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.
The additional denials were discovered following a review of nearly 4,000 claims between July 2014 and December 2017. All told, the nation’s largest public hospital said it is owed $40.1 million.
“Our clinicians have no incentive to admit patients needlessly, while UnitedHealthcare has an obvious conflict of interest: They want the premiums from their beneficiaries and don’t want to pay for their care,” Mitchell Katz, M.D., president and CEO of NYC Health + Hospitals said in a statement. “Rather than provide appropriate reimbursement for services rendered, they prefer to give more money to their shareholders and reap big bonuses for themselves.”
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UnitedHealth reported $8.3 billion in profits during the first half of 2018. The company’s two CEOs pulled in more than $110 million in compensation last year.
“The priorities are skewed,” Katz added. “It’s our responsibility to stand up and challenge wrongful denials, as all health systems should.”
On average, UnitedHealthcare denied reimbursement for three newly hospitalized patients every day over a three-and-a-half-year period, according to the health system. The “vast majority” of the denied claims involved emergency services, NYC Health + Hospitals spokesperson Bob de Luna told FierceHealthcare.
The denied claims included a pregnant woman with a history of miscarriages admitted for medical treatment at 22 weeks because an ultrasound showed she was at high risk for losing her baby. Another denied claim involved a 62-year-old woman who showed up at the emergency department with multiple signs of a stroke or heart attack, just three days after she was discharged from a previous stroke.
Another claim involved a one-year-old girl that required a surgical consultation and IV antibiotics.
Matthew Siegler, senior vice president for managed care and patient growth at NYC Health + Hospitals said he was “appalled” by some of the denied claims and UnitedHealthcare’s decision not to provide coverage.
The health system has been reviewing all its managed care contracts as it modernizes its financial operations and indicated it may pursue arbitration against other insurers. An arbitration hearing is scheduled for this fall, although no date has been set.
“As we continue to negotiate fair rates and terms with private insurance companies, we see that some want to be good partners for the benefit of their beneficiaries, and some care more about profits,” Siegler said. “Some are especially egregious. And then, there’s UnitedHealthcare.”
“We have offered to meet with NYC Health + Hospitals to review their concerns, but they have declined our invitation," UnitedHealthcare spokesperson Maria Gordon Shydlo said in a statement to FierceHealthcare. "We remain willing to meet with them as soon as they are ready to address this issue with us directly.”
Other insurers have come under fire for emergency department policies seeking to limited unnecessary visits. Earlier this year, UnitedHealth said it would begin rejecting complex ED claims. 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.
ACEP said the insurer has been retrospectively denying claims for what it deems “non-emergent” services since it announced the new policy last year.
Editor's Note: This story has been updated to include a statement from UnitedHealthcare.
NEW YORK — An estimated 80,000 Americans died of flu and its complications last winter — the disease’s highest death toll in at least four decades.
The director of the Centers for Disease Control and Prevention, Dr. Robert Redfield, revealed the total in an interview Tuesday night with The Associated Press.
Flu experts knew it was a very bad season, but at least one found size of the estimate surprising. “That’s huge,” said Dr. William Schaffner, a Vanderbilt University vaccine expert. The tally was nearly twice as much as what health officials previously considered a bad year, he said. In recent years, flu-related deaths have ranged from about 12,000 to — in the worst year — 56,000, according to the CDC.
Last fall and winter, the U.S. went through one of the most severe flu seasons in recent memory. It was driven by a kind of flu that tends to put more people in the hospital and cause more deaths, particularly among young children and the elderly.
The season peaked in early February. It was mostly over by the end of March, although some flu continued to circulate.
Making a bad year worse, the flu vaccine didn’t work very well. Experts nevertheless say vaccination is still worth it, because it makes illnesses less severe and save lives.
“I’d like to see more people get vaccinated,” Redfield told the AP at an event in New York. “We lost 80,000 people last year to the flu.”
CDC officials do not have exact counts of how many people die from flu each year. Flu is so common that not all flu cases are reported, and flu is not always listed on death certificates. So the CDC uses statistical models, which are periodically revised, to make estimates.
Fatal complications from the flu can include pneumonia, stroke and heart attack. CDC officials called the 80,000 figure preliminary, and it may be slightly revised. But they said it is not expected to go down.
It eclipses the estimates for every flu season going back to the winter of 1976-1977. Estimates for many earlier seasons were not readily available.
Last winter was not the worst flu season on record, however. The 1918 flu pandemic, which lasted nearly two years, killed more than 500,000 Americans, historians estimate.
It’s not easy to compare flu seasons through history, partly because the nation’s population is changing. There are more Americans — and more elderly Americans — today than in decades past, noted Dr. Daniel Jernigan, a CDC flu expert.
U.S. health officials on Thursday are scheduled to hold a media event in Washington, D.C., to stress the importance of vaccinations to protect against whatever flu circulates this coming winter.
And how bad is it going to be? So far, the flu that’s been detected is a milder strain, and early signs are that the vaccine is shaping up to be a good match, Jernigan said.
“We don’t know what’s going to happen, but we’re seeing more encouraging signs than we were early last year,” he said.
— Mike Stobbe
Tom Charland is the founder and CEO of Merchant Medicine, a management consulting firm he founded in 2007 to help hospital systems and large medical groups with urgent care strategy and development. Tom is one of the leading experts on the urgent care and on-demand healthcare industry.
He is formerly the SVP for Strategy and Business Development for MinuteClinic; Executive Director of National Association for Ambulatory Care (NAFAC); CEO Digital Cyclone (acquired by Garmin); Executive Director at Control Data Systems (acquired by British Telecom). In the last several years, he has been quoted regarding walk-in medicine in the Wall Street Journal, New York Times, Chicago Tribune, Boston Globe, Fox News, Dow Jones, and Bloomberg. He also speaks frequently on the subject at investment research meetings and hospital strategy conferences throughout the year. Mr. Charland received a BS in Communications from Boston University. He is a member of the American College of Healthcare Executives (ACHE) and the Urgent Care Association of America (UCAOA).
Tom will present his views on the current state of the urgent care industry, including a look at what we are likely to see over the next five years.
Click here for more conference information.
FRIDAY, Sept. 7, 2018 (HealthDay News) -- For minor ills such as sore throats, privately insured Americans increasingly use urgent care centers rather than hospital emergency rooms, a new study finds.
Researchers at Brigham and Women's Hospital in Boston analyzed 2008-2015 data from Aetna, the commercial health insurance company.
"The drop in emergency department visits is quite striking and represents a substantial shift in where patients go to get care for conditions such as sore throat and minor injuries," study author and emergency physician Dr. Sabrina Poon said in a hospital news release.
Poon and her colleagues found a 36 percent decline in ER visits for minor conditions and injuries during the study period. Meanwhile, use of non-ER services -- including urgent care clinics, retail clinics and telemedicine -- rose 140 percent.
The largest increase (119 percent) in non-ER services was at urgent care centers, according to the study.
Given the high cost of emergency room care, many insurance plans encourage patients to go elsewhere for treatment of trivial problems, the researchers noted.
"The increasing popularity of alternatives to the emergency department is likely being driven by a variety of factors, including cost, convenience, and long wait times," said study co-author Dr. Jay Schuur, an emergency physician at Brigham and Women's.
"In the next few years, it will be important to see how these trends evolve and whether the growth of alternative sites results in lower cost care or more use of medical care," Schuur said.
The findings were published in the Sept. 4 JAMA Internal Medicine.
The American College of Emergency Physicians explains the difference between emergency care and urgent care.
SOURCE: Brigham and Women's Hospital, news release, Sept. 4, 2018
-- Robert Preidt
Last Updated: Sep 7, 2018
Monroe County has the only human fatality from West Nile virus so far this year and two of the four cases of West Nile virus reported outside of New York City, according to state Department of Health data.
The death occurred sometime between Aug. 23 and Sept. 4, according to a statewide mosquito-borne disease activity report posted Sept. 6and confirmed Wednesday by the Monroe County Department of Public Health.
“Since we announced the first human case on Aug. 22, subsequent to that there was a second individual,” said senior public health educator and department spokesman John Ricci. He said the person became seriously ill and eventually died from complications of West Nile virus.
Ricci would only say that the person who died was an older adult and a county resident. No information was available about where the person resided or whether the individual had an underlying health condition.
The county health department did not have records of any previous deaths from West Nile. It investigates cases as they occur but does track each case to its conclusion.
Last month, the county health department issued its annual warning about West Nile,saying that there had been a confirmed case in the county and urging residents to protect themselves from mosquito bites.
Mosquitoes carrying West Nile are active in late summer and early fall. Risk continues until the first heavy frost. Ricci said this is the peak time for risk to humans.
As of Sept. 6, there were 12 cases statewide, with eight in New York City. That Monroe has half of the cases upstate is more a function of small numbers than any outbreak, Ricci said.
“If there were 90 cases and we had 70, there would be more meaning to that,” he said. “Don’t read anything into that there’s greater risk in Monroe County than anywhere else.”
Ricci said the state report lags by a week, and he said there are likely to be more cases throughout upstate in subsequent weeks.
No cases were reported in Livingston, Ontario, Genesee or Wayne counties through Sept. 4.
West Nile is not transmitted from person to person.
Less than 1 percent of mosquitoes carry the virus, according to the federal Centers for Disease Control and Prevention. Of people who are bitten, less than 1 percent become seriously ill. People older than 50 and those with chronic illness are at highest risk for serious illness. There is no vaccine or specific treatment for West Nile, but people who develop symptoms such as high fever and headache should see a doctor.
People at risk for developing serious complications are more likely to be older, male and have high blood pressure or diabetes, according to a report from California health officials that was published in 2007 by the CDC.
The majority of people bitten by an infected mosquito will have no symptoms. About 20 percent will have mild flu-like symptoms.
Health officials provide the following suggestions to reduce the risk of a mosquito bite:
Democrat & Chronicle
Dr. John McLean is a critical care specialists for Velocity Care in Shreveport, Louisiana. He received his medical degree from Louisiana State University School of Medicine and has been in practice for more than 20 years.
Dr. John McLean sees a better future — he’s a visionary and an entrepreneur. He has a passion and a vision for making the world a better place for all to live. Learning something new is his hobby, which explains the many and varied business experiences he’s enjoyed. He even opened a coffee shop and learned how to roast coffee beans! His latest project is the building of a string of micro-hospitals in the U.S. He’s learned something: the atmosphere of a business is the key to its success. So he’s passionate about helping business-owners create workplaces where employees thrive, making many small differences into a big impact.
"Fire her now!" Creating Culture in the Work Place
It's a new world out there, and creating a cohesive work-environment is proving to be key to the success of any size business. This presentation will provide real-life examples of change and specific how-to's as to creating a workplace culture where employees not only enjoy coming to work but thrive as well.
ALBANY, N.Y. (AP) — Public health officials in New York state are encouraging residents to protect themselves against West Nile Virus.
Seven human cases of the mosquito-borne illness have been discovered in New York state so far this year, with three recent cases in Nassau, Westchester and Monroe counties.
Officials at the state Health Department said Thursday that residents can prevent exposure by eliminating standing water, wearing long sleeves and pants when outdoors and using repellant.
Health officials say the virus was first found in New York state in 1999. Since 2000, 497 human cases have been reported in the state.
While most people infected with the virus show no symptoms, others can develop fever, headache, body aches and stiffness.
By Annalise Knudson
STATEN ISLAND, N.Y. -- The Centers for Disease Control and Prevention (CDC) is investigating over 100 cases of measles in 21 states, including New York.
There have been 107 people who have contracted the measles, the CDC reported.
The disease has been reported in Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Michigan, Missouri, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, and Washington and the District of Colombia.
Many of the people who contracted the measles were not vaccinated. However, it hasn't been confirmed if the cases were linked to those without the vaccination.
Measles is a highly contagious virus that lives in the nose and throat mucus of an infected person. It can spread to others through coughing and sneezing.
The virus can live for up to two hours in an airspace where the infected person coughed or sneezed.
It's so contagious that if one person has it, 90 percent of the people close to that person who aren't immune will also become infected.
Infected people can spread measles to others from four days before through four days after the rash appears.
Symptoms include high fever, runny nose, cough, red eyes and a rash that starts on the face and then spreads. In severe cases, patients develop pneumonia and brain swelling.
Measles can be serious for people of all ages, but is especially dangerous for those younger than five years of age and adults older than 20.
The disease is still common in many parts of the world, including Europe, Asia, the Pacific and Africa.
Travelers continue to bring the disease into the U.S. It spreads when it reaches a community in the country where groups of people are not vaccinated.
From Today's Crain's:
NYC Health + Hospitals/Coney Island is requesting the state's permission to transfer the operating certificate for its ambulatory care clinic to its Cumberland Diagnostic and Treatment Center.
The move is part of a reorganization of the public health system's neighborhood ambulatory care clinics. More such requests for operating certificate changes are in the offing, an H+H spokesman said
"It's part of a broader systemic approach," he said. "We're moving all of these sites off of the hospital operating certificates."
H+H is reorganizing its neighborhood outpatient clinics so that they will be under the umbrella of Gotham Health NYC, a designated Federally Qualified Health Center Look-alike, which is operated by the public health system, according to its certificate-of-need application. Gotham Health serves more than 140,000 city residents annually through 39 sites, which include Cumberland and five other diagnostic and treatment centers, 19 extension clinics and 14 school-based clinics.
A FQHC Look-alike doesn't qualify for the same federal funding as a standard FQHC, but it does get enhanced Medicare and Medicaid reimbursement rates.
Besides saving the health system money, the FQHC model also allows for greater responsiveness to community needs, such as providing trauma-informed care, the H+H spokesman said.
CVS Health is well-positioned to manage its customers' care needs, and its role will only grow if its proposed $69 billion acquisition of Aetna gets regulatory approval, Dr. Troyen Brennan, CVS' executive vice president and chief medical officer, said Thursday.
"We're trying to shrink the distance between the patient's everyday life and care engagement," Brennan said at a forum hosted by Northwell Health at the Time Warner Center in Manhattan. "Our physical footprint is the big strategic value we have associated with that."
That footprint, which includes nearly 10,000 outposts, puts 71% of Americans within 5 miles of a CVS store, according to Quartz. CVS is trying to extend its reach through telehealth. It announced this week that it has partnered with Teladoc to make video visits available for $59.
Through a team of coordinators, pharmacists and MinuteClinic nurses, CVS has targeted five chronic diseases that it believes it can address—diabetes, hypertension, high cholesterol, asthma and depression—to drive savings, Brennan said. It is targeting $20 million in savings per 100,000 commercially insured members and double that amount for Medicare members.
But Brennan stressed that CVS hopes to complement, not replace, primary care.
"We're not going to buy up an entire layer of primary care, urgent-care centers and ambulatory surgery and then play the hospitals against one another," he said. "We see ourselves as part of the medical home, with everyone having their primary care provider."
From Today's Crain's
Jonathan S. Halpert MD FACEPChair, Government AffairsNorth East Regional Urgent Care Associationwww.neruca.org
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