Audit News Exacerbates Healthcare Crisis

No good news is not good news.

Last week brought some news that may have significant financial consequences for many providers. The Health Resources and Services Administration (HRSA) program that funded care for uninsured patients with COVID-19 will run out of money and stop accepting claims on March 22.

While numbers are down substantially, COVID is not gone. As of March 15, there were over 20,000 people hospitalized nationwide, and cases of the new variant are rising. We can hope that hospital numbers continue to decline but should also hope that Congress adds more funds to the program, so providers do not have to start sending bills to patients without coverage. This fund also pays for vaccines, and if it is determined that more boosters are needed, the lack of funds is sure to have serious consequences.

Next, UnitedHealthcare (UHC) recently released a notice for gastroenterologists who are participating providers with Oxford New York. The subhead of the notice went on to state that “Oxford New York gastroenterologists are required to use Oxford participating anesthesiologists.”

After stating this use of Oxford participating anesthesiologists as a requirement twice, they went on to note that this only applies to non-emergent office or Ambulatory Surgical Center (ASC) procedures, and that if the patient signs a consent and agrees to an out-of-network anesthesiologist, then it is permitted. So, it is required, but not really required; that’s pretty clear. But what is not clear is why this applies only to UHC Oxford plan in New York; there must be an interesting backstory.

Last week also brought word that the Part B premiums for Medicare beneficiaries will likely be adjusted downward once the Centers for Medicare & Medicaid Services (CMS) announces its final decision on the coverage of Aduhelm. As you’ll recall, premiums went up substantially for 2022 to cover the possible expense of millions of patients getting infusions of Aduhelm. But CMS has proposed only coverage in a clinical trial, so the U.S. Department of Health and Human Services (HHS) will be adjusting the premium. Now, seniors should not necessarily go put a down payment on that Florida condo they have always dreamed of, because the reduction will only be about $10 a month, or barely the cost of a gallon of gas.

Finally, a word about readmissions. On one of the user groups, a doctor recently posted two readmission denials his hospital received. Both were patients who were admitted with COVID-19, treated, and deemed able to be discharged home without oxygen. One returned a week later with COVID-induced myocarditis and was hospitalized for 17 days, and one returned 26 days after discharge with atypical pneumonia and stayed five days. In both cases, the insurer denied payment for the second admission.

Now, I admit I do not have access to the hospital’s contract with the payer to know what it says about readmissions, but in what rational world should a provider be held financially liable for totally unpreventable complications that may develop after treating the patient exactly to the standard of care and ensuring stability at discharge? This also applies to the payer who says prior authorization is not needed for surgery if done as outpatient, and then denies outpatient payment, stating that it was an inpatient-only surgery.

This madness simply has to stop. Contracts need to be reviewed. It is one thing to be held responsible for a readmission when the patient was not stable on discharge or the discharge planning process was flawed, but to refuse payment for every readmission within an arbitrary time frame makes no sense.

If faced with such denials, fight back. Appeal. And consider a complaint to your state insurance commissioner.

Programming Note: Listen to Dr. Hirsch every Monday as he makes his Monday rounds on Monitor Mondays, 10 Eastern, and sponsored by R1 RCM.