No good news is not good news.
Last week brought some news that could have significant financial implications for many providers. The Health Resources Services Agency (HRSA) program that funded care for uninsured COVID-19 patients will run out of funds and stop accepting claims on March 22.
Although the numbers have dropped significantly, COVID is not gone. As of March 15, more than 20,000 people have been hospitalized nationwide, and cases of the new subspecies are on the rise. You should also expect to add funds for The fund also covers the cost of vaccines, and the lack of funds will surely have serious consequences if it is determined that additional boosters are needed.
Second, UnitedHealthcare (UHC) recently released a notice for gastroenterologists participating in providers in Oxford New York. A subheading in the notice read, “New York gastroenterologists at Oxford must use Oxford participating anesthesiologists.”
After stating this use twice as a requirement for anesthesiologists attending Oxford, they stated that this only applies to non-emergency office or ambulatory surgery center (ASC) procedures and that the patient signs a consent form and is out. If you agree with the network anesthesiologist, you are allowed. So, while it’s required, it’s not really required. It’s pretty clear. But it’s not clear why this only applies to his UHC Oxford project in New York. There should be an interesting backstory.
Last week, when the Centers for Medicare and Medicaid Services (CMS) announced its final decision on Aduhelm coverage, we also learned that Part B premiums for Medicare beneficiaries are likely to be revised downwards. As you will recall, premiums have increased significantly in 2022 to cover the costs that could be incurred if millions of patients received her Aduhelm infusion. However, the US Department of Health and Human Services (HHS) plans to adjust premiums because CMS only offers coverage for clinical trials. Now seniors don’t necessarily have to pay down payment for the Florida condo they’ve always dreamed of.
Finally, a word about readmission. In one of his user groups, the doctor recently posted his two readmission denials his hospital received. Both patients were hospitalized with COVID-19, treated, and considered eligible for discharge without oxygen. One, he was readmitted a week later with her COVID-induced myocarditis and was hospitalized for 17 days. One patient was readmitted with atypical pneumonia 26 days after discharge and was hospitalized for 5 days. In both cases, the insurance company refused to pay for her second hospitalization.
Now, I admit I don’t have access to hospital-payer contracts to know what they say about readmissions, but in a rational world, exactly what happens after you treat a patient? Should healthcare providers be financially responsible for possible complications that cannot be fully prevented? Ensuring standards of care and stability at discharge? This also applies to payers who have stated that pre-approval is not required for outpatient surgery and have refused to pay outpatient fees stating that it is an inpatient only surgery.
This madness must stop. The contract needs to be reviewed. Although a patient may be held liable for readmission if the patient was not stable at discharge or if the discharge planning process was flawed, it does not make sense to refuse to pay for each readmission within any given time period. There is none.
When faced with such denial, fight back. bring the action. And consider filing a complaint with your state insurance board.
Programming notes: Dr. Hirsch runs Monday rounds every Monday on Eastern 10th Monitor Monday sponsored by the R1 RCM.
