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How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them — ProPublica
The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.
Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.
The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.
Insurers Are Dictating Care and We're Sick, Sick, Sick of It! | MedPage Today
A final tactic is step therapy
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, or the practice of requiring patients to attempt less expensive treatments first, even if a clinician believes another option may offer a better outcome. This summer, government officials in New York negotiated a $1 million settlement with UnitedHealthcare for allegedly failing to cover
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all federally approved birth control without restriction. The company allegedly denied a patient coverage
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for a certain progestin-only oral contraception pill, forcing the patient to try alternative treatments, despite the fact that progestin-only contraceptives can be a good option
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for patients with certain health conditions.
Hospitalization Should Not Mean Financial Ruin for Medicare Beneficiaries | MedPage Today
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Chatterjee is a physician, health policy researcher, and an assistant professor of medicine. Macneal is a statistical analyst. Patel is a senior research coordinator.
Medicare was created to ensure older adults in the U.S. have healthcare coverage while protecting them from financial ruin. But for at least 10 million older adults today, one of the most influential insurance programs in the U.S. is failing. For this financially precarious population of Medicare beneficiaries, a hospitalization costs around $1,600 and triggers an immediate financial crisis. And with the risk of hospitalization rising with age, this kind of threat is all but unavoidable. Nearly 60 years after its founding, Medicare is full of coverage gaps
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and may be driving many near-poor older Americans into a poverty trap.
More than half of older adults in the U.S. are "near-poor," meaning they have incomes ranging from around $15,000 to $60,000 for individuals or $20,000 to $80,000 for couples. They are too well-off to qualify for Medicaid
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, but often cannot afford supplemental insurance. Some older adults enroll in Medicare Advantage plans or supplemental insurance called Medigap, but each program has a host of its own barriers. Most of these poor older adults live on fixed incomes and modest savings
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, so they can't just raise their income to pay off medical bills, particularly unexpected ones.
Soaring Cost of Insurance Due to Storms, Fires Is Crushing Homeowners
Along with the increased natural risk, Waters blames Gov. Ron DeSantis for the crisis. Without robust rate caps such as those in California, insurance costs have risen by over 200% while DeSantis has been in office. And the actions DeSantis, who has received $3.9 million in donations from the insurance industry since 2018, has taken have done little to mitigate Floridians' concerns. In May of last year, DeSantis approved a $2 billion reinsurance fund that aimed to reduce prices and keep insurance companies from bankruptcy. He also signed legislation in December that protects insurance companies from liability claims and disincentivizes homeowners from filing claims to begin with. At the bill signing, Desantis said, "The issues in Florida's property insurance market did not occur overnight, and they will not be solved overnight." Despite these policies, insurance prices have continued to go up and insurers have continued to flee the market. Farmers Insurance and AAA are the most recent names to join the growing list of insurance companies that have stopped issuing policies in Florida.
Solve surprise medical bills with benchmarking, not arbitration - STAT
I know many doctors who are waiting to see if mandatory arbitration becomes law before deciding to leave their insurance networks. Doctors like me who practice orthopedic surgery, for example, along with general surgeons, cardiologists who treat heart attack victims, and neurologists who treat stroke patients will all have financial incentives to promptly leave insurance networks and bill patients directly at rates significantly above those allowed by insurers, safe in the knowledge that insurance companies are now legally required to pay all out-of-network bills.
Next for Apple Watch: a clinical trial with J&J to track heart health - STAT
Typically, clinical trials use their own research infrastructure to track how patients do, but the HEARTLINE trial will plug into insurance claims databases to track patients. This approach, called a pragmatic clinical trial, could be cheaper and more efficient than the way studies are conducted now, without sacrificing the clarity and certainty that comes from having a control group in a study. But this is also risky: Using insurance claims data this way is new and untested.
“It’s certainly a vast and gross departure form the bricks and mortar model,” said Gibson. “This is one of the most exciting things, the idea that you’re going to find participants through the media, the news, potentially through insurers and even health care providers.”
Why Exercise May Be the Best Fix for Depression - Scientific American
Despite the mounting evidence that exercise can remedy some forms of depression, skepticism persists in academia and health care, Trivedi notes. “There is this general bias that exercise is not a bona fide treatment—it's just something you should do in addition to treatment, like trying to sleep and eat well,” he says. “Even though recognition of exercise as a treatment is increasing,” only some health insurance companies pay for gym time, he explains, and when they do, they often offer small temporary discounts. “I can prescribe a drug that costs $200 and insurance will pay, but they won't give $40 to open a gym membership.”
#The27Percent: Patients with preexisting conditions rally online
As the Kaiser Family Foundation report pointed out, a sizable portion of this group is covered by employer insurance or a public option like Medicaid, but they could be denied coverage if Trump administration reverts to pre-ACA policies. Indeed, there could be many more than 55 million at risk, Kaiser said, since its surveys didn’t include questions about conditions like HIV or hepatitis C, which would have also barred respondents from coverage in pre-Obamacare insurance markets.
Crossing State Lines Is No Easy Jaunt for Insurers and Local Regulators - WSJ
Insurance executives question how much interstate sales would unleash competition. Premiums are closely tied to underlying costs, such as rates paid to local doctors and hospitals and projected health needs of enrollees. The regulatory environment notwithstanding, selling coverage in any given state would require an insurer to have a local network of allied doctors and hospitals, something new entrants to a market might find costly to arrange. “In order to offer more value, you will need to have relationships and contracts with the providers in a state,” said Paul Markovich, chief executive of Blue Shield of California.
Insurers almost certainly wouldn’t sell coverage at the same price in multiple states, said Jim O’Connor, a principal at consultants Milliman Inc. They would adjust rates to reflect costs in each location, even if all the policies were under the same regulatory regime, he said.
BCBSNC amps up security due to 'frustrated customers'
A so-called "system failure" at BCBSNC enrolled thousands of customers in the wrong health insurance. Customers across the state complained of long wait times with customer service representatives and problems with their bills.
The Sticks and Carrots of Employee Wellness Programs - The New York Times
Most significantly, the law said employers could provide more rewards — or levy more surcharges, depending on how it’s framed — than they could previously: Maximum rewards or penalties now cannot exceed 30 percent of the total cost of the worker’s insurance, up from 20 percent, including both the employee’s and employer’s shares. (And if a tobacco cessation program is included, the figure rises to 50 percent).
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So for a family with coverage that is valued at $17,545 — that was the annual average total cost in 2015, according to the Kaiser Family Foundation — it would be perfectly fine for the employer to charge up to about $5,264 more, or 30 percent, for not fulfilling a goal like filling out a health risk assessment form or completing a biometric screening. That is a significant chunk of most families’ budgets.
