Tax season is never fun. But some tax filers this year face an added complication: Their returns are being rejected because they failed to provide information about Affordable Care Act coverage they didn’t even know they had.
While the concern about unscrupulous brokers enrolling unsuspecting people in ACA coverage has simmered for years, complaints have risen in recent months as consumers discover their health insurance coverage isn’t what they thought it was.
Now such unauthorized enrollments are also causing tax headaches. Returns are getting rejected by the IRS and some people will have to pay more in taxes.
“It’s definitely gotten worse over the past year. We’ve helped three to four dozen people this year already,” said Erin Kinard, director of systems and intake for the Health and Economic Opportunity Program at Pisgah Legal Services in North Carolina, which helps low-income families enroll in ACA plans and get tax help.
Neither the IRS nor the Centers for Medicare & Medicaid Services, which oversees the federal Obamacare marketplace, responded to questions about the problem.
The IRS did, however, issue an FAQ in February instructing consumers on what to do if their electronically filed returns are rejected because of ACA issues.
Unauthorized sign-ups can happen in several ways, Kinard and others said. Some rogue agents troll online enrollment portals that are accessible only to brokers but are integrated with the healthcare.gov website. When those agents open a new policy or switch an already enrolled policyholder to a different plan, they garner the associated monthly commissions. Other consumers unwittingly sign up when they respond to advertisements touting gift cards or government subsidies then are transferred to agents who enroll them in health coverage. It’s happening even after new rules were put in place requiring agents to get written or recorded consent from clients before making changes.
CMS has not released details on how many consumers have been affected or how many agents have been sanctioned for participating in such schemes.
There’s also no public tally of how many taxpayers are facing problems as a result. And the tax consequences can come as a surprise.
“Many people are finding out when they go to e-file their taxes and it bounces back and the IRS says it can’t accept your return,” said Christine Speidel, an associate professor and the director of the Federal Tax Clinic at Villanova University’s Charles Widger School of Law.
Returns are rejected if the IRS has information indicating the taxpayer has ACA coverage but the returns don’t include forms that help determine whether premium tax credits paid on the policyholder’s behalf to insurers were correct. If their income was misstated by the rogue broker who enrolled them, for example, they might not have qualified for the full amount paid. Or, if they had affordable employer coverage, they would not have been eligible for ACA subsidies at all.
Ashley Zukoski, an ultrasound technologist in Charlotte, North Carolina, had employer coverage but now faces a tax bill for an ACA plan she said she never signed up for. She reached out to KFF Health News after it reported on such unauthorized plan enrollments.
Unbeknownst to her, she said, a broker in Florida enrolled her family in an ACA plan in late February 2023, even though Zukoski had coverage starting that January through her job. The broker listed an income that qualified the household for a full subsidy, so Zukoski never received a premium bill.
Her first inkling that something was amiss came early in 2024 when she received a special form, called a 1095-A, which showed she had an ACA plan. After reporting the problem to the federal marketplace, she sought to get the 1095-A voided so she would not be liable for the plan’s premium subsidies paid by the government to the insurer.
But, because Zukoski’s pharmacy had billed the ACA plan instead of her job-based coverage, her request was denied. She plans to appeal.
In the meantime, the family has filed an extension on their taxes.
“Instead of getting a $4,100 refund, we now owe almost $700 in taxes based on the 1095-A and premium tax credit applied,” Zukoski said.
With the April 15 federal tax filing deadline upon us, there are some important steps for affected consumers to take, tax and insurance experts said.
First, because it could take weeks to get corrected forms, experts recommend filing for an extension to buy more time. When consumers file for that extension, they should also pay any taxes owed to avoid penalties and interest.
In general, consumers who at any point in the year think they are victims of an unauthorized enrollment or plan switch should report it immediately to the relevant federal or state ACA marketplace and request a corrected Form 1095-A. But move fast. Appeals to cancel coverage retroactively must be made within 60 days of discovering the fraudulent enrollment, Speidel said.
Consumers can ask for help filing a complaint with federal or state regulators by contacting their own insurance agents or seeking help from assisters or “navigator” programs, which are government-funded nonprofit groups that help people enroll or deal with insurance problems.
Navigators and assisters are fielding many such cases this year and can submit what are called “complex case forms,” which help federal officials investigate such complaints, said Lynn Cowles, program manager for Prosper Health Coverage, a navigator program in Texas.
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Nearly a quarter of adults disenrolled from Medicaid in the past year say they are now uninsured, according to a survey released Friday that details how tens of millions of Americans struggled to retain coverage in the government insurance program for low-income people after pandemic-era protections began expiring last spring.
The first national survey of adults whose Medicaid eligibility was reviewed during the unwinding found nearly half of people who lost their government coverage signed back up weeks or months later — suggesting they should never have been dropped in the first place.
While 23% reported being uninsured, an additional 28% found other coverage — through an employer, Medicare, the Affordable Care Act’s insurance marketplace, or health care for members of the military, the survey by KFF found.
“Twenty-three percent is a striking number especially when you think about the number of people who lost Medicaid coverage,” said Chima Ndumele, an associate professor of health policy at the Yale University School of Public Health.
Going without insurance even for a short period of time can lead people to delay seeking care and leave them at financial risk when they do.
Seven in 10 adults who were disenrolled during the unwinding process say they became uninsured at least temporarily when they lost their Medicaid coverage.
Adrienne Hamar, 49, of Plymouth Meeting, Pennsylvania, said she struggled to enroll in an Affordable Care Act marketplace plan this winter after the state informed her that she and her two children no longer qualified for Medicaid. They had been enrolled since 2020. She said phone lines were busy at the state’s marketplace and she couldn’t complete the process online.
Hamar, who works as a home health aide, and her children were uninsured in March. But since April 1, they’ve been enrolled in a marketplace plan that, with the help of government subsidies, costs $50 a month for the family.
“I was very relieved,” she said. Unsure of their insurance status, Hamar said, her 23-year-old daughter delayed getting a dental checkup.
Hamar’s struggles were common, the survey found.
Of adults enrolled in Medicaid before the unwinding, about 35% who tried to renew their coverage described the process as difficult, and about 48% said it was at least somewhat stressful.
About 56% of those disenrolled say they skipped or delayed care or prescriptions while attempting to renew their Medicaid coverage.
“People’s current insurance status is likely to be very much in flux, and we would expect at least some of the people who say they are currently uninsured to reenroll in Medicaid — many say they are still trying — or enroll in other coverage within a short period of time,” said Jennifer Tolbert, a co-author of the KFF report and the director of KFF’s State Health Reform and Data Program.
The survey didn’t include children, and the KFF researchers said their findings therefore couldn’t be extrapolated to determine how the Medicaid unwinding has affected the overall U.S. uninsured rate, which hit a record low of 7.7% in early 2023. Nearly half of enrollees in Medicaid and the related Children’s Health Insurance Program are children.
The unwinding, in which states are reassessing eligibility for Medicaid among millions of Americans who enrolled before or during the pandemic and dropping those who no longer qualify or did not complete the renewal process, won’t be completed until later this year. Enrollment in Medicaid and CHIP grew to a record of nearly 94.5 million in April of last year, three years after the federal government prohibited states from cutting people from their rolls during the covid-19 public health emergency.
Nationally, states have disenrolled about 20 million people from Medicaid in the past year, most of them for procedural reasons such as failure to submit required paperwork. That number is expected to grow, as states have a few more months to redetermine enrollees’ eligibility.
Among adults who had Medicaid prior to the start of the unwinding, 83% retained their coverage or reenrolled, while 8% found other insurance and 8% were uninsured. The share left uninsured was larger in states that have not expanded Medicaid under the ACA (17%) than in states that have (6%). Forty states have expanded Medicaid to cover everyone with an income under 138% of the federal poverty rate, or $31,200 for a family of four this year.
The KFF survey found that nearly 1 in 3 disenrolled adults discovered only when they sought health care — such as going to a doctor or a pharmacy — that they had been dropped from Medicaid.
Indira Navas of Miami found out that her 6-year-old son, Andres, had been disenrolled from Florida’s Medicaid program when she took him to a doctor appointment in March. She had scheduled Andres’ appointment months in advance and is frustrated that he remains uninsured and his therapy for anxiety and hyperactivity has been disrupted.
Navas said the state could not explain why her 12-year-old daughter, Camila, remained covered by Medicaid even though the children live in the same household with their parents.
“It doesn’t make sense that they would cover one of my children and not the other,” she said.
Kate McEvoy, executive director of the National Association of Medicaid Directors, said the sheer volume of millions of people being redetermined for eligibility has overwhelmed some state call centers trying to support enrollees.
She said states have tried many ways to communicate with enrollees, including through public outreach campaigns, text, email, and apps. “Until the moment your coverage is at stake, it’s hard to penetrate people’s busy lives,” she said.
The KFF survey, of 1,227 adults who had Medicaid coverage in early 2023 prior to the start of the unwinding on April 1, 2023, was conducted between Feb. 15, 2024, and March 11, 2024. The margin of sampling error was plus or minus 4 percentage points.
KFF Health News correspondent Daniel Chang contributed to this article.
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Federal lawmakers face a year-end deadline to solidify or scuttle an array of covid-era payment changes for telehealth services that include allowing people to stay in their homes to see a doctor or therapist.
During the hearing in early March, Wenstrup and other House members offered personal anecdotes on how telehealth, home visits, and remote monitoring helped their patients, relatives, and constituents. Wenstrup, a Republican from Ohio who is also a podiatric surgeon and a retired Army reservist, told the audience: “Patients are less anxious and heal better when they can be at home.”
Most of the proposals focus on how Medicare covers telehealth services. But the rules affect patients on all types of insurance plans because typically private insurers and some government programs follow Medicare’s example. Without congressional action, virtual health care services like audio-only calls or meeting online with specialty doctors — such as an occupational therapist — could end. The bills would also continue to allow rural health clinics and other health centers to offer telehealth services while waiving a requirement for in-person mental health visits.
Telehealth use ballooned in the early months of the covid-19 pandemic and grew into a household term. The practice has become a popular issue for lawmakers on both sides of the aisle.
In one U.S. Census Bureau survey conducted from April 2021 to August 2022, Medicare and Medicaid enrollees reported using telehealth visits the most — 26.8% and 28.3%, respectively. The survey of nearly 1.2 million adults also found that Black patients and those earning less than $25,000 reported high rates of telehealth use. Notably, people of color were more likely to use audio-only visits.
Ensuring access to telehealth services “is the best public policy,” said Debbie Curtis, a vice president of McDermott+Consulting, a Washington, D.C.-based health care lobbying firm. “It’s the best business outcome. It’s the best patient care outcome.”
But it’s a presidential election year and Congress is a “deadline-driven organization,” Curtis said. She expects that Congress will be “kicking the can” past the November election.
Kyle Zebley, senior vice president of public policy at the American Telemedicine Association who also lobbies on Capitol Hill, said Congress “might well be in that lame-duck period.” “This is no way to run a health care system on a popular bipartisan issue,” he said.
In January, lawmakers — including senators from Mississippi and South Dakota — sent a letter to the Biden administration urging the White House to work quickly with Congress to ensure payments continue for Medicare patients who use telehealth, “especially for rural and underserved communities.”
Maya Sandalow, a senior policy analyst for the Bipartisan Policy Center, a Washington, D.C.-based think tank, said lawmakers and policymakers are likely to consider a temporary extension of the payments rather than permanent changes.
“Research is still coming out that covers more recent years than the acute effects of the pandemic,” Sandalow said. The center expects to release policy recommendations in the coming months.
Questions being considered include which kind of health care services are best for audio-only and video visits. Sandalow said researchers are also weighing how telehealth can “expand access to affordable, high-quality care while ensuring in-person options remain for patients.”
In North Dakota, Sanford Health’s David Newman said virtual care is often the only way some of his patients in the western part of the state can get sub-specialty care, such as with behavioral health.
Newman, an endocrinologist and Sanford’s medical officer of virtual care, said 10% to 20% of his patients are seen virtually during the summer, as compared with about 40% in the winter months because “the weather can be so bad” that roads are impassable.
In winters past, Newman would sit around “doing nothing for a day” because patients couldn’t visit him. Now, he has a full clinic using telehealth technology.
“I tell my patients that if you can make a restaurant reservation or if you can order a pizza online, you can do a virtual visit,” Newman said.
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Covering the American health care system means we tell some scary stories. This episode of “An Arm and a Leg” sounds like a real horror movie.
It uses one of Hollywood’s favorite tropes: machines taking over. And the machines belong to the private health insurance company UnitedHealth Group.
Host Dan Weissmann talks to Stat News reporter Bob Herman about his investigation into Medicare Advantage plans that use an algorithm to make decisions about patient care. The algorithm is owned by a subsidiary of UnitedHealth Group.
Herman tells Weissmann that some of UnitedHealth’s own employees say the algorithm creates a “moral crisis” in which care is unfairly denied.
Scary stuff! Such reporting even has caught the eye of powerful people in government, putting Medicare Advantage plans under scrutiny.
Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.
Dan: Hey there–
So this is kind of a horror story. But it’s not quite the kind of story it might sound like at first.
Because at first, it might sound like a horror story about machines taking over, making all the decisions– and making terrible, horrifying choices. Very age-of-Artificial Intelligence.
But this is really a story about decisions made by people. For money.
It’s also kind of a twofer sequel– like those movies that pit two characters from earlier stories against each other. Like Godzilla vs King Kong, or Alien vs Predator.
Although in this case, I’ve gotta admit, the two monsters are not necessarily fighting each other.
Let’s get reacquainted with them.
On one side, coming back from our very last episode, we’ve got Medicare Advantage: This is the version of Medicare that’s run by private insurance companies.
It’s got a bright and appealing side, compared to the traditional Medicare program run by the federal government, because: It can cost a lot less, month to month — saving people money on premiums. And it often comes with extra benefits, like dental coverage, which traditional Medicare doesn’t offer. [I know.]
But Medicare Advantage can have a dark side, which is basically: Well, you end up dealing with private insurance companies for the rest of your life. You need something — a test, a procedure, whatever — they might decide not to cover it.
Which can be scary.
Our other returning monster — am I really calling them a monster? — well, last time we talked about them, in 2023, we had an expert calling them a behemoth. That’s United HealthGroup. You might remember, they’re not only one of the biggest insurance companies
— and maybe not-coincidentally the very biggest provider of Medicare Advantage plans —
they’ve also got a whole other business– under the umbrella name Optum. And Optum has spent the last bunch of years buying up a gazillion other health care companies of every kind.
That includes medical practices — they employ more doctors than anyone else, by a huge margin. It includes surgery centers, and home-health companies, and every kind of middleman company you can imagine that works behind the scenes — and have their hands in a huge percentage of doctor bills and pharmacy visits.
A few years ago, United bought a company called NaviHealth, which provides services to insurance companies that run Medicare Advantage plans.
NaviHealth’s job is to decide how long someone needs to stay in a nursing home, like if you’re discharged from a hospital after surgery, but you’re not ready to go home yet.
And the horror story– the stories, as dug up by reporters — starts after United bought NaviHealth.
And according to their reports, it involves people getting kicked out of those nursing homes who aren’t ready to go home.
People getting sent home who can’t walk up the stairs in their house. Who can’t walk at all. Who are on feeding tubes. People who NaviHealth’s own employees are saying, “Wait. This person isn’t ready to go home.”
But their new bosses have told them: You’re not really making these decisions anymore.
This is where machines do enter the picture.
NaviHealth’s distinctive offering has always been its proprietary algorithm– an algorithm that makes predictions about how long any given patient might need to stay.
Before United bought the company, that algorithm was used as a guide, a first-guess. Humans weighed in with their own judgment about what patients needed.
After United bought the company, people inside have told reporters, that changed: The new owners basically told their employees, If the algorithm says someone can go home after x days, that’s when we’re cutting them off.
Like pretty much any horror movie, this story’s got people running around trying to tell everyone: HEY, WATCH OUT! THERE’S SOMETHING BIG AND DANGEROUS HAPPENING HERE.
And in this case, they’ve actually gotten the attention of some people who might have the power to do something about it. Now, what those people will do? We don’t know yet.
And, by the way: Yes, I said at the end of our last episode that we’d be talking about Medicaid this time around. That’s coming! But for now, strap in for this one.
This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.
So. I said that, like every horror movie, this one has people who are seeing what’s going on and are trying to warn everybody?
Like those movies, we’re gonna follow one of those people, watch them discover the problem, see how deep it goes, and start ringing alarm bells. Let’s meet our guy.
Bob Herman: My name is Bob Herman. I’m a reporter at STAT News
Dan: Stat is an amazing medical news publication. Bob covers the business of medicine there. Bob started working on this story in November 2022, after talking to a source who runs nursing homes. Bob’s source was complaining about Medicare Advantage.
Bob Herman: There were a lot of payment denials. They just weren’t able to get paid. And just offhandedly, the source mentioned like, um, you know, and they’re attributing everything to this algorithm. This algorithm said, You know, only 17 days for our patients and then time’s up and I went running to Casey Ross
Dan: Casey is a reporter at Stat who focuses on tech and AI in healthcare. Bob said, hey, what do you think of this? Wanna team up?
Bob Herman: And he was hooked.
Dan: They started talking to people who worked at nursing homes, talking to experts, and talking to families. And it was clear: They were onto something.
Bob Herman: It took so many families by surprise to be like, what do you mean we’re going home? The, you know, my husband, my wife, my grandma, my grandpa, they can’t go to the bathroom on their own. Like, what do you? It was just, it was so confusing to people. It seemed like such a, a cold calculation,
Dan: One person they ended up talking with was Gloria Bent. Her husband Gary was sent to a nursing home for rehab after brain surgery for cancer. He was weak. He couldn’t walk. And he had something called “left neglect”: His brain didn’t register that there was a left side of his body. Here’s Gloria testifying before a Senate committee about how — when Gary arrived at the nursing home — the first thing he got was a discharge date. That is…
Gloria Bent: Before the staff of the facility could even evaluate my husband or develop a plan of care, I was contacted by someone who identified themselves as my Navi Health Care Coordinator
Dan: Gloria says when she told the nursing home staff she’d heard from NaviHealth, they groaned. And told her what to expect.
Gloria Bent: I was told that I had just entered a battlefield, that I could expect a series of notices of denial of Medicare payment accompanied by a discharge date that would be two days after I got that notice.
Dan: Yeah, they said she’d get two days notice. Gloria says the nursing home staff told her she’d have 24 hours to appeal each of those, but even if she won, the denials would keep coming. In fact, they said,
Gloria Bent: If we won a couple of appeals, then we could expect that the frequency with which these denials were going to come would increase.
Dan: All of which happened. NaviHealth started issuing denials July 15, 2022, after Gary had been at the home for a month.
Gloria appealed. She told senators what the doctor who evaluated the appeal found: Gary couldn’t walk. He couldn’t even move — like from bed to a chair — without help from two people.. That reviewer took Gloria’s side.
Her husband’s next denial came a week after the first. Gloria won that appeal too. She says the reviewer noted that Gary needed maximum assistance with activities of daily living.
The third denial came four days later, and this time Gloria lost.
Gary came home in an ambulance: As Gloria testified, he couldn’t get into or out of a car without assistance from someone with special training.
And when he got into the ambulance, he had a fever. The next morning, he wound up in another ambulance — headed to a hospital with meningitis. He lost a lot of the functioning he’d picked up at the nursing home.
He died at home a few months later. When Gloria testified in the Senate, all of it was still fresh. She told them that as awful as Gary’s illness and decline had been, the fights with insurance were an added trauma.
Gloria Bent: This should not be happening to families and patients. It’s cruel. Our family continues to struggle with the question that I hear you asking today. Why are people who are looking at patients only on paper or through the lens of an algorithm
making decisions that deny the services judged necessary by health care providers who know their patients.
Dan: Bob Herman calls Gloria’s story heartbreaking, like so many others he’s seen.
And his attention goes to one part of Gloria’s story beyond denial-by-algorithm.
Because: It’s not just one denial. It’s that series of denials. You can appeal, but as Gloria testified, the denials speed up. And you have to win every single time. The company only has to win once.
I mean, unless you’re ready to get a lawyer and take your chances in court– which, in addition to being a major undertaking, also means racking up nursing home bills and legal bills you may never get reimbursed for, while the court process plays out.
Bob Herman: This appeal system is designed in such a way that people will give up. If you have a job, you know, even if you don’t, and you’re, and you’re also trying to take care of a family member, um, it’s a rigorous monotonous process that will chew people up and spit them out and then the people are inevitably going to give up. And I think in some ways insurers know that.
Dan: Going out on a limb to say: I think so too. So Bob and Casey’s first story on NaviHealth came out in March of 2023. They were the characters in the movie who go, “HEY, I THINK THERE’S SOMETHING REALLY BAD HAPPENING HERE.”
And people started paying attention. Like the U.S. Senate. which held that hearing where Gloria Bent told her story.
And like the federal agency that runs Medicare — the Centers for Medicare and Medicaid Services, CMS.
CMS finalized a rule that told insurers: You can’t deny care to people just from using an algorithm.
And something else happened too: Bob and Casey started suddenly getting a lot MORE information.
Bob Herman: We received so many responses from people and it just opened the floodgates for former employees, just patients and family members, just everyone across the board.
Dan: And not just former employees. Current employees. And what they learned was: There was absolutely a strategy at work in how this algorithm was being used. It was strategy some people on the inside didn’t feel good about.
And this strategy got developed after United HealthGroup — and its subsidiary, Optum– bought NaviHealth in 2020. And here’s what NaviHealth employees started telling Casey and Bob about that strategy.
Bob Herman: For some of us, it’s creating this moral crisis. Like we know that we are having to listen to an algorithm to essentially kick someone out of a nursing home, even though we know that they can barely walk 20 feet.
Dan: What Bob and Casey learned from insiders– and how it connects to United’s role as a health care behemoth– that’s next.
This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering healthcare in America. Their reporters do amazing work, and I’m honored to work with them. We’ll have a little more about KFF Health News at the end of this episode.
So, NaviHealth — the company with the algorithm — got started in 2015.. And the idea behind it was to use data to get people home faster from nursing homes if they didn’t actually need to be there.
Because there was a lot of evidence that some people were being kept longer than they needed.
Bob Herman: There is some validity to the idea that there’s, there’s wasteful care in Medicare, like, you know, there’s been cases in the past proving that people stay in a nursing home for way longer than is necessary. And obviously there’s financial incentives for nursing homes to keep people as long as possible.
Dan: Traditional Medicare does have limits on nursing home care — but if you need “post-acute care” — help getting back on your feet after leaving a hospital traditional Medicare pays in full for 20 days– pretty much no questions asked. One of the selling points of Medicare Advantage — like selling points to policy nerds and politicians — was that it could cut waste, by asking those kinds of questions. NaviHealth and its algorithm were designed to help Medicare Advantage plans ask those questions in a smart way.
Bob Herman: There were… a lot of believers within NaviHealth that were like, okay, I think we’re doing the right thing. We’re trying to make sure people get home sooner because who doesn’t want to be at home.
Dan: And as those employees told Bob and Casey: Before United and Optum came in, the algorithm had been there as a guide — a kind of first guess — but not the final word.
NaviHealth has staff people who interact directly with patients. And back in the day, the pre-United day, Bob and Casey learned that those staff could make their own judgments.
Which made sense, because the algorithm doesn’t know everything about any individual case. It’s just making predictions based on the data it has.
Bob Herman: And there was just, just this noticeable change after United and OptiMentor that it felt more rigid. There’s no more variation.
Dan: If the algorithm says you go, you are pretty much going.
Bob Herman: United has said, no, that’s not the case, but obviously these documents and other communications that we’ve gotten kind of say otherwise.
Dan: Because these employees weren’t just talking. They were sharing. Internal memos. Emails. Training materials. All making clear: The company wanted people shipped out on the algorithm’s timetable.
Bob Herman: Documents came in showing that like this was a pretty explicit strategy. You know, UnitedHealth was telling its employees. Listen, we have this algorithm. We think it’s really good. So when it tells you how many, how many days someone should be in a nursing home, stick to it.
Dan: Stick to it or maybe be fired. Bob and Casey got documents — employee performance goals– saying: How close you stick to the algorithm’s recommendations? That’s part of how we’re evaluating your job performance.
Bob Herman: It’s okay. Algorithm said 17 days, you better not really go outside of that because your job is on the line.
Dan: Here’s how closely people were expected to stick to it. In 2022, employee performance goals shared with STAT showed that workers were expected to keep actual time in nursing homes to within three percent of what the algorithm said it should be. Across the board.
So, say you had 10 patients, and the algorithm said they each should get 10 days. That’s 100 days. Your job was to make sure that the total actual days for those patients didn’t go past 103 days.
Then, in 2023, the expectations got more stringent: Stay within one percent of the algorithm’s predictions. 10 patients, the algorithm says 100 days total? Don’t let it get past a hundred and one.
Bob Herman: Like that is, almost nothing. Like what, what, your hands are tied. If you’re that employee, what are you going to do? Are you going to get fired? Are you going to do what you’re told?
Dan: And one person who ended up talking, to did get fired.
Bob Herman: Correct. Yes. Uh, Amber Lynch did get fired And what she said was what we had also heard just more broadly was it, it created this internal conflict, like, Oh my God, what I’m doing doesn’t feel right.
Dan: Amber Lynch was a case manager. She told Bob and Casey about onepatient who couldn’t climb the stairs in his home after knee surgery. But the algorithm said he was ready. Amber’s supervisor said, “Have you asked the nursing home staff if they’ve tried to teach him butt bumping?” Amber grit her teeth and made the suggestion to the rehab director.
Amber Lynch: And she looked at me like I had two heads. She’s like, he is 78 years old. He’s not going to do that. He’s not safe to climb the stairs yet. He’s not doing it. We’re not going to have it butt bump the stairs.
Dan: Amber told Bob and Casey that when she got fired, it was partly for failing to hit the one percent target and partly for being late with paperwork– which she told Bob and Casey she fell behind because her caseload was so heavy.
She wasn’t the only one with that complaint.
Bob and Casey’s story shows another NaviHealth case manager– not named in the story because they’re still on the job — in their home office, struggling to keep up.
That week, they were supposed to work with 27 patients and their families. Gather documents, hold meetings. Another week, shortly before, they’d had 40 patients.
“Do you think I was able to process everything correctly and call everyone correctly the way I was supposed to?” the case manager asked. “No. It’s impossible. No one can be that fast and that effective and capture all of the information that’s needed.”
Bob and Casey watched this case manager fill out a digital form, feeding the algorithm the information it asked for on a man in his 80s with heart failure, kidney disease, diabetes and trouble swallowing, who was recovering from a broken shoulder.
A few minutes later, the computer spat out a number: 17 days.
The case manager didn’t have a lot of time or leeway to argue, but they were skeptical that the algorithm could get that number exactly right based on only the data it had.
And what data is the algorithm working with? What’s it comparing the data on any given patient TO? Bob Herman says that’s a big question.
Bob Herman: It’s something that for sure, like Casey and I, it’s been bothering us. Like, what, how is this whole system? Like, what is it based on? And we were never really given straight answers on that. NaviHealth and Optum and United have said it’s based on millions of patient records over time. The sources of that, it’s, it’s a little unclear, where all that’s coming from.
Dan: Bob and Casey talked with an expert named Ziad Obermeyer, a professor at the University of California Berkeley School of Public Health, who is not anti-algorithm. He actually builds algorithmic tools for decision making in public health.
AND he’s done research showing that some widely-used algorithms just scale up and automate things like racial bias.
He told Bob and Casey: Using an algorithm based on how long other, earlier patients have stayed in a nursing home — that’s not a great idea.
Because people get forced out of nursing homes, in his words, “because they can’t pay or because their insurance sucks.” He said, “So the algorightm is basically learning all the inequalities of our current system.”
And leaving aside that kind of bias, it seems unlikely to Bob that any algorithm could predict exactly what every single patient will need every single time.
No matter how much data it’s got, it’s predicting from averages.
Bob Herman: It reminds me of, like, a basketball game where let’s say someone averages 27 points per game. They don’t have 27 points every single, the game they go out there. It just varies from time to time.
Dan: But the NaviHealth algorithm doesn’t have to be right every time for United to make money using it.
Using it to make decisions can allow United to boost profits coming and going.
Bob Herman: United health and the other insurance companies that use Navi health. Are using this technology to more or less kick people out of nursing homes before they’re ready. And that is the claims denial side where it’s like, okay, let’s save as much money as we can instead of having to pay it to a nursing home.
Dan: And that’s just one side of it. The insurance side. Claims denial. But United isn’t just in the insurance business.
United’s Optum side is in every other part of health care.
Including — in the years since United took over NaviHealth — home health services. The kind of services you’re likely to need when you leave a nursing home.
In 2022, Optum bought one top home health company in what one trade publication called a “monster, jaw-dropping mega-deal” — more than 5 billion dollars. In 2023, Optum made a deal to buy a second mega-provider.
Bob and Casey’s story says NaviHealth’s shortening nursing home stays is integral to United’s strategy for these acquisitions. It does seem to open up new opportunities.
Bob Herman: You’re out of the nursing home because our algorithm said so. Now we’re going to send you to a home health agency or we’re going to send some home health aides into your home. And by the way, we own them.
Dan: Oh, right, because: If you’re in a Medicare Advantage plan, your insurer can tell you which providers are covered.
Bob Herman: So the real question becomes, how much is United potentially paying itself?
Dan: That is: How much might United end up taking money out of one pocket — the health insurance side — and paying itself into another pocket, Optum’s home-health services?
We don’t know the answer to how much United is paying itself in this way, or hoping to. And United has said its insurance arm doesn’t favor its in-house businesses.
But it seems like a reasonable question to ask. Actually, it’s a question the feds seem to be asking.
Optum hasn’t wrapped up its purchase of that second home-health company yet, and in February 2024, the Wall Street Journal and other outlets reported that the U.S. Department of Justice had opened an anti-trust investigation.
And you don’t have to be in a Medicare Advantage plan run by United to get kicked out of a nursing home on an algorithm’s say-so.
Bob Herman says NaviHealth sells its algorithm-driven services to other big insurance companies
He says, put together, the companies that use NaviHealth cover as many as 15 million people — about half of everybody in Medicare Advantage.
Bob Herman: Odds are, if you’re in a Medicare Advantage plan, there’s a, there’s a really good shot that your coverage policies, if you get really sick and need nursing home care, for example, or any kind of post acute care, an algorithm could be at play at some point.
Dan: This is the dark side of Medicare Advantage.
Bob Herman: Everyone loves their Medicare Advantage plan when they first sign up, right? Because it’s offering all these bells and whistles. It’s, here’s a gym membership. It’s got dental and vision, which regular Medicare doesn’t have. And it’s also just, it’s, it’s cheaper. Like, if it’s just from a financial point of view, if, if you’re a low income senior, How do you turn it down? There’s, there’s so many plans that offer like free, there’s no monthly premiums in addition to all the bells and whistles. But Nobody understands the trade offs , When you’re signing up for Medicare and Medicare Advantage, you’re on the healthier side of, of being a senior, right?
Dan: And none of us can count on staying healthy forever. When you sign up for Medicare you’re signing up your future self — whether that’s ten or twenty or more years out. That future you, might really need good medical care.
And at that point, as we explained in our last episode, if Medicare Advantage isn’t working for you, you may not be able to get out of it.
Bob Herman: You could potentially not fully get the care that you need. We shouldn’t assume that, that this couldn’t happen to us because it can.
Dan: So, yeah. Kind of a horror story. But: Unlike some horror movies, when Bob and Casey started publishing their stories, they started getting people’s attention.
We mentioned the new rules from the feds and the senate hearings after Bob and Casey’s first story in March 2023
Later in the year, when Bob and Casey published their story with documents and stories from inside NaviHealth, a class-action lawsuit got filed.
Since then, CMS has said it will step up audits under its new rules.
Bob Herman: There was a memo that CMS sent out to Medicare advantage plans that said, Hey, listen, we’re telling you again, do not deny care solely on any AI or algorithms. Like just don’t do it.
Dan: And in February 2024, the Senate held another hearing.
Here’s Senator Elizabeth Warren at that hearing, saying these CMS rules aren’t enough. We need stronger guardrails.
Elizabeth Warren: Until CMS can verify that AI algorithms reliably adhere to Medicare coverage standards by law, then my view on this is CMS should prohibit insurance companies from using them in their MA plans for coverage decisions. They’ve got to prove they work before they put them in place.
Dan: So people — people with at least some power– are paying some attention.
Bob Herman: I don’t think this is necessarily going to escape. Political scrutiny for a while.
Dan: So, basically, the story isn’t over.
This isn’t one of those horror movies where the monster’s been safely defeated at the end, and everybody just starts cleaning up the mess. And it’s not one where the monster is just on the loose, unleashing the apocalypse.
Because it’s not a movie. There’s no ending. There’s just all of us trying to figure out what’s going on, and what we can maybe do about it.
One last thing: I got a lot of emails after our last episode, where we laid out a lot of information about Medicare Advantage and traditional Medicare. Most of it was along the lines of, Thank you! That was really helpful! Which made me feel really good.
And we got a couple notes about things we could have done better. Especially this: We said Traditional Medicare leaves you on the hook for 20 percent of everything, without an out of pocket limit.
Which is true — but only for Medicare Part B: Doctor visits, outpatient surgeries and tests. Which can add up, for sure.
Medicare Part A — if you’re actually hospitalized — covers most services at 100 percent, after you meet the deductible. In 2024 that’s one thousand, six hundred thirty-two dollars.
Thanks to Clarke Lancina for pointing that out.
There have been a bunch of other, amazing notes in my inbox recently, and I want to say: Please keep them coming.
If you go to arm and a leg show dot com, slash, contact, whatever you type there goes straight to my inbox. You can attach stuff too: documents… voice memos.
Please let me hear from you. That’s arm and a leg show dot com, slash contact.
I’ll catch you in a few weeks.
Till then, take care of yourself.
This episode of an arm and a leg was produced by me, Dan Weissmann, with help from Emily Pisacreta, and edited by Ellen Weiss.
Adam Raymonda is our audio wizard. Our music is by Dave Weiner and blue dot sessions. Extra music in this episode from Epidemic Sound.
Gabrielle Healy is our managing editor for audience. She edits the first aid kit newsletter.
Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager.
And Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism.
Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.
And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax exempt donations. You can learn more about INN at INN. org.
Finally, thanks to everybody who supports this show financially– you can join in any time at arm and a leg show dot com, slash, support — and thanks for listening.
“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
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Federal and state regulators aren’t doing enough to stop the growing problem of rogue health insurance brokers making unauthorized policy switches for Affordable Care Act policyholders, say consumers.
“We think it’s urgent and it requires a lot more attention and resources,” said Jennifer Sullivan, director of health coverage access for the Center on Budget and Policy Priorities.
The Centers for Medicare & Medicaid Services, which oversees the ACA, “has acknowledged the issue,” said former Oklahoma insurance commissioner John Doak. “But it appears their response is inadequate.”
The reactions follow a KFF Health News article outlining how licensed brokers’ easy access to policyholder information on healthcare.gov has led unscrupulous agents to switch people’s policies without express permission. Those agents can then take the commission that comes with signing a new customer. Dozens of people and insurance brokers responded to the earlier report recounting similar situations.
Some switched policyholders end up in plans that don’t include their doctors or the medications they regularly take, or come with higher deductibles than their original coverage choice. If their income or eligibility for premium tax credits is misrepresented, some people end up owing back taxes.
Agents whose clients have been affected say the switches ramped up last year and are continuing into 2024, although quantifying the problem continues to be difficult. The problem seems concentrated on the federal healthcare.gov website, which is the marketplace where people in 32 states buy ACA plans, which are also known as Obamacare. CMS declined to provide the number of complaints that have been filed.
Even so, CMS representatives said during a December committee meeting of the National Association of Insurance Commissioners that they were “acutely aware” of the problem and were working on solutions.
A similar NAIC gathering was held in March. During those meetings, state regulators urged CMS officials to look for unauthorized switches, rather than reacting only to filed complaints. State regulators also want the agency to tell them sooner about agents or brokers under investigation, and to be provided with the number of affected consumers in their regions.
In an April 4 written statement to KFF Health News, Jeff Wu, acting director of CMS’ Center for Consumer Information & Insurance Oversight, pointed to the agency’s sharp prohibition on agents enrolling people or changing their plans without getting written or recorded consent, and said his team is “analyzing potential additional system controls to block unauthorized or fraudulent activity.”
It is also working with state regulators and large broker agencies, Wu wrote, to identify “the most effective ways to root out bad actors.” He also said more agents and brokers are being suspended or terminated from healthcare.gov.
Wu did not provide, however, a tally of just how many have been sanctioned.
Low-income consumers are often targeted, possibly because they qualify for zero-premium plans, meaning they might not know they’ve been switched or enrolled because they aren’t paying a monthly bill.
Also, rules took effect in 2022 that allow low-income residents to enroll at any time of the year, not just during the annual open enrollment period. While the change was meant to help people who most need to access coverage, it has had the unintended effect of creating an opportunity for this scheme to ramp up.
“There have been bad apples out there signing people up and capturing the commissions to do so for a while, but it’s exacerbated in the last couple of years, turning it from a few isolated incidents to something more common,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.
Many victims don’t know they’ve been switched until they try to use their plans — either because agents changed the policy without talking to them or because the consumer unknowingly enrolled by responding to online advertisements promising gift cards, government subsidies, or free health insurance.
The challenge now is how federal regulators and their counterparts in the states can thwart the activity without diminishing enrollment — a top priority for the marketplace. In fact, Obamacare’s record-breaking enrollment figures are being touted prominently in President Joe Biden’s reelection campaign.
Thwarting the switches “really comes down to oversight and enforcement,” Corlette said. “As soon as regulators identify someone who is engaged in unauthorized plan-switching or enrollment, they need to cut them off immediately.”
That isn’t simple.
For starters, consumers or their agents must report suspected problems to state and federal regulators before investigations are launched.
Such investigations can take weeks and states generally don’t have access to complaints until federal investigators finish an inquiry, state regulators complained during the NAIC meetings.
Doak attended the December meeting, where he urged federal regulators to look for patterns that might indicate unauthorized switching — such as policyholders’ coverage being changed multiple times in a short period — and then quickly initiate follow-up with the consumer.
“All regulators have a duty to get on top of this issue and protect the most vulnerable consumers from unknowingly having their policies moved or their information mistreated,” Doak told KFF Health News. He is now executive vice president of government affairs for Insurance Care Direct, a health insurance brokerage.
Being more proactive requires funding.
Wu said the agency’s administrative budget has remained nearly flat for 13 years even as enrollment has grown sharply in the ACA and the other health programs it oversees.
And the complaint process itself can be cumbersome because it can involve different state or federal agencies lacking coordination.
Even after complaints are filed, state or federal officials follow up directly with the consumer, who might have limited English proficiency, lack an email address, or simply not answer their phone — which can stall or stop a resolution, said Katie Roders Turner, executive director of the Family Healthcare Foundation, a Tampa Bay, Florida, nonprofit that helps people enroll or deal with problems that arise with their plans.
Suggested improvements include creating a central form or portal for complaints and beefing up safeguards on the healthcare.gov site to prevent such unauthorized activity in the first place.
Currently, licensed agents need only a name, date of birth, and state of residence to access policyholder information and make changes. That information is easy to obtain.
States that run their own marketplaces — there are 18 and the District of Columbia — often require more information, such as a one-time passcode sent to the consumer, who then gives it to their chosen agent.
In the meantime, the frustration is increasing.
Lauren Phillips, a sales agent in Georgia, said she reached out to an agent in Florida who was switching one of her clients, asking her to stop. When it happened again to the same client, she reported it to regulators.
“Their solution was for me to just watch the policy and fix it if it happens again, which is not a viable solution, “Phillips said.
Recently, after noticing the client’s policy had been switched again, she reported it and changed it back. When she checked two mornings later, the policy had been terminated.
“Now my client has no insurance at all,” Phillips said. “They say they are working on solutions. But here we are in the fourth month of the year and agents and consumers are still suffering at the hands of these terrible agents.”
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.
Florida this week became a major focus for advocates on both main sides of the abortion debate. The Florida Supreme Court simultaneously ruled that the state’s 15-week ban, passed in 2022, can take effect immediately before a more sweeping, six-week ban replaces it in May and that voters can decide in November whether to create a state right to abortion.
Meanwhile, President Joe Biden, gearing up for the general election campaign, is highlighting his administration’s health accomplishments, including drug price negotiations for Medicare.
This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University schools of nursing and public health, Tami Luhby of CNN, and Lauren Weber of The Washington Post.
Panelists
Among the takeaways from this week’s episode:
The Florida Supreme Court’s decisions this week will affect abortion access not only in the state, but also throughout the region. Florida’s six-week ban, which takes effect on May 1, would leave North Carolina and Virginia as the only remaining Southern states offering the procedure beyond that point in pregnancy — and, in North Carolina, abortion is banned at 12 weeks after a woman’s last menstrual period.
Since the U.S. Supreme Court overturned the constitutional right to an abortion in 2022, six states have voted on their own constitutional amendments related to abortion access. In every case, the side favoring abortion rights has won. But Florida’s measure this fall will appear on the ballot with the presidential race. Could the two contests, waged side by side, boost turnout and influence the results?
Former President Donald Trump made many attempts during his term to undermine the Affordable Care Act, and this week the Biden administration reversed another one of those lingering attempts. Under a new regulation, the use of short-term insurance plans will be limited to four months — down from 36 months under Trump. The plans, which Biden officials call “junk plans” due to their limited benefits, will also be required to provide clearer explanations of coverage to consumers.
In other Biden administration news, March has come and gone without the release of an anticipated ban on menthol flavoring in tobacco, and anti-tobacco groups are suing to force administration officials to finish the job. Menthol cigarettes are particularly popular in the Black community, and — like Trump’s decision as president to punt a ban on vaping to avoid alienating voters in 2020 — the Biden administration may be loath to raise the issue this year. Activists say, however, that it may be at the expense of Black lives.
“This Week in Medical Misinformation” looks at an article from PolitiFact about the health misinformation that persists even with the pandemic mostly in the rearview mirror.
Also this week, Rovner interviews health care analyst Jeff Goldsmith about the growing size and influence of UnitedHealth Group in the wake of the Change Healthcare hack.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
A for-profit company has proposed turning a boarded-up former nursing home here into a psychiatric hospital, joining a national trend toward having such hospitals owned by investors instead of by state governments or nonprofit health systems.
The companies see a business opportunity in the shortage of inpatient beds for people with severe mental illness.
The scarcity of inpatient psychiatric care is evident nationwide, especially in rural areas. People in crisis often are held for days or weeks in emergency rooms or jails, then transported far from their hometowns when a bed opens in a distant hospital.
Eight nonprofit Iowa hospitals have shuttered their psychiatric units since 2007, often citing staffing and financial challenges. Iowa closed two of its four mental health institutions in 2015.
The state now ranks last in the nation for access to state-run psychiatric hospitals, according to the Treatment Advocacy Center. The national group, which promotes improving care for people with severe mental illness, recommends states have at least 50 state-run psychiatric beds per 100,000 people. Iowa has just two such beds per 100,000 residents, the group said.
Two out-of-state companies have developed psychiatric hospitals in Iowa in the past four years, and now a third company has obtained a state “certificate of need” to open a 60-bed facility in Grinnell.
Before 2020, Iowa had no privately owned, free-standing psychiatric hospitals. But several national companies specialize in developing such facilities, which treat people in crisis from conditions such as depression, schizophrenia, or bipolar disorder, sometimes compounded by drug or alcohol abuse. One of the companies operating in Iowa, Universal Health Services, says it has mental health facilities in 39 states.
Lisa Dailey, the Treatment Advocacy Center’s executive director, said that for-profit hospitals don’t necessarily provide worse care than nonprofit ones but that they tend to be less transparent and more motivated by money. “Private facilities are private,” she said. “As a result, you may not have a great insight into why they make the decisions that they make.”
Dailey said solid data on privately run mental health hospitals nationwide is scarce. But she has heard for-profit companies have recently set up free-standing psychiatric hospitals in several states, including California. The California Department of Public Health confirmed three such facilities have opened there since 2021, in Aliso Viejo, Madera, and Sacramento.
The latest Iowa psychiatric hospital would be housed in a vacant nursing home on the outskirts of Grinnell, a college town of 9,500 people in a rural region of the state. The project’s developers noted there are no other inpatient mental health facilities in Poweshiek County, where Grinnell is located, or in any of the eight surrounding counties. The nearest inpatient mental health facilities are 55 miles west in Des Moines.
The Indiana-based company proposing the hospital, Hickory Recovery Network, primarily runs addiction treatment centers in Indiana. But it opened psychiatric hospitals in Ohio and Texas in 2023 and 2024, and it told Iowa regulators it could open the Grinnell hospital by August.
An affiliated company ran the facility as a nursing home, called the Grinnell Health Care Center, until 2022, according to a Hickory Recovery Network filing with Iowa regulators.
Medicare rated the nursing home’s overall quality at just two out of five stars. And in 2020, the facility was suspended indefinitely from Iowa’s Medicaid program because of billing issues, state records show.
Officials from Hickory Recovery Network responded only briefly to KFF Health News inquiries, including about how the former Iowa nursing home’s spotty record could affect the proposed psychiatric hospital.
In a short telephone interview in February, Melissa Durkin, the company’s chief operating officer, declined to say who owns Hickory Recovery Network.
Durkin denied in the interview that her organization was associated with the company that ran the defunct and troubled Grinnell nursing home.
However, Hickory Recovery’s application for a certificate of need refers to the nursing home operator as “Hickory’s affiliated company.” In testimony before Iowa regulators, Durkin made a similar reference as she expressed confidence her organization could find sufficient staff to reopen the facility as a psychiatric hospital. “We have a history with that building. We operated a nursing home there before,” she said at the video-recorded hearing.
Durkin said in the interview that company leaders had not decided for sure to redevelop the vacant Iowa nursing home into a psychiatric hospital, although they twice went through the complicated process of applying for a state “certificate of need” for the project. The first attempt was stymied in 2023 by a tie vote of the board that considers such permits, which are a major hurdle for large health care projects. The second application was approved by a unanimous vote after a hearing on Jan. 25.
Keri Lyn Powers, a Hickory executive, told regulators the company planned to spend $1.5 million to remodel the building. The main changes would include making rooms safe for people who might be suicidal, she said.
The company predicted in its application that 90% of the hospital’s patient revenues would come from Medicare or Medicaid, public programs for seniors or people who have low incomes or disabilities. It doesn’t mention that the nursing home was suspended from Iowa’s Medicaid program, which covers about half of the state’s nursing home residents.
Iowa authorities suspended the Grinnell Health Care Center nursing home in 2020 for failing to repay nearly $25,000 in overpayments from Medicaid, state records show. When the nursing home closed in 2022, its former medical director told the local newspaper part of the reason for its demise was its inability to collect Medicaid reimbursements. Iowa administrators recently notified the owners that the former nursing home owed $284,676 to Medicaid. A state spokesperson said in March that neither amount had been repaid.
The proposal to reopen the building as a psychiatric hospital won support from patient advocates, Grinnell’s nonprofit community hospital, and the regional mental health coordinator.
The only opposition at the state hearing came from Kevin Pettit, leader of one of Iowa’s two other private free-standing psychiatric hospitals. Pettit is chief executive officer of Clive Behavioral Health Hospital, a 100-bed facility in suburban Des Moines that opened in 2021. Pettit told regulators he supports expanding mental health services, but he predicted the proposed Grinnell facility would struggle to hire qualified employees.
He said despite strong demand for care, many Iowa psychiatric facilities are limiting admissions. “The beds exist, but they’re not actually open, … because we’re dealing with staffing issues throughout the state,” Pettit testified.
Overall, Iowa has 901 licensed inpatient mental health beds, including in psychiatric units at community hospitals, in free-standing psychiatric hospitals, and in the two remaining state mental health institutes, according to the Iowa Department of Health and Human Services. But as of January, just 738 of those beds were staffed and being used.
Pettit’s facility is run by Pennsylvania-based Universal Health Services in partnership with MercyOne, a hospital system based in the Des Moines area.
In an interview, Pettit said his hospital only has enough staff to use about half of its beds. He said it’s especially difficult to recruit nurses and therapists, even in an urban area with a relatively robust labor supply.
State inspectors have cited problems at the Clive facility, including four times declaring that deficiencies put patients’ safety in “immediate jeopardy.” Those issues included insufficient staff to properly monitor patients and insufficient safeguards to prevent access to items patients could use to choke or cut themselves.
Pettit said such citations are not unusual in the tightly regulated industry. He said the organization is committed to patient safety. “We value the review by our regulatory entities during the survey process and view any finding as an opportunity for continuous improvement of our operations,” he wrote in an email.
Iowa’s other privately owned psychiatric hospital, Eagle View Behavioral Health in Bettendorf, also has been cited by state inspectors. The 72-bed hospital was purchased in 2022 by Summit BHC from Strategic Behavioral Health, which opened the facility in 2020. Both companies are based in Tennessee.
State inspectors have cited the Bettendorf facility twice for issues posing “immediate jeopardy” to patient safety. In 2023, inspectors cited the facility for insufficient supervision of patients, “resulting in inappropriate sexual activity” between adult and adolescent patients. In 2021, the facility was cited for insufficient safety checks to prevent suicide attempts and sexual misconduct.
Eagle View officials did not respond to requests for comment.
Advocates for Iowa patients have supported the development of free-standing psychiatric hospitals.
Leslie Carpenter of Iowa City, whose adult son has been hospitalized repeatedly for severe mental illness, spoke in favor of the Grinnell facility’s application for a certificate of need.
In an interview afterward, Carpenter said she was optimistic the new facility could find enough staff to help address Iowa’s critical shortage of inpatient psychiatric care.
She said she would keep a close eye on how the new facility fares. “I think if a company were willing to come in and do the job well, it could be a game changer.”
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
For adults hospitalized for alcohol-related reasons, receiving a prescription for an alcohol use disorder (AUD) medication at the time of discharge may lower their risk of return to hospital within 30 days of discharge, including emergency room visits and readmissions.
That’s according to a recent study published in JAMA Network Open led by researchers at Massachusetts General Hospital (MGH) andthe University of Pittsburgh.
For the study, the investigators identified 9,834 alcohol-related hospitalizations among 6,794 Medicare Part D beneficiaries across the United States in 2016. Only 2.0% of hospitalizations involved filled prescriptions for alcohol use disorder medications-;including oral naltrexone, acamprosate, and disulfiram-;at the time of discharge.
Return to the hospital or death within 30 days (the combined primary outcome assessed in the study) occurred among 49.3% of hospitalizations overall, including 25.5% of hospitalizations that involved prescriptions for alcohol use disorder medications at discharge and 49.7% of hospitalizations that did not.
After controlling for important differences between the two groups, the investigators observed that there were 42% fewer returns to the hospital or deaths within 30 days among patients who received such discharge prescriptions compared with those who did not. Regarding absolute risk, patients with these discharge prescriptions had an 18% lower risk of returning to the hospital or dying than other patients.
Similar results were seen for alcohol-related hospital returns. Those who received medications were also 22% more likely to have primary care or mental health follow-up visits. Differences in mortality alone were not apparent because deaths within 30 days were rare in both groups (approximately 1%).
Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting. Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge.”
Eden Y. Bernstein, MD, lead author, physician scientist in the Division of General Internal Medicine at MGH
“These therapies are evidence based, inexpensive, and have manageable side effects,” says senior author Timothy Anderson, MD, MAS, a primary care physician, health services researcher and assistant professor of medicine at the University of Pittsburgh, who began on the study while on the faculty at Harvard University. “Given the potential upsides demonstrated in this study, training inpatient clinicians to initiate these medications and to develop plans for post-hospital follow up with patients and their primary care team has the potential to improve patient outcomes and to reduce preventable readmissions.”
Additional authors include Travis P. Baggett, MD, MPH, Shrunjal Trivedi, MPH, Shoshana J. Herzig, MD, MPH, and Timothy S. Anderson, MD, MAS.
This work was funded by the Agency for Healthcare Research and Quality and the National Institute on Aging.
Bernstein, E. Y., et al. (2024). Outcomes After Initiation of Medications for Alcohol Use Disorder at Hospital Discharge. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2024.3387
Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.
The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.
Klion refused to pick the lesser of two bad options without a fight.
He contacted Humana, the Saratoga hospital, and the health system. The couple’s doctors “are an exceptional group of caregivers and have made it possible for us to live an active and productive life,” he wrote to the hospital’s CEO. He called his wife’s former employer, which requires its retirees to enroll in a Humana Medicare Advantage plan to receive company health benefits. He also contacted the New York StateWide Senior Action Council, one of the nationwide State Health Insurance Assistance Programs that offer free, unbiased advice on Medicare.
Klion said they all told him the same thing: Keep your doctors or your insurance.
With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time.
Disputes between insurers and providers can lead to entire hospital systems suddenly leaving the plans. Insurers must comply with extensive regulations from the Centers for Medicare & Medicaid Services, including little-known protections for beneficiaries when doctors or hospitals leave their networks. But the news of a breakup can come as a surprise.
In the nearly three decades since Congress created a private-sector alternative to original, government-run Medicare, the plans have enrolled a record 52% of Medicare’s 66 million older or disabled adults, according to the CMS. But along with getting extra benefits that original Medicare doesn’t offer, Advantage beneficiaries have discovered downsides. One common complaint is the requirement that they receive care only from networks of designated providers.
Many hospitals have also become disillusioned by the program.
“We hear every day, from our hospitals and health systems across the country, about challenges they experience with Medicare Advantage plans,” said Michelle Millerick, senior associate director for health insurance and coverage policy at the American Hospital Association, which represents about 5,000 hospitals. The hurdles include prior authorization restrictions, late or low payments, and “inappropriate denials of medically necessary covered services,” she said.
“Some of these issues get to a boiling point where decisions are made to not participate in networks anymore,” she said.
An escape hatch
CMS gives most Advantage members two chances to change plans: during the annual open enrollment period in the fall and from January until March 31.
But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare.
According to CMS rules, there’s an SEP patients may use if their health is in jeopardy due to problems getting or continuing care. This may include situations in which their health care providers are leaving their plans’ networks, said David Lipschutz, an associate director at the Center for Medicare Advocacy.
Another SEP is available for beneficiaries who experience “significant” network changes, although CMS officials declined to explain what qualifies as significant. However, in 2014, CMS offered this SEP to UnitedHealthcare Advantage members after the insurer terminated contracts with providers in 10 states.
When providers leave, CMS ensures that the plans maintain “adequate access to needed services,” Meena Seshamani, CMS deputy administrator and director of the federal Center for Medicare, said in a statement.
While hospitals say insurers are pushing them out, insurers blame hospitals for the turmoil in Medicare Advantage networks.
“Hospitals are using their dominant market positions to demand unprecedented double-digit rate increases and threatening to terminate their contracts if insurers don’t agree,” said Ashley Bach, a spokesperson for Regence BlueShield, which offers Advantage plans in Idaho, Oregon, Utah, and Washington state.
Patients get caught in the middle.
“It feels like the powers that be are playing chicken,” said Mary Kay Taylor, 69, who lives near Tacoma, Washington. Regence BlueShield was in a weeks-long dispute with MultiCare, one of the largest medical systems in the state, where she gets her care.
“Those of us that need this care and coverage are really inconsequential to them,” she said. “We’re left in limbo and uncertainty.”
Other breakups this year include Baton Rouge General hospital in Louisiana leaving Aetna’s Medicare Advantage plans and Baptist Health in Kentucky leaving UnitedHealthcare and Wellcare Advantage plans. In San Diego, Scripps Health has left nearly all the area’s Advantage plans.
In North Carolina, UNC Health and UnitedHealthcare renewed their contract just three days before it would have expired, and only two days before the deadline for Advantage members to switch plans. And in New York City, Aetna told its Advantage members this year to be prepared to lose access to the 18 hospitals and other care facilities in the NewYork-Presbyterian Weill Cornell Medical Center health system, before reaching an agreement on a contract last week.
Limited choices
Taylor didn’t want to lose her doctors or her Regence Advantage plan. She’s recovering from surgery and said waiting to see how the drama would end “was really scary.”
So, last month, she enrolled in another plan, with help from Tim Smolen, director of Washington’s SHIP, Statewide Health Insurance Benefits Advisors program. Soon afterward, Regence and MultiCare agreed to a new contract. But Taylor is allowed only one change before March 31 and can’t return to Regence this year, Smolen said.
Finding an alternative plan can be like winning at bingo. Some patients have multiple doctors, who all must be easy to get to and covered by the new plan. To avoid bigger, out-of-network bills, they must find a plan that also covers their prescription drugs and includes their preferred pharmacies.
“A lot of times, we may get through the provider network and find that that’s good to go but then we get to the drugs,” said Kelli Jo Greiner, state director of Minnesota’s SHIP, Senior LinkAge Line. Since Jan. 1, counselors there have helped more than 900 people switch to new Advantage plans after HealthPartners, a large health system based in Bloomington, left Humana’s Medicare Advantage plans.
Choices are more limited for low-income beneficiaries who receive subsidies for drugs and monthly premiums, which only a few plans accept, Greiner said.
For almost 6 million people, a former employer chooses a Medicare Advantage plan and requires them to enroll in it to receive retiree health benefits. If they want to keep a provider who leaves that plan, those beneficiaries must forfeit all their employer-subsidized health benefits, often including coverage for their families.
The threat of losing coverage for their providers was one reason some New York City retirees sued Mayor Eric Adams to stop efforts to force 250,000 of them into an Aetna Advantage plan, said Marianne Pizzitola, president of the New York City Organization of Public Service Retirees, which filed the lawsuit. The retirees won three times, and city officials are appealing again.
CMS requires Advantage plans to notify their members 45 days before a primary care doctor leaves their plan and 30 days before a specialist physician drops out. But counselors who advise Medicare beneficiaries say the notice doesn’t always work.
“A lot of people are experiencing disruptions to their care,” said Sophie Exdell, a program manager in San Diego for California’s SHIP, the Health Insurance Counseling & Advocacy Program. She said about 32,000 people in San Diego lost access to Scripps Health providers when the system left most of the area’s Advantage plans. Many didn’t get the notice or, if they did, “they couldn’t get through to someone to get help making a change,” she said.
CMS also requires plans to comply with network adequacy rules, which limit how far and how long members must travel to primary care doctors, specialists, hospitals, and other providers. The agency checks compliance every three years or more often if necessary.
In the end, Bart Klion said he had no alternative but to stick with Humana because he and his wife couldn’t afford to give up their retiree health benefits. He was able to find doctors willing to take on new patients this year.
But he wonders: “What happens in 2025?”
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
Sara England was putting together Ghostbusters costumes for Halloween when she noticed her baby wasn’t doing well.
Her 3-month-old son, Amari Vaca, had undergone open-heart surgery two months before, so she called his cardiologist, who recommended getting him checked out. England assigned Amari’s grandparents to trick-or-treat duty with his three older siblings and headed to the local emergency room.
Once England and the baby arrived at Natividad Medical Center in Salinas, California, she said, doctors could see Amari was struggling to breathe and told her that he needed specialized care immediately, from whichever of two major hospitals in the region had an opening first.
Even as they talked, Amari was declining rapidly, his mother said. Doctors put a tube down his throat and used a bag to manually push air into his lungs for over an hour to keep his oxygen levels up until he was stable enough to switch to a ventilator.
According to England, late that night, when doctors said the baby was stable enough to travel, his medical team told her that a bed had opened up at the University of California-San Francisco Medical Center and that staffers there were ready to receive him.
She, her son, and an EMT boarded a small plane around midnight. Ground ambulances carried them between the hospitals and airports.
Amari was diagnosed with respiratory syncytial virus, or RSV, and spent three weeks in the hospital before recovering and returning home.
Then the bill came.
The Patient: Amari Vaca, now 1, who was covered by a Cigna policy sponsored by his father’s employer at the time.
Medical Services: An 86-mile air-ambulance flight from Salinas to San Francisco.
Service Provider: Reach Medical Holdings, which is part of Global Medical Response, an industry giant backed by private equity investors. Global Medical Response operates in all 50 states and has said it has a total of 498 helicopters and airplanes. It is out-of-network with Amari’s Cigna plan.
Total Bill: $97,599. Cigna declined to cover any part of the bill.
What Gives: Legal safeguards are in place to protect patients from big bills for some out-of-network care, including air-ambulance rides.
Medical billing experts said the No Surprises Act, a federal law enacted in 2022, could have protected Amari’s family from receiving the $97,000 “balance bill,” leaving the insurer and the air-ambulance provider to determine fair payment according to the law. But the protections apply only to care that health plans determine is “medically necessary” — and insurers get to define what that means in each case.
According to its coverage denial letter, Cigna determined that Amari’s air-ambulance ride was not medically necessary. The insurer cited its reasoning: He could have taken a ground ambulance instead of a plane to cover the nearly 100 roadway miles between Salinas and San Francisco.
“I thought there must have been a mistake,” England said. “There’s no way we can pay this. Is this a real thing?”
In the letter, Cigna said Amari’s records did not show that other methods of transportation were “medically contraindicated or not feasible.” The health plan also noted the absence of documentation that he could not be reached by a ground ambulance for pickup or that a ground ambulance would be unfeasible because of “great distances or other obstacles.”
Lastly, it said records did not show a ground ambulance “would impede timely and appropriate medical care.”
When KFF Health News asked Cigna what records were referenced when making this decision, a spokesperson declined to respond.
Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation, said that even though Amari’s bill isn’t technically in violation of the No Surprises Act, the situation is exactly what the law was designed to avoid.
“What they’re basically saying is that the parents should have opted against the advice of the physician,” Donovan said. “That’s insane. I know ‘medical necessity’ is this nebulous term, but it seems like it’s becoming a catch-all for turning down patients.”
On Feb. 5, the National Association of Emergency Medical Services Physicians said that since the No Surprises Act was enacted two years ago, it has seen a jump in claim denials based on “lack of medical necessity,” predominantly for air-ambulance transports between facilities.
In a letter to federal health officials, the group cited reasons commonly given for inappropriate medical-necessity denials observed by some of its 2,000 members, such as “the patient should have been taken elsewhere” or “the patient could have been transported by ground ambulance.”
The association urged the government to require that health plans presume medical necessity for inter-facility air transports ordered by a physician at a hospital, subject to a retrospective review.
Such decisions are often “made under dire circumstances — when a hospital is not capable of caring for or stabilizing a particular patient or lacks the clinical resources to stabilize a patient with a certain clinical diagnosis,” the group’s president, José Cabañas, wrote in the letter. “Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan.”
Patricia Kelmar, a health policy expert and senior director with the U.S. Public Interest Research Groups, noted, however, that hospitals could familiarize themselves with local health plans, for example, and establish protocol, so that before they call an air ambulance, they know if there are in-network alternatives and, if not, what items the plan needs to justify the claim and provide payment.
“The hospitals who live and breathe and work in our communities should be considering the individuals who come to them every day,” Kelmar said. “I understand in emergency situations you generally have a limited amount of time, but, in most situations, you should be familiar with the plans so you can work within the confines of the patient’s health insurance.”
England said Cigna’s denial particularly upset her.
“As parents, we did not make any of the decisions other than to say, yes, we’ll do that,” she said. “I don’t know how else it could have gone.”
The Resolution: England twice appealed the air-ambulance charge to the insurer, but both times Cigna rejected the claim, maintaining that “medical necessity” had not been established.
The final step of the appeals process is an external review, in which a third party evaluates the case. England said staff members at Natividad Medical Center in Salinas — which arranged Amari’s transport — declined to write an appeal letter on his behalf, explaining to her that doing so is against the facility’s policy.
Using her son’s medical records, which the Natividad staff provided, England said she is writing a letter herself to assert why the air ambulance was medically necessary.
Andrea Rosenberg, a spokesperson for Natividad Medical Center, said the hospital focuses on “maintaining the highest standards of health care and patient well-being.”
Despite receiving a waiver from England authorizing the medical center to discuss Amari’s case, Rosenberg did not respond to questions from KFF Health News, citing privacy issues. A Cigna spokesperson told KFF Health News that the insurer has in-network alternatives to the out-of-network ambulance provider, but — despite receiving a waiver authorizing Cigna to discuss Amari’s case — declined to answer other questions.
“It is disappointing that CALSTAR/REACH is attempting to collect this egregious balance from the patient’s family,” the Cigna spokesperson, Justine Sessions, said in an email, referring to the air-ambulance provider. “We are working diligently to try to resolve this for the family.”
On March 13, weeks after being contacted by KFF Health News, England said, a Cigna representative contacted her and offered assistance with her final appeal, the one reviewed by a third party. The representative also told her the insurer had attempted to contact the ambulance provider but had been unable to resolve the bill with them.
Global Medical Response, the ambulance provider, declined to comment.
England said she and her husband have set aside two hours each week for him to take care of their four kids while she shuts herself in her room and makes calls about their medical bills.
“It’s just another stress,” she said. “Another thing to get in the way of us being able to enjoy our family.”
The Takeaway: Kelmar said she encourages patients to appeal bills that seem inaccurate. Even if the plan denies it internally, push forward to an external review so someone outside the company has a chance to review, she said.
In the case of “medical necessity” denials, Kelmar recommended patients work with the medical provider to provide more information to the insurance company to underscore why an emergency transport was required.
Doctors who write a letter or make a call to a patient’s insurer explaining a decision can also ask for a “peer-to-peer review,” meaning they would discuss the case with a medical expert in their field.
Kelmar said patients with employer-sponsored health plans can ask their employer’s human resources department to advocate for them with the health plan. It’s in the employers’ best interest since they often pay a lot for these health plans, she said.
No matter what, Kelmar said, patients shouldn’t let fear stop them from appealing a medical bill. Patients who appeal have a high likelihood of winning, she said.
Patients with government health coverage can further appeal insurance denials by filing a complaint with the Centers for Medicare & Medicaid Services. Those who believe they have received an inappropriate bill from an out-of-network provider can call the No Surprises Act help desk at 1-800-985-3059.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
