“Marcela Villa isn’t a big name in healthcare — but she played a crucial role in the lives of thousands of Medicaid patients in California,” Chad Terhune, lately of Kaiser Health News, writes over at The Los AngelesTimes. “Her official title: denial nurse. Each week, dozens of requests for treatment landed on her desk after preliminary rejections. Her job, with the assistance of a part-time medical director, was to conclusively determine whether the care — from doctor visits to cancer treatment — should be covered under the nation’s health insurance program for low-income Americans. She was drowning in requests, Villa said, and felt pressed to uphold most of the denials she saw. ‘If it was a high-dollar case, they tried to deny it,’ Villa said. ‘I told them you can’t deny it just because it’s going to cost $20,000.’ Villa, 32, did not work for the government. She did not even work for an insurer under contract with the government. She worked for a company now called Agilon Health. Owned by a private equity firm, it’s among the legion of private subcontractors looking to profit from Medicaid patients. California’s Medicaid program, known as Medi-Cal, has determined that the Long Beach company, which was paid to coordinate care for about 400,000 patients, improperly denied or delayed care for at least 1,400 of them, state officials confirmed. The state Department of Managed Health Care is investigating further. The state findings, along with internal company documents and a whistleblower complaint obtained by Kaiser Health News, shine a light on the potential dangers of outsourcing care for poor people. Government oversight, not rigorous to begin with, fades as taxpayer money filters down through layers of companies eager to seize on Medicaid’s substantial growth under the Affordable Care Act. Medicaid officials say they have authority only over the health plans, not their subcontractors.” Chad Terhune, “Coverage denied: Medicaid patients suffer as layers of private companies profit,” The Los Angeles Times.
Jeanne Pinder is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded... More by Jeanne Pinder