It’s Not Your Money

California’s Insurance Commissioner took UnitedHealthcare (UHC) to Court for wrongfully denying health insurance coverage.  This resulted in $91 Million in fines against UHC.

The case involved over 900,000 violations involving patient claims and other issues against a UHC subsidiary.  UHC, through its subsidiary, was found to have committed unfair acts against consumers.

A review of the Indiana “Insurance Commissioner” site indicates that Indiana’s Insurance Commissioner has found no reason to impose any fines upon UHC in 10 years.

Please Hold

The AMA surveyed over 1,000 physicians regarding issues with prior authorization programs imposed by insurance plans.  Some of the AMA findings:

• Each week medical practices complete an average of over 30 prior authorization requirements per physician;
• Over 90% say prior authorization programs have negative impact on patient clinical outcomes;
• 65% of physicians report waiting at least one business day and 26% said they waited three business days or longer for prior authorization decisions; and
• Over 25% of the responding physicians said the prior authorization process has lead to serious or life threatening adverse events for patients.

Close But No Cigar

Earlier this decade federal rules allowed the payment to doctors of subsidies for electronic health records systems.  Many physicians took advantage of such subsidies and payments and stayed within the AKS and Stark Law rules.

Some companies, however, targeted physicians they believed could provide high volumes of referrals to the subsidy payor.  An example is Miraca Life Sciences (now known as Informed Diagnostics) who provided pathology laboratory services.  The Department of Justice announced that Miraca had agreed to pay $63.5 Million for providing illegal inducements outside of the EHR Safe Harbor as a result of three whistleblower claims.

The takeaway on this is that anytime any payment, reimbursement rates or other amounts are tied to referrals, directly or indirectly, this arrangement will receive strict scrutiny from regulators and likely lead to claims and fines.

A Step Better for Veterans

We’ve previously noted issues not only with the quality of care at VA medical centers, but a serious problem with regard to access to care at VA medical centers, whether this care is adequate or less than adequate.

Several years ago the VA began allowing veterans to access non-VA care centers for needed medical care-but on a very, very limited basis.  The VA has now released new proposals that would allow a veteran to get treatment from the private sector under an expanded access program.  These standards are known as the “Designated Access Standards.” 

This proposal sets a 30-minute average drive time standard or a 20-day wait time standard for primary care, mental health and non-institutional extended care.  For specialty care the standards are 60-minute drive or 28-day wait.  These are the minimums required to allow access to non-VA healthcare providers.  The reality is only when these minimum requirements are met can the veteran then seek to schedule the outside the VA care.  Likely result is an even greater delay.

While these standards are a step in the right direction, is a 20-day wait time for primary care acceptable for our veterans?  Is a 20-day wait time acceptable for veterans who need mental health care?

Mine, Mine, Mine

At a recent IT conference, following the just released HHS rule on data blocking (preventing patients or healthcare providers from accessing patient data in electronic form), HHS officials made it clear that patient data belongs to patients.

To the healthcare industry, apparently it has not been obvious who owns patient data as they try to package and resell patient data and to impose charges for access to patient healthcare data that they have scraped from EHR records.

The takeaway is that when the proposed rules take effect, there will be a change in the approach to EHR and its usage and availability.  Again, as with other articles we have published on this, each one of these rules and requirements is a step towards having patient health information available to patients without additional costs, freely available and when needed.

This newsletter is edited by Paul Wallace of Jones • Wallace, LLC, a member of the American Bar Association Healthcare Law Section and the American Health Lawyers Association who has been representing physicians and healthcare practices for over 25 years.  Mr. Wallace assists physicians, practices and hospitals in contract items, federal legal compliance, practice entity creation, estate and wealth planning and similar issues.  Please feel free to call if you have any questions on this newsletter or legal matters at (812) 402-1600 or pwallace@joneswallace.com.