Sunday, October 4, 2009

Canada Shifting Senior Care Away From Hospitals

Story from Calgary Herald

CALGARY - Alberta Health Services have announced a three-year plan to add almost 800 "community living options" in the province for senior patients - who would otherwise crowd hospital beds, officials said.

Dr. Stephen Duckett, the provincial body's president and CEO, added that there will be no healthcare staff layoff announcemnts today, and there will be none until Alberta Health Services work through its current care plan.

"The key thing here is that, not only did we identify where we want to go, but also how to get there," Duckett said during a press call at noon. "This is not vapourware, as you call it... it's a concrete thing."

The plan, Duckett says, is to invest about $13 million in both the Calgary and Edmonton CMA to expand community care. The new spaces - about 775 between the two metropolitan areas - will include home care, supportive living and long-term care facilities.

The move of seniors who don't need acute care will allow health officials to free up hospital beds, Duckett says. Officials estimate the shift to community care would save up to $50 million for the cash-strapped provincial body.

Doctor Files Supreme Court Case Vs. BCBS of Texas

Story from California Newswire

Dr. Dralves Edwards, a board-certified family physician in Dallas today filed a civil case in the U.S. Supreme Court against Blue Cross Blue Shield of Texas, the contractor for Medicare. For the past 13 years, Edwards has challenged the integrity and unethical practices of Blue Cross Blue Shield (BCBS) and is confident that the U.S. Supreme Court will rule in a responsible way such that every Medicare provider and patient benefits.

In 2003, the original suit was filed in Dallas district court alleging that BCBS engaged in fraud, gross negligence, and criminal acts that, according to Edwards, forced him to close his doors. Today, he works as a hospital emergency room physician.

BCBS responded to the suit by removing it to federal court, but the case was remanded back to district court. BCBS then filed a “No Evidence” Motion for Summary Judgment that was granted sovereign immunity by the lower courts.

Edwards acknowledges that lower court decisions have historically disagreed with well established U.S. Supreme Court cases (i.e., Ardary vs. Aetna; Heckler vs. Ringer; and Kelly vs. Advantage Health, Rochester vs. Travelers).

In 1997, Edwards says BCBS caused irreparable harm to his thriving practice and marred his professional name when he was placed on a 100 percent prepayment review. For three consecutive years, 96 percent of his claims were denied; his practice was 90 percent Medicare.

“I provided free transportation and made house calls that saved Medicare millions of dollars,” reports Edwards. “These were patients who probably would have ended up in the emergency room.”

In October 1996, Edwards was featured in USA Today as, “One of the few doctors in America making house calls.”

BCBS denied most of Edwards’ claims as “non-covered services and not reasonable and medically necessary.”

Medical conditions like breast cancer, diabetes, and decubitus ulcers were denied. However, after the course of five years, claims were appealed through Medicare’s administrative process and paid.

“Something was terribly wrong,” Edwards says. “Other doctors were being paid by BCBS for these same medical conditions, but payment continued to be denied to me.”

Edwards alleges that, “BCBS was tested for profiling and got caught.”

He explains what happened. One doctor employed by him applied for a new Medicare group number. Dr. Edwards’ name was deliberately left off of the original application. The group number was granted, 300 claims were submitted, and BCBS paid 98 percent of them. A month later, Edwards’ name was added, 300 claims were submitted and all were denied.

BCBS told Edwards he had a documentation problem. However, after meeting with a Medicare representative to review the denied claims, no problems were discovered. It was recommended that he sign his progress notes and resubmit the claims for payment. He did and they were still denied as “non-covered services and not reasonable and medically necessary.”

Edwards then obtained the list of 100 doctors on the prepayment review list for 1997 through 1998. He contacted most all of these doctors and discovered that they knew nothing about a “prepayment review.”

“This evidence was highlighted in the suit, but ignored by the courts,” says Edwards.

It was becoming apparent that some unethical practices were in play.

To date, this 13-year ordeal has led to thousands of dollars spent; countless hours; a five-year administrative process; five summary-judgment hearings; numerous investigations; nine attorneys; 19 judges; a 100 percent prepayment review; and protectionism from the lower courts.

“Justice for the innocent has not been served,” Edwards says. “The guilty remain in business. Right now, it rests in the hands of the U.S. Supreme Court.”

BCBS Vs Chiropractors

Story from AIS Health

Chiropractors Bent Out of Shape Over Blues’ Post-Payment Denials

The Blue Cross and Blue Shield Association (BCBSA) and 22 Blue Cross and Blue Shield (BCBS) plans were named as defendants Sept. 11 in a class-action suit alleging they engaged in “abusive practices in using post-payment audits and reviews.” The suit contends that Blues plans made improper repayment demands “to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.”

Providers Want Recouped Funds Returned

Pomerantz Haudek Grossman & Gross LLP and Buttaci & Leardi LLC filed the suit on behalf of the Pennsylvania Chiropractic Association (PCA), the New York Chiropractic Council (NYCC) and the Association of New Jersey Chiropractors as well as 15 independent providers. Hundreds of millions of dollars could be at stake, said co-counsel Vincent Buttaci, who pointed out that BCBS plans’ anti-fraud efforts in 2008 resulted in more than $350 million in recoveries and savings for the plans. He adds, “We believe a substantial portion of this ‘recovery’ falls within the improper practices we are challenging in this action.”

According to the suit — filed in U.S. District Court in Chicago — the post-payment actions are in violation of the Employee Retirement Income Security Act of 1974 (ERISA) and the Racketeer Influenced and Corrupt Organizations Act (RICO). The suit contends that the Blues are in violation of ERISA because the “repayment demands are retroactive determinations that particular services are not covered under the terms of the BCBS health care plans,” and the demands lack a proper appeal process or other protections available under ERISA for both self-funded and fully insured health care plans offered through private employers. The suit also alleges that the insurers’ post-payment audit and review process and “forced withholds of unrelated benefit payments to offset alleged prior overpayments” violate RICO.

The suit seeks an undetermined amount of money. According to the filing, the “Plaintiffs seek appropriate declaratory and injunctive relief to enjoin Defendants from pursuing their effort to coerce recoupment and, further, to order Defendants to return any funds they have received or withheld from Individual Plaintiffs and members of the Classes as a result of their recoupment efforts.” It also seeks interest on the withheld funds.
The suit contends that Blues plans made improper repayment demands “to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.”
Plaintiff’s counsel D. Brian Hufford of Pomerantz tells The AIS Report, “In essence, the BCBS entities are alleging overpayments and then just taking the money from the providers, without valid due-process protections. We believe this is a blatant violation of law.” According to Hufford, some chiropractors have tens of thousands of dollars because of the plan’s alleged repayment practices.

He adds, “We believe they’re withholding money even in situations with self-funded plans when they didn’t pay for the treatment.” And the insurers, he alleges, haven’t repaid the plan sponsor for the money withheld from the provider in these instances.

“We met on numerous occasions with Blues senior management [at Highmark, Inc. and Independence Blue Cross] in an effort to establish a fair and balanced approach to conducting post-payment reviews, but to no avail,” said PCA Executive Director Gene Veno.

According to Pomeranz, BCBSA “is coordinating the recoupment efforts with its state BCBS licensees on a nationwide basis.” The plaintiffs, the law firm adds, seek to enjoin Blues plans from “continuing to engage in impermissible audit and recovery practices and to compel them to return the funds they have improperly withheld.”

BCBSA spokesperson Kelly Miller said the association does not comment on pending litigation. The 22 Blues plans named in the suit are: Blue Cross and Blue Shield of Rhode Island, Blue Cross and Blue Shield of Alabama, Arkansas Blue Cross and Blue Shield, Blue Shield of California, Blue Cross and Blue Shield of Florida, Blue Cross and Blue Shield of Georgia, Health Care Service Corp., Blue Cross and Blue Shield of Kansas, CareFirst Inc., Blue Cross and Blue Shield of Massachusetts, Blue Cross and Blue Shield of Minnesota, Blue Cross and Blue Shield of Kansas City, Horizon Blue Cross and Blue Shield of New Jersey, Excellus Blue Cross and Blue Shield, Blue Cross and Blue Shield of North Carolina, Highmark, Inc., Blue Cross and Blue Shield of South Carolina, Blue Cross and Blue Shield of Tennessee, Premera Blue Cross, The Regence Group, Wellmark, Inc., and WellPoint, Inc.

The NYCC and the ANJC had previously joined in a class action filed Aug. 4 against Aetna, Inc. regarding similar post-payment audit practices.

Some Exercise Their Right To Opt Out Of Health Insurance

AP Story

NEW YORK — Call it a health care gamble: the decision by some people to opt out of health insurance, paying cash for routine care while playing the odds that an accident or catastrophic illness won't plunge them into financial ruin.

President Barack Obama's goal of requiring everyone to carry health insurance has drawn a great deal of skepticism from this group. Many pay far less for health care than they would on premiums, and doubt that insurance would even cover them if they needed it.

It's unknown how many of the nearly 50 million uninsured in the United States voluntarily go without coverage. Researchers at the Kaiser Family Foundation, which studies the uninsured, said most are young, generally healthy adults who are self-employed or in relatively low-wage jobs that do not offer insurance coverage and don't pay enough for workers to afford individual policies.

"Income is key and most of the uninsured have low incomes," foundation researcher Karyn Schwartz said. "If you look at your budget and think you can't afford it or can afford it if you eat only ramen noodles, you may choose not to get it."

All the health care plans that have emerged from the Democratic-controlled Congress would require everyone to have insurance, the way drivers in nearly every state must purchase auto insurance. Proponents say that by bringing everyone into the system, medical risk is spread over a broader population, bringing costs down.

Those who opt out voluntarily might have to pay a penalty. Sen. Max Baucus, D-Mont., who drafted the Senate Finance Committee's plan, set the penalty at $3,800 for a family but cut it to $1,900 amid complaints that the original level was too high.

Republicans have called the insurance mandate a new tax on the middle class. Obama disputes that, saying that whatever plan emerges from Congress must offer subsidies to lower-income people that will make coverage affordable.

In exchange for the requirement that everyone buys coverage, Obama wants a guarantee from insurers that they no longer will deny coverage based on an individual's health or drop coverage when a person gets sick. The insurance industry has signaled it will accept that trade-off, but needs to convince skeptical consumers that it actually means it.

Doubts about what insurers will cover — coupled with the high cost of premiums — have driven some to opt out and take their chances.

Krista Neher, who's starting her own social media and marketing venture, is one.

The 30-year-old from Cincinnati recently left Procter & Gamble Co., where she was covered by the company's health care plan. After researching the costs of an individual policy, she decided to remain uninsured.

"I want to have health coverage, I think it's important. It bothers me that I could be hit by a car," Neher said. "But I have really low confidence that any insurance company would even cover me in that case, even after I paid all the high premiums. It just seems like a lose-lose situation."

Many people who go without coverage have found that health care providers often will cut the price of a procedure if they know they'll be paid in cash rather than through insurance.

Jason Jepson, a self-employed communications consultant based in Southern California, decided against buying an individual policy he said would have cost twice as much as his $1,250 monthly rent. He pays out of pocket for all medical treatment, saving money even after being treated for a broken ankle and severe strep throat.

"If you pay with cash, they do give you a discount — it's the big secret of not having insurance," Jepson, 35, said.

But Jepson said his lack of insurance has meant lifestyle adjustments, such as driving less and staying off freeways to avoid accidents. He says he supports Obama's requirement that everyone carry insurance if it can be made affordable.

"I would pay for it. I'm just not sure it will really cover everything," Jepson said.

To ease fears of an unexpected medical crisis, registered nurse Mary Pitman of Vero Beach, Fla., refuses health insurance and takes the extra cash in her paycheck. Pitman, 54, puts $3,000 per year into a pretax flexible spending account for routine care and another $300 per month in an emergency fund in the event of a major illness.

"I have more control over my money this way, and there's a tax advantage," she said.

As skeptical as many are about insurers, some are equally doubtful about government's ability to do a better job managing health care.

Laura Silverthorn of Tampa, Fla., left a nursing job to start her own business designing and selling temporary tattoos. She and her toddler son have gone without health coverage for nearly two years.

While Silverthorn, 36, said she wishes she could afford insurance — "Just one accident and you're done," as she put it — she's also grown disillusioned with government-run programs after working part time reviewing medical charts for Medicaid.

"I don't know if I want the government running health care when I see how they run Medicaid — there is so much fraud," she said.

The only test case for Obama's plan to bring everyone into the health insurance system is Massachusetts. In 2006, it enacted a program to cover all state residents. Those who opt out must pay a $912 annual tax penalty.

Michael Widmer, president of the nonpartisan Massachusetts Taxpayer Foundation, which researched the effectiveness of the state's health insurance mandate, said most people chose to buy insurance rather than pay the penalty — even those who are "young, healthy and immortal."

"Most are saying, 'If I'm going to have to pay this much in any case, I should be covered,'" he said.

While about 65,000 people in Massachusetts were allowed for financial reasons to opt out of the mandate last year, the state now has the lowest rate of uninsured residents in the country — 4.1 percent, according to the latest census data.