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UnitedHealthcare delays mental health payments, causing outrage
UnitedHealthcare has delayed payments to patients, psychiatrists and therapists by imposing a “pre-payment review” for mental health treatment, sparking outrage among clinicians and presumably patients. It goes like this: The visit takes place, the out-of-network psychiatrist or therapist is paid by the patient (usually) and the patient submits the bill for reimbursement, to UnitedHealthcare. But Optum, the subsidiary managing health services and technology for UnitedHealthcare, sends a letter to clinician and patient saying it wants detailed and voluminous records for a “pre-payment review” before sending money. No reason is given. Most reports at this point seem to be out-of-network, with patients paying and then seeking reimbursement as per usual, but finding themselves in limbo — but there are some reports of in-network clams in the same limbo, and one of a psychologist who submits for reimbursement for her patients and got the same letter. Most of the reports were from the New York City area. Lynn Spevack, a New York psychotherapist and practice-building consultant, wrote in an email. “While audits aren’t anything new, my impression is that there’s a big increase.”
Medicare Advantage: Prior authorization rates high and rising
Almost all the older Americans who have Medicare Advantage insurance (99%) are subject to prior authorization for some things, most often higher-cost services like inpatient hospital stays, skilled nursing facility stays and chemotherapy, a new study found. Prior authorization — when an insurer requires a request before a procedure or service — is also rising, according to the Kaiser Family Foundation study, by Jeannie Fuglesten Biniek, Nolan Sroczynski and Tricia Neuman. “More than 46 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees in 2022, up from 37 million in 2019.”
Buying prescriptions: A new middleman is likely to raise the price
Middlemen to the middlemen to the middlemen — how many people get paid when you buy a prescription? It’s no secret that pharmacy prices are high and rising for people using their insurance in the United States. Part of the reason is the middlemen. The cut the middlemen take is at the heart of a new lawsuit against Wells Fargo for mismanaging employees’ drug benefits that is making headlines. The lawsuit “accuses the company of mismanaging its employee health plan by paying inflated prices for drugs, not engaging in fiduciary processes and notably for this discussion, overpaying Express Scripts for administrative services,” Chris Deacon, founder of VerSan Consulting, writes on her LinkedIn. And — there’s a new middleman in town.
How your private health data is traded and used behind the scenes by industry giants
The Health Resources and Services Administration (HRSA) collects data like patient characteristics, services provided, health outcomes, staffing, costs and revenues from certain health centers to evaluate operations and performance via the Uniform Data System (UDS). Today, employers are hitting a brick wall when trying to get their own insurance claims data from big carriers like Blue Cross Blue Shield, UnitedHealthcare, Cigna, and Aetna—often called BUCA. These carriers often argue that the data is proprietary, confidential, or a trade secret, making it tough for employers to use the info effectively. But here’s the kicker: these same carriers hand over your de-identified claims data to big consulting firms twice a year in a standardized format, without your permission or compensation! This data exchange, known as the Uniform Discount Data Specification (UDS), is used for RFPs and evaluations.
What we’re reading
The big business of denying medical care. Gift link from The New York Times.
The hidden fee costing doctors millions every year. We reposted this ProPublica story from a year ago on the blog, with permission, because it’s worth noting all the different ways insurance companies make money.
The F.D.A. calls them “recalls,’”yet the targeted medical devices often remain in use. A remarkable Kaiser Health News story.
America is in the midst of a mental health crisis. But finding a therapist who takes insurance can feel impossible. Hard to read — imagine the patients. ProPublica.
The percentage of U.S. adults readily able to access and afford quality healthcare when they need it has dropped six percentage points since 2022 to 55%, the lowest since West Health and Gallup began tracking healthcare affordability in 2021. Gallup.
The desire to be mentally and physically “tough” can also drive athletes to keep pushing through Long Covid symptoms, often making their condition worse. The Sick Times.
Long Covid is a significant health crisis affecting more than 400 million people with a price tag of $1 trillion per year. Fortune.
“I won’t go to the ER unless I’m literally dying” — how health care is different for people with disabilities. The Disabled Ginger.
