Tag Archives: Life

UnitedHealthcare Tightens Specialist Access for Medicare Advantage Enrollees

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New referral requirement for HMO and HMO-POS plans alarms patients and doctors, who predict bureaucratic delays and reduced access to care.

Theresa Schwartz, a 66-year-old Milwaukee plumber, says she’s one of those people who never went to a doctor before she was 40. That has changed in the second half of her life as she has dealt with major health issues, including lung cancer and rheumatoid arthritis.

In recent years, her regular visits to the Milwaukee Rheumatology Center have been covered, without hassle, by her Medicare Advantage insurance provided through the nation’s largest health insurer, UnitedHealthcare. But Schwartz was surprised and became upset during her most recent visit there when she was told that — because of a new UnitedHealthcare policy — she will now need a referral from a primary care physician to be covered.

Schwartz said she’s never had a primary care physician.

“I’m just spinning the hamster wheel,” said Schwartz, who said in a phone interview that she is already confused and frustrated by the new policy and has little patience or interest in finding a UnitedHealthcare in-network physician. She even offered to pay cash for her visits, which the Milwaukee clinic said it cannot accept for Medicare patients.

Schwartz’s discontent over the new UnitedHealthcare policy — which launched at the beginning of the year, with reimbursements for visits without referrals to certain types of specialists set to stop after April 30 — is hardly unique. Health care advocates say the policy change affects a large pool of senior citizens in the insurer’s HMO and HMO-Point of Service (POS) Medicare Advantage plans. This is a healthy chunk of the estimated 8.5 million seniors who get their Medicare Advantage coverage through UnitedHealthcare — one of every four MA enrollees.

“I have patients in their 90s who are now facing this, if you can imagine,” said Nilsa Cruz, the tireless patient advocate for Milwaukee Rheumatology Center who frequently speaks out at the Wisconsin state capitol and elsewhere about health care issues. “And they don’t understand their insurance cards, anyway.”

Cruz predicted “a total disaster” when the UnitedHealthcare policy, which is currently in a sort of soft-launch mode, takes full effect in May, as both patients — many who’ve been seeing a specialist for 15 or 20 years without ever needing a referral — and their doctors struggle to adapt to an onerous new system.

The change, which is likely to have the effect of reducing specialist visits and thus saving UnitedHealthcare millions if not billions of dollars, isn’t taking place in a vacuum. Rather, it’s one more assault on seamless and efficient health care coverage. Patient inconvenience seems to be a cornerstone of this icon of Big Insurance’s plan for dealing with what its executives claimed last year were $6.5 billion in annual higher costs.

In recent months, UnitedHealthcare has dropped as many as 180,000 enrollees from its Medicare Advantage plans in targeted geographic areas and plans to drop more than a million by the end of this year. It has also “narrowed” its provider networks, relegating certain clinical practices, such as rheumatology clinics, which provide costly infusion therapies, to out-of-network status.

Some analysts had predicted a kinder, gentler UnitedHealth after a tragedy that made national headlines — the murder in New York of UnitedHealthcare CEO Brian Thompson in December 2024 — focused new attention on the company’s aggressive use of prior authorization to deny coverage for medically necessary care. Instead, the giant insurer has doubled down on ways to drive the highest-cost patients and providers from its system, making it necessary for millions of seniors to scramble to find either new MA insurers or new doctors. Many undoubtedly will go untreated.

The unwelcome requirement for many of UnitedHealth’s Medicare Advantage patients to get primary-doctor referral for treatments they’ve often been getting for years from a specialist looks to be one more way the company is nickel-and-diming a path back to higher profits on the backs of patients with chronic health issues.

Needless to say, UnitedHealthcare, whose financial performance has disappointed investors for more than a year, doesn’t portray the change that way. In announcing the move late last year the company hailed it as a way to improve communication between its affiliated providers and prevent unnecessary tests or procedures, or visits to a specialist that aren’t really necessary.

“The goal of this referral process is to help increase primary care provider (PCP) engagement with patients and help foster collaborative partnerships between PCPs and specialists,” is the upbeat jargon UnitedHealthcare used to explain the change on its provider portal.

Since Jan. 1, the change has been in what UnitedHealthcare considers “a trial period,” which means that while it wants patients to begin getting primary-care referrals before seeing certain types of specialists, visits without a referral are still covered for now. That will no longer be the case after April 30.

The policy does exempt more than a dozen specialists or types of visits — most notably oncology, as well as mental health treatment, physical therapy, and some other common medical treatments. It also won’t affect MA enrollees in California, Texas, and Nevada where referrals were already required.

Madelaine Feldman, M.D., the New Orleans-based immediate past president of the Coalition of State Rheumatology Organizations, said she imagines dire scenarios in which a patient with a sudden flare-up cannot get speedy treatment because of the inability to get a speedy referral, or visits that aren’t covered because the referral is mishandled.

“So the fact that UnitedHealthcare has decided that rheumatologists are not capable of deciding when a patient needs to be seen is ludicrous, capricious, and most importantly, dangerous,” Feldman said. She added that situations that are harmful for patient care “will be seen more and more as a result of policies enacted to improve UnitedHealthcare’s bottom line.”

But for people enrolled in the company’s HMO and HMO-POS Medicare Advantage plans, the new policy seems less a way of improving communication than an additional and unwanted barrier to receiving care.

“Today I found out about it, and I don’t think it’s fair,” said Pamela Matias, a 63-year-old infusion-therapy patient at the Milwaukee Rheumatology Center who filmed a video after learning of the change. “I’ve been getting this medication for 20 years and never needed a referral.”

Unlike Schwartz, Matias does see a primary care doctor, but she still worries that the extra hassles of getting a referral — and making sure it goes through properly — have longtime rheumatoid arthritis patient alarmed. “Without my medication, I would not be able to walk,” she said. “I’ll be in 100% pain all day long.”

Cruz, the center’s patient advocate, said that during this trial period, it’s not just patients who are disoriented. An early problem she’s seen with the program is that doctors’ offices are often faxing or attempting to call in patient referrals when UnitedHealthcare is only recognizing those that are made electronically through its online portal. What’s more, she said doctors need to specify how many visits are covered during a six-month window.

Cruz said even one of the largest health care practices in Wisconsin was improperly faxing the referrals. “I think they were faxing up until the other day — you know, a month and a half, almost, into this thing,” she said. “So that tells you something. Andrimary care physicians were not all fully informed.” Even if they are trained, primary-care doctors don’t always know how many specialist visits a patient will need until they are reevaluated by the specialist and begin their treatments.

If doctors don’t understand the new UnitedHealthcare policy, she worries, then how will elderly Medicare patients — including some with major disabilities — be able to follow the rules? Furthermore, if a patient’s current primary-care doctor retires or relocates, it often takes months in today’s frenzied health care environment to get an appointment with a new one, which could delay critical care.

As a rabble-rousing patient advocate, Cruz seems somewhat ahead of the curve in anticipating a crisis. Many specialists are just beginning to absorb the changes and won’t feel a real impact until May, when UnitedHealthcare stops paying specialists for their patients who didn’t obtain referrals.

But Cruz said she is already lobbying the Coalition of State Rheumatology Organizations, where she is a highly active member, to take a stand against UnitedHealthcare’s new policy, noting that it targets only the lowest-cost Medicare Advantage HMO plans and not the higher-end PPO policies, let alone its commercial insurance customers. To her mind, that is discrimination. “They’re doing the HMO — the sickest patients,” she said. “The sickest.”

This and other moves from UnitedHealthcare and its competitors have the effect of pushing the sickest and most expensive patients off their rolls, either by dropping customers outright or making it harder for them to access the medical care they so desperately need. Forcing sick people to make extra doctor visits to get treatment undoubtedly will cause many to delay or even forgo care — which, sadly, seems to be what UnitedHealthcare is going for as it tries to get back into Wall Street’s good graces.

Immigration crackdown sets off alarms in hospitals

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The Trump administration’s rollback of a policy that prohibited immigration enforcement in hospitals is sparking fear and confusion in exam rooms and emergency departments amid a surge in ICE arrests.

Why it matters: 

Health care workers say stepped-up enforcement is interfering with care in some instances, and lawyers say it has created enough privacy concerns that some are erasing whiteboards on patient floors and concealing medical records.

  • Many hospitals don’t have clear protocols, Sandy Reding, president of the California Nurses Association and vice president for National Nurses United told Axios.
  • That’s put nurses and other health workers in situations in which they have to confront ICE agents carrying warrants in unauthorized areas.

State of play: 

A Homeland Security Department directive in January rescinded a Biden administration policy that designated hospitals, schools and churches “sensitive locations” that were off limits to immigration enforcement.

  • That had the effect of giving Immigration Customs and Enforcement more leeway to detain individuals in hospitals. They are also able to closely monitor people in their custody who are brought in for medical care.
  • Health systems have been seeking legal advice and stepping up training for employees about what’s permissible in public and private spaces.
  • “The judicial warrant needs to be specific as to the place and who you’re looking for. It’s not going to say you can just walk into the ICU and check everybody,” Douglas Grimm, head of ArentFox Schiff’s national health care practice and a former hospital administrator, told Axios.

Zoom in: 

The legal gray areas were driven home by physicians at a Los Angeles hospital who told LAist that ICE personnel interfered with the care of a detainee. Medical personnel were not able to call the patient’s family, even to find out health history, and agents refused to leave during confidential medical conversations.

  • Adventist Health White Memorial, in a statement, said it provides the same level of care to patients who come in while in government custody. “Our guidelines for caring for patients who are in custody are based on legal requirements. Our primary goal is to ensure the health and safety of our patients, staff and visitors,” the hospital operator said.
  • Elsewhere, a UCLA emergency nurse said she was blocked from assessing a screaming patient by an ICE agent, the Guardian reported.
  • And a Chicago alderwoman was arrested by ICE agents while checking on detainee at hospital in Humboldt Park, CBS reported.

Between the lines: 

Distinguishing which areas are public and which are private is the first order of business, said Maria Kallmeyer of Quarles & Brady. So is laying out a protocol, including a phone tree with whom to call if ICE agents arrive, for front desk receptionists.

  • Staff are generally told to inform ICE that they don’t have the authority to grant access and should keep them in the lobby until they are able to reach a supervisor, she said.
  • Agents can access private areas like patient rooms if they have a judicial warrant or if they brought the patient in for care while in ICE custody.
  • In such scenarios, Grimm said, he advises health facilities to have a plan for wiping whiteboards and ensuring that all medical records on paper or on screens are put away.
  • Grimm noted past instances in which one officer enters a patient’s room while a second wanders the halls. In those scenarios, it’s up to the nurse manager or compliance manager to orally point out the officer is not authorized to be anywhere but with the specific patient.
  • “If the officer keeps walking, you have to take the next step, which is just try and record that. But don’t try and impede their progress,” Grimm said.

The other side: 

ICE did not respond to requests for comment from Axios.

  • A spokeswoman previously told LAist the agency “is not denying any illegal alien access to proper medical care or medications” and that it’s “longstanding practice to provide comprehensive medical care from the moment an alien enters ICE custody.”

Yes, but: 

Reading of the California Nurses Association said she received an Instagram video from some of her union members this summer showing ICE agents with large guns sitting behind a hospital reception desk. She learned they were there because they had brought a patient in custody to the facility.

  • It was intimidating for visitors and staff alike, and also created a clear potential privacy violation for any patient entering and being asked to provide personal information as they enter the building, she said.
  • “The nurses couldn’t do their work unencumbered because they were worried about the ICE agents,” she said. “There was one [agent] that was found in another unit which was off limits. They had to ask that person to leave because they weren’t supposed to be in patient care areas. So it became very clear that we need some rules.”
  • California Gov. Gavin Newsom (D) recently signed into law a requirement that hospitals have protocols prohibiting health providers from giving immigration authorities access to non-public areas unless there’s a warrant or court order. It also expanded the definition of protected “medical information” to immigration status.

It’s an important step toward setting some ground rules, but certain health facilities are still seeing dramatic drops in caseloads as patients forgo care.

  • “It is creating an atmosphere of fear,” Céline Gounder, clinical professor at NYU, told CBS Mornings about her experience in New York. “My colleagues and I have had numerous patients tell us that they hesitated or waited too long to come in for health care.”

Help! Do I have to pay for the hospital’s $47,000 mistake?

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They were late filing a claim. Now I’m in collections.

Hey there —

I get a lot of questions from An Arm and a Leg listeners. Sometimes I write back with advice. So: Why not share? Welcome to an experiment: Our occasional advice column!

Maybe let’s call it: Can they freaking DO that?!?

Disclaimer: I don’t know everything, I’m not a lawyer, and I haven’t done new reporting for this. It’s the kind of advice I’d give a friend.

Or, in this case, a listener named Chris.

Q: Can they charge me $47,000 for their mistake?

I had an emergency appendectomy. The hospital rang me up for about $47,000 — but, insurance denied the claim because they say the hospital didn’t submit it to them until eight months after the fact — beyond their 60-day “timely filing” limit in the contract [between the hospital and the insurance company].

After that, the hospital started billing me.

I have spent hours and hours on the phone over the last two months with various people in their billing department. I followed their recommendation to send a letter, and an email, requesting that they write off these charges since it was their billing error — and nothing has been fixed.

Now they’ve sent me to collections.

What do I do now? Do I sue? How can I sue? Help!

Chris

A: Don’t run for a lawyer (yet)

Chris, thanks so much for writing in — and YIKES.

I think you’re zeroing in on the right question, which is: How can you demand redress?

Put another way: Where’s your leverage? How can you get them to see they’re better off dealing with you in good faith, versus… getting themselves in actual trouble?

I don’t think you need to run out and hire a lawyer. But there’s a bunch of homework to do.

Start with your insurance

Because it’s their job to protect you from getting unfairly harassed like this.

Sounds like the hospital promised the insurance company — in a contract — to submit bills within 60 days.

That contract probably does not say, “and if we’re late on that, we’ll just go after Chris.”

No. I’m thinking it says, “If we don’t get you that bill on time, that’s just too bad for us.”

So: the insurance company has a right — and an obligation to you — to tell the hospital where to stick that bill.

So ask your insurance company: What’s *supposed* to happen if a hospital doesn’t submit a bill on time? What’s their process for getting things fixed? Can they tell the hospital to just knock it off, already?

And while you’ve got them, you may as well ask: If the hospital had submitted the bill on time, what would you have been on the hook for?

…because when this gets fixed, you’ll probably owe that amount.

If your insurance won’t cough up the info and won’t go to bat for you, get help. If you get your insurance through work, call HR. Otherwise, ring up your state insurance regulator.

Dispute the bill in collections

Meanwhile, you’ve got the hospital siccing a collection agent on you. That’s not right.

Notify the collection agency that you’re disputing this debt, as described in this recent First Aid Kit — which includes a dispute-letter template. (While you’re at it, send a copy to the hospital billing office.)

Document your efforts to get the hospital to see the light on this. If you’ve written to them, attach copies of previous correspondence. If it’s been all phone calls, document them: You called them on this day, at that time, etc.

If you haven’t been logging calls — keeping a set of notes with times, dates, who you spoke to, and where things stood at the end of the call — start now.

Let the hospital know: They could get in trouble

Your state’s consumer-protection office might take a dim view of what the hospital is doing here.

I mean, I’m not a lawyer, but I’m pretty sure there are laws against chasing you for money you don’t actually owe.

Look up that consumer-protection office here. If you can talk with someone there, great. If your state’s consumer-protection laws are easy to find online (and understand), also great.

(If not, consider calling your local public library. Seriously, librarians are amazing at helping dig up useful information.)

Once you’ve got some sense of your legal rights — from the hospital’s contract with the insurance company, from your state’s consumer-protection laws…

Start writing letters. To the hospital, to the collection agency — saying: Let’s get this settled before I have to complain to regulators about this. (When you write to the hospital, maybe cc the General Counsel’s office.)

Let them know how you expect things to go, and indicate — subtly but clearly —that you know what kind of trouble they could be in and why.

And make it all as confident and calm as possible. I’m thinking of something the legal expert Jacqueline Fox told me once:

The person who gets the letter has to make the decision: “Do I ignore this, or do I bring it to my manager?”

And if I was that person and [the letter-writer] was very calm — just saying, “this is happening, and it’s starting to look like this [legal issue] and I want this to be handled according to your processes,” that’s the part I’d find alarming.

If I was that person, I would either make sure it’s handled according to my processes, or give my manager a heads up: that there’s a grownup who seems somewhat irritated.

Somehow, we never actually used that tape, even though I think about it all the time — until now. Thanks for the chance to bring it back.

Segment 8 – Applying Our Values & Philosophy to Healthcare Reform

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Segment 8 – Applying Our Values & Philosophy to Healthcare Reform

Slide24

This segment reviews traditional American values and philosophical principles that can help resolve the core dilemma that has stopped us from fixing US healthcare for years – the unresolved conflict between “social justice” and “market justice.”

In the first six Segments, we reviewed the relentless growth of healthcare spending. And how rising costs are literally built into the system as it is now.

In Segment 7 we talked about some landmines that lurk beneath the surface of fixing healthcare – power and politics.

In this Segment, we will look at traditional American values and at philosophical principles that can help us resolve the core dilemma that has stopped us from fixing US healthcare all these years.

Let’s start with the American traditions. Some of these have been a bit romanticized in our imagination. So we’ll look at each of them in more detail.

Slide25

Freedom of the individual is pretty clear. It brings to mind the pioneer spirit of early adventurers and settlers.

Slide07

There is a presumption for rugged individualism and against government entanglement. But even by the time of the Revolutionary War and Constitutional Convention growing colonial cities were developing governmental and civic services like fire departments and sanitation programs.

Free enterprise is a core American value. But here again, there are examples from earliest Colonial days of collective projects, such as the Boston Commons, schools, and toll roads that stood alongside freestanding farms and shops.

Slide09

Next is “Yankee ingenuity.” Americans are entrepreneurs, innovators, practical problem solvers. We have never been bound by tired old ideas from Europe or elsewhere. We come up with our own ideas and forge ahead with progress. We’ll come back to these concepts.

There is an American tradition to distrust government. But if we look more closely at what this meant to the Founding Fathers, it was not government itself that they distrusted. In fact, Americans never embraced anarchy; they always set up orderly civic structures in every settlement and colony. What they abhorred was tyranny, the concentration of power in the hands of a sometimes capricious and self-serving autocrat. Further, they distrusted any individual person wielding authority. And so the Constitutional Framers crafted a government with the right balance between too much and too little authority, separate branches, and checks and balances. Today’s institutions – including healthcare – will do well to build in the same kind of accountability, transparency and checks and balances, especially since so much money and power is involved.

And so I am going to rename this tradition, Distrust of Tyranny (and of Human Fallibility).

Lastly is our tradition to protect under the law outcasts, the weak, and the vulnerable. Colonial settlers were often themselves oddballs or failures, seeking the opportunity for a new life in America. They enshrined protections for themselves in law, notably the Bill of Rights.

Since a large group of Americans today express misgivings that government involvement in healthcare would be a betrayal of our Founding traditions, I would like to offer several more reflections.

Look at the principles listed in the Declaration of Independence and the Preamble to the Constitution – life, liberty and pursuit of happiness.

Slide14

Slide15

Slide16

 

More perfect union, justice, domestic tranquility, general welfare, and the blessings brought by liberty to ourselves and our posterity. These sound to me like values that would flow from a people who don’t worry about getting care when they become sick, and who willingly embrace practical healthcare reforms that advance the common good. This is a far cry from the notion that the Framers would have wanted to freeze us into their time – 1788, to be exact. I have a feeling that the Founding Fathers were too practical minded, ingenious and adaptable to lock themselves into even their own ideas. Rather, I think they would try to honor American traditions, compromise over seemingly different viewpoints, seek solutions that bring us together and bind us together, promote the common good, and maximize our freedom, wellbeing (or “welfare,” to use their terminology), and stewardship of our great blessings.

Slide17

Not to belabor this point, but I’d like to look back at Dr. Benjamin Rush, who we met in Segment 2 as a prominent doctor in the Revolutionary period who signed the Declaration of Independence. Recollect that he received his medical training at University of Edinburgh, the foremost medical school of that time, which in the European system was state-run. He supported publicly-funded mental asylums and is considered to be the father of American psychiatry. In 1794 he was inducted as a foreign member of Swedish Academy of Medicine, which is the historic root of Sweden’s modern-day national healthcare system. Rush supported public health and sanitation initiatives, such as rerouting Dock Creek and draining its surrounding swamp on the east side of Philadelphia to eliminate mosquito breeding grounds. He established a public dispensary for low income patients. And he founded the Pennsylvania Prison Society to protect rights of prisoners and promote their humane treatment.

Slide18

Slide19

 

Based on this profile, I don’t think it’s a stretch to believe that this 18th century Founding Father might support innovative public and private partnerships ensuring healthcare for all citizens if a time machine could transport him into the 21st century.

Now let’s now look at what some healthcare philosophers in this century say about fair ways to run the system. The basic principles of healthcare ethics are autonomy (which is self-determination), justice (fair distribution of costs and benefits), beneficence (the most good for all), and professional integrity (meaning that society has a stake in the independence of doctors).

Slide20

One philosopher who has applied these principles to modern healthcare is Paul Menzel from Pacific Lutheran University in Washington state.

Slide21

He has been writing on the ethics of the healthcare system since 1983, when he came to Washington DC to apply his philosopher’s methodology to the issue, until his retirement in 2012. Here are his view of the features of a fair system of healthcare delivery and financing.

  1. The system should provide costworthy care, and costworthy care only, no wasteful treatments.
  2. The system should provide financial protection to sick individuals who need care.
  3. The system should make health care equitably accessible to all.
  4. The system should equitably distribute the costs of care between the ill and the well
  5. The system should justly allocate the costs of care between the rich and the poor.
  6. The system should respect autonomy of patient choice.
  7. The system should respect provider choice.

Two other philosophers, one an ethicist and the other a doctor, have laid out fair, publicly acceptable ways to set limits on healthcare spending. There needs to be:

  1. Open, transparent deliberations
  2. Use of relevant criteria agreed on by all
  3. An appeals procedures for individual extenuating cases.
  4. Uniform standards and regulations applying to all delivery and financing systems.

Let’s end on a key philosophical controversy in the US – market justice versus social justice. Market justice means, in starkest form, that consumers can buy only what they can afford, and that giving them something they have not earned is ethically and economically wrong. Social justice sees equitable distribution of health-care as a societal responsibility, without regard to ability to pay. (Note that I am purposely avoiding the loaded words – “rights” and “privileges,” which tend to inflame this controversy.)

Slide24

It has been said that progress on healthcare reform is stymied by our country’s inability to choose one or the other – we’ve been caught between the two ideas of justice.

In the next Segment I will ask whether the two sides of the argument can come together. Does it need to be either-or? Or can we blend market justice and social justice? Can the US take what’s best from both the commercial business world and the public sector world?

My answer is Yes. And we’ll look at a successful plan that did just that 20 years ago.

I’ll see you then.