UnitedHealthcare issues warning to hospitals about out-of-network coverage for ER physicians

https://www.healthcarefinancenews.com/news/unitedhealthcare-issues-warning-hospitals-about-out-network-coverage-er-physicians?mkt_tok=eyJpIjoiTUdaa00yUXhZVGhsWlRObSIsInQiOiJSNFQ0ZWR5dDlLeHVVWE9nUEFWcGNwazZDWXorRUJoanpLWHE1UmVEMU1RbjVZSFwvT3pmR0xMMVc0Snp2ZWQzMHlQMHp2c01XbzgwOEdBN1BsSGZJbFhWTnUydnpaWkNKVDlSbGR0aUxYY2Jpbmg0VndqRVNTQVdLTXpqS0RvV28ifQ%3D%3D

 

UnitedHealth plans to update its provider directories to show its beneficiaries those hospitals that use non-participating hospital-based physicians.

WHAT HAPPENED

UnitedHealthcare sent out an advanced notice to more than 700 hospitals that its emergency room contractor, Envision Healthcare, could be out of network starting January 1, 2019. 

WHY IT MATTERS

Dissolving the contract is expected to result in more “surprise bills” for patients who are unaware that their ER doctor, anesthesiologist or radiologist is out-of-network for their insurance coverage.

THE BIGGER TREND

Both hospitals and UnitedHealthcare would bear the brunt of patient complaints, at a time when consumer satisfaction is seen as a priority for value-based care and in rankings that include patient surveys.

UnitedHealth said it plans to update its provider directories to show its beneficiaries those hospitals that use non-participating hospital-based physicians. It is also activating a dedicated hotline for members to call if they receive a surprise bill from Envision and UnitedHealth said it would advocate on their behalf to have the bill waived or reduced.

ON THE RECORD

“A study published by the National Bureau of Economic Research shows ER physicians are paid on average 297 percent of what Medicare allows,” said Dan Rosenthal, president of UnitedHealthcare Networks in the letter to hospitals. “In comparison, Envision demands to be paid nearly 600 percent of Medicare, two times this amount for ER physician services.”

Envision said by statement, “We have offered United a solution that helps with the affordability of healthcare, and yet United is making egregious demands that will force all of our physicians out of network.  They’ve elected to use data for one group in one market and have presented it as the single source of truth. This is misleading and designed to fit their narrative rather than the reality.”

THEIR TAKE

Envision said there were never any problems until UnitedHealth demanded massive cuts to allow it to stay in-network. It calls the insurer’s letters to its hospital partners “aggressive” and “filled with half-truths and inaccuracies.”

UnitedHealthcare, the country’s largest insurer, said it has offered Envision competitive rates for all of their hospital-based services, similar to what other ER and hospital-based physicians are paid in each market, and given them the opportunity to earn additional reimbursement based on the value they bring to customers.

In May, a court ordered arbitration between the insurer and network provider after dismissing a lawsuit brought by Envision claiming UnitedHealthcare changed its payment rate agreement. Envision charged patients at rates three times higher than it should have, UnitedHealth said. Envision said this was due to out-of-network charges because the insurer refused to bring Envision provider groups into their contract agreement.

OUR TAKE

This is about money, with patients paying the difference and hospitals caught in the middle. A hospital can choose to employ physicians, but many doctors are independent contractors, including emergency room physicians. Since, Envision has its highest concentration of contracts with UnitedHealthcare in Florida, Texas and Arizona and to a lesser extent, in New York, Wisconsin, Georgia, Tennessee and California, both patients and hospitals in those regions are likely to find themselves managing more surprise bills. 

Insurance start-up launches on-demand health coverage

https://www.cnbc.com/2018/06/27/insurance-start-up-launches-on-demand-health-coverage.html

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  • Start-up Bind uses proprietary algorithms, powered by machine learning, to lower health-care costs.
  • Bind discovered that it could break out certain procedures and reduce health benefit costs more effectively than with a high-deductible plan.
  • It is backed by Ascension Ventures, Lemhi Ventures and UnitedHealthcare.

Technology has made on-demand services a reality for everything from food deliveries to gym classes and car-sharing. What if you could have on-demand health coverage for big-ticket procedures like knee surgery?

On-demand health insurance seems like an oxymoron, but digital health insurance firm Bind is betting that by structuring health plans so that people can add coverage and pay for it when they need it, companies and employees can save money in the long run.

“It’s not intuitive for people, but I think when we started this we thought, ‘how do people really use the health-care system?’ And we used it in an on-demand way,” explained Tony Miller, co-founder and CEO of Bind.

The two-year old start-up is not a full-fledged insurer, it administers benefits for self-insured employers using UnitedHealth Group’sprovider networks and data analytics. Using its own proprietary algorithms, powered by machine learning, Bind discovered that it could break out certain procedures and reduce health benefit costs more effectively than with a high-deductible plan. It is backed by Ascension Ventures, Lemhi Ventures and UnitedHealthcare.

Plans are designed with basic co-pays and no deductibles for core medical coverage. In addition to free preventive care required under the Affordable Care Act, Bind’s plans cut out deductibles for primary care and specialist visits, maternity coverage, hospital care, medications and even cancer treatment. Co-pays are priced on a sliding scale — from $15 for a visit to retail clinic to $100 at an urgent care facility.

The big-ticket out-of-pocket costs kick in for elective procedures, such as knee replacement or back surgery. The extra co-pay for those procedures is based on the total cost, with consumers being given the full price of the procedure up front and no surprise bills on the back end. The co-pay can be structured so the worker can pay it off through payroll deductions, like a premium.

By outlining the total costs, Bind said it helps employees generate 10 to 15 percent in savings for themselves and for their employer compared to traditional out-of-pocket deductible plans.

“A market might be $6,000 to $24,000 for knee arthroscopy,” explained Miller. “What Bind does is says (for) the $6,000 performer — you only have to pay $1,000 to have access to them. If you want to go to the $24,000 knee arthroscopy with no difference in quality, no difference in performance, you have to pay $6,000 as a consumer.”

“What happens is the consumers actually go and buy the more cost-effective provider and they save money. But more importantly, the entire pool saves money … we save $18,000 for the group,” he said.

That was the way high-deductible plans were supposed to work, with consumers making the most cost-effective choice. Miller should know. He co-founded Definity Health in the late 1990s, which helped pioneer so-called consumer directed health plans; UnitedHealth bought that firm in 2004.

Does he worry that employers could use Bind’s on-demand plans to skimp on core benefits, and shift more costs to their workers? He does.

“What I would worry about is, taking this very novel plan design and if someone wanted to create a skinny plan out of it,” which he admitted would defeat the goal of Bind plan designs.

“Let’s make sure we fund the things we all need in health insurance and make sure that’s a part of everyone’s core benefit,” he said.

Bind has so far signed up small regional employers for its plan, but hopes to launch with a large Fortune 500 company for 2019 coverage.

 

Study: ‘Big five’ insurers depend heavily on Medicare, Medicaid business

https://www.fiercehealthcare.com/cms-chip/big-five-insurers-medicare-medicaid-growth-profits?mkt_tok=eyJpIjoiT0RnMFkySXdPV0psWldSaCIsInQiOiJQSllQNlpcL2RhTzBDZFwvZXh5M1ZUSDJyUU5JTGw3dnh1QTVac01rZUFcL2pNUUhhMXBaQjBxK29ScHRrOHhsT3d6aE5pcFRJUWd4Sm0rYXA4S0RYVGE2N0czN2hhc2hsXC9EZk9mSGVLR0V1UFlwVDZpQmdkcll0eTBMNDUzTHlIZDIifQ%3D%3D&mrkid=959610&utm_medium=nl&utm_source=internal

Rising Stocks

Even as they’ve retreated from the Affordable Care Act exchanges, the country’s biggest for-profit health insurers have become increasingly dependent on Medicare and Medicaid for both profits and growth.

In fact, Medicare and Medicaid accounted for 59% of the revenues of the “big five” U.S. commercial health insurers—UnitedHealthcare, Anthem, Aetna, Cigna and Humana—in 2016, according to a new Health Affairs study.

From 2010 to 2016, the combined Medicare and Medicaid revenue from those insurers ballooned from $92.5 billion to $213.1 billion. The companies’ Medicare and Medicaid business also grew faster than other segments, doubling from 12.8 million to 25.5 million members during that time.

All these positive trends, the study noted, helped offset the financial losses that drove the firms to reduce their presence in the individual marketplaces. Indeed, the big five insurers’ pretax profits either increased or held steady during the first three years of the ACA’s individual market reforms (2013-2016). Their profit margins did decline during those three years, but stabilized between 2014 and 2016.

Not only do these findings demonstrate the “growing mutual dependence between public programs and private insurers,” the study authors said, but they also suggest a useful policy lever. The authors argued that in order to help stabilize the ACA exchanges, federal and state laws could require any insurer participating in Medicare or state Medicaid programs to also offer individual market plans in those areas.

Nevada has already done something similar: It offered an advantage in Medicaid managed care contract billing for insurers that promised to participate in the state’s ACA exchange. The state credited that policy with its ability to coax Centene to step in and cover counties that otherwise would have lacked an exchange carrier in 2018.

It’s far less certain, though, whether such a concept will ever be embraced at the federal level during the Trump administration, since its focus has been on unwinding the ACA rather than propping it up.

Either way, recent events underscore the study’s findings about how lucrative government business has become for major insurers. One of the main goals of CVS’ proposed acquisition of Aetna is to improve care for Medicare patients, which would help the combined company “be more competitive in this fast-growing segment of the market,” CVS CEO Larry Merlo said on a call this week.

Aetna CEO Mark Bertolini added that the transaction has “incredible potential” for Medicare and Medicaid members, as the goal is to provide the type of high-touch interaction and care coordination they need to navigate the healthcare system.

 

1 in 3 People in Medicare is Now in Medicare Advantage, With Enrollment Still Concentrated Among a Handful of Insurers

http://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/?hsCtaTracking=cf7ca7bd-f263-4b1f-9f13-7153c1da02a1%7Ceb71522c-161b-4f47-906e-5abc935ef3b4

Medicare Advantage plans have played an increasingly larger role in the Medicare program as the share of Medicare beneficiaries enrolled in Medicare Advantage has steadily climbed over the past decade.  The trend in enrollment growth is continuing in 2017, and has occurred despite reductions in payments to plans enacted by the Affordable Care Act of 2010 (ACA).  This Data Spotlight reviews national and state-level Medicare Advantage enrollment trends as of March 2017 and examines variations in enrollment by plan type and firm. It analyzes the most recent data on premiums, out-of-pocket limits, and quality ratings.  Key findings include:

  • Enrollment Growth. Since the ACA was passed in 2010, Medicare Advantage enrollment has grown 71 percent. As of 2017, one in three people with Medicare (33% or 19.0 million beneficiaries) is enrolled in a Medicare Advantage plan (Figure 1).

 

  • Market Concentration. UnitedHealthcare and Humana together account for 41 percent of enrollment in 2017; enrollment continues to be highly concentrated among a handful of firms, both nationally and in local markets. In 17 states, one company has more than half of all Medicare Advantage enrollment – an indicator that these markets may not be very competitive.

 

  • Medicare Advantage Penetration. At least 40 percent of Medicare beneficiaries are enrolled in Medicare private plans in six states: CA, FL, HI, MN, OR, and PA. In contrast, fewer than 20 percent of Medicare beneficiaries are enrolled in Medicare Advantage plans in 13 states, plus the District of Columbia.

 

  • Premiums and Cost-Sharing. While average Medicare Advantage premiums paid by MA-PD enrollees have been relatively stable for the past several years ($36 per month in 2017), enrollees may be liable for more of Medicare’s costs, with average out-of-pocket limits increasing 21 percent and average Part D drug deductibles increasing more than 9-fold since 2011; however, there was little change in out-of-pocket limits and Part D drug deductibles from 2016 to 2017.

Medicare Advantage enrollment is projected to continue to grow over the next decade, rising to 41 percent of all Medicare beneficiaries by 2027.1  As private plans take on an even larger presence in the Medicare program, it will be important to understand the implications for beneficiaries covered under Medicare Advantage plans and traditional Medicare, as well as for plans, health care providers and program spending.