Health Estimates
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Health Estimates Newswire

Sep. 27, 2018: HHS OIG Report Says Medicare Advantage Denies Too Many Claims

HHS OIG Report Says Medicare Advantage Denies Too Many Claims.

Bloomberg News  (9/27, Tozzi) says a report from the HHS Office of Inspector General found “widespread and persistent problems related to denials of care and payment in Medicare Advantage,” the privately administered plans that insure millions of older Americans. The report said Medicare Advantage plans have become popular with consumers “because they combine traditional Medicare benefits with additional coverage, such as vision, dental care, and prescription drugs.” The report found Medicare Advantage denied 4 percent of prior authorization requests and 8 percent of requests for payment after treatment. But while just one percent of patients disputed the insurers’ denials, those decisions were overturned three-quarters of the time. The inspector general “recommended that CMS increase its oversight of Medicare Advantage plans and give patients better information about violations,” and HHS “concurred with the findings.”

Legislation and Policy

Rhode Island Governor Issues Executive Order To Protect Residents’ Access To Healthcare.

The Providence (RI) Business News (9/26, Borkowski) reports that on Wednesday, Rhode Island Gov. Gina M. Raimondo (D) “signed an executive order...formalizing her commitment to preserve the Affordable Care Act by directing state agencies to take ‘all necessary actions’ to protect access to quality health care.” The order charges “the R.I. Executive Office of Health and Human Services, HealthSource RI, and the R.I. Office of the Health Insurance Commissioner with protecting health care access, maintaining affordability and ensuring the public is informed and educated about their options.” Raimondo is quoted as saying, “No matter what happens in Washington, I am committed to defending Rhode Islanders’ access to high-quality, affordable health coverage.”

        The AP  (9/26, Smith) reports that the order “directs the state to seek to codify in state law protections for people with preexisting conditions, dependents up to age 26, prescription drug benefits and maternity coverage in case federal action is taken to weaken the Affordable Care Act.”

Tennessee Posts Medicaid Work Requirements Waiver.

Modern Healthcare  (9/26, Dickson, Subscription Publication) reports Tennessee became the fourth state to officially post a Medicaid work requirement waiver for comment this month, joining Alabama, Michigan, and Virginia. The proposal will require TennCare-enrolled “parents and caretakers that are not pregnant, disabled or elderly adults” to engage in “work or community engagement activities for an average of 20 hours per week.” Enrollees who do not comply will have their benefits suspended. Coverage will remain suspended “until they have complied with the requirement for one month.”

Public Health and Private Healthcare Systems

Tennessee Health Systems Form Partnership To Create Value-Based Alliance.

The Knoxville (TN) News Sentinel  (9/26, Nelson) reports that University Health Network and Vanderbilt Health Affiliated Network in Tennessee “announced Wednesday that they are joining to create a value-based health alliance.” The partnership is expected to “ultimately provide statewide coverage,” and to “achieve better long-term health at a lower cost.”

        The AP  (9/26) reports the alliance “will include teaching hospitals, 87 practices and more than 1,000 providers in University Health Network, plus the 13 health systems, 67 hospitals, more than 350 practices and over 5,000 providers in Vanderbilt Health Affiliated Network.”

Additional $28.6M Sought From UnitedHealthcare Over Wrongful Claim Denials In New York.

Fierce Healthcare  (9/26, Sweeney) reports that four months after taking UnitedHealthcare to arbitration over $11.5 million in denied claims, “NYC Health + Hospitals says it has uncovered an additional $28.6 million in wrongful denials” following a review of “nearly 4,000 claims between July 2014 and December 2017.” In addition to UnitedHealth, other insurers have “come under fire for emergency department policies seeking to limited unnecessary visits,” the article says, mentioning that in July, “the American College of Emergency Physicians (ACEP) took Anthem to court to prevent Anthem from implementing a policy to restrict coverage for ED visits.”

Analysis Shows “Room For Improvement” In New Jersey’s Shift To Value-Based Care.

The Asbury Park (NJ) Press  (9/26, Diamond) reports that despite a shift towards value-based care, an analysis conducted by Catalyst for Payment Reform “found New Jersey has fewer vaccinations, more C-section deliveries and a tougher time controlling patients’ high blood pressure.” However, Horizon Blue Cross Blue Shield of New Jersey “said it has seen dramatically better results with patients who receive care from” physicians receiving value-based payments, and inpatient admissions decreased by four percent. The piece concludes that the analysis shows there is” room for improvement,” and “health systems still need to invest in technology to help them coordinate care among their doctors.”

Federal Employees’ Health Premiums For 2019 To Rise By 1.5%.

The Washington Post (9/26, Yoder) reports that government workers’ share of premiums in the Federal Employees Health Benefits Program “will increase by 1.5 percent on average in 2019, although there will be decreases in some plans, including in the two Blue Cross and Blue Shield options that account for nearly two-thirds of enrollees,” the Office of Personnel Management said Wednesday. In addition, “Blue Cross and several other plans will offer a new third option in the Federal Employees Health Benefits Program, the largest employer-sponsored health insurance program in the nation,” according to OPM.

        Federal News Radio (DC)  (9/26, Causey) reports that this increase “is the smallest” in years. In fact, many enrollees “will actually pay less for coverage in 2019 than they are paying this year.”

        Government Executive  (9/26, Wagner) also covers the story.


Many Oregonians Remain Uninsured Despite Qualifying For Healthcare Coverage, Data Indicate.

The Oregonian  (9/26, Harbarger) reports that while “Oregon’s rate of uninsured people is just a third of what it was before the Affordable Care Act in 2011,” it is “still higher than it could be, according to new data from the Oregon Health Authority,” which “found that many people who qualify for insurance don’t take advantage of it – either because they don’t know they could, or they distrust the Oregon Health Plan.” State officials conducted their study to identify why people are forgoing coverage “and who is most affected.”

Also in the News

House-Senate Compromise Bill Could Hold Air Ambulances Accountable For Unfair Business Practices.

NPR  (9/26, Fortier) reports that a House-Senate compromise bill would “set up a council of industry representatives” that would “include air ambulance providers and insurance company representatives” in order to “write and re-evaluate consumer protections, including balance-billing practices.” Additionally, an “aviation consumer advocate” would take patient complaints “and could pursue enforcement or ‘corrective action’ against unfair or deceptive practices, including air ambulance operators.”

Jeff Sopko