, Mr. Rashid only hired physicians who were willing to administer the unnecessary injections in exchange for a split of the Medicare reimbursements for the procedures. Tri-County Wellness Group was paid more for facet joint injections than any other medical clinic in the U.S., according to the Justice Department. 

Proceeds of the fraud were used to fund private jets and to buy luxury cars, real estate and tickets to NBA games, prosecutors said. Mr. Rashid was ordered to forfeit to the U.S. government $11.5 million in proceeds traceable to the healthcare fraud scheme, including commercial and residential real estate and Detroit Pistons season tickets. 

New York physician charged with manslaughter in patient death

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A New York physician has been charged with manslaughter in the second degree and is facing other felonies related to the overdose death of a patient, New York Attorney General Letitia James announced Feb. 19. 

Sudipt Deshmukh, MD, allegedly prescribed a lethal mix of opioids and other controlled substances that resulted in the overdose death of a patient. The physician allegedly knew the patient struggled with addiction.

An indictment, unsealed Feb. 18, alleges that between 2006 and 2016, Dr. Deshmukh ignored his professional responsibilities by prescribing combinations of opioid painkillers and other controlled substances, including hydrocodone, methadone and morphine, without regard to the risk of death associated with the combinations of those drugs.  

Dr. Deshmukh is facing several felony charges, including healthcare fraud, for allegedly causing Medicare to pay for medically unnecessary prescriptions. 

The indictment comes after the attorney general’s office filed a felony complaint against Dr. Deshmukh in August. In 2019, the New York State Office of Professional Medical Conduct found that he committed several counts of misconduct.