Concerns About Insurer and Telehealth Rule

UnitedHealthcare's Flawed ED Coverage Policy 

The big health insurance company UnitedHealthcare (UHC) floated a proposed policy on its coverage of emergency room care, and just as quickly pulled it back based on the outcry from the provider community and patient advocates.
United said its new policy would retroactively deny patients' claims of emergency department visits that are considered non-emergent. That is, a person rushes to an emergency department seeking care, after which, upon review, the insurer determines that the condition didn’t rise to the level of emergency care, and therefore denies coverage.
“Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” the American Hospital Association wrote the insurer last Tuesday in a strongly worded letter. “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.”
On Thursday, UHC tweeted it was delaying the policy: “Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period.”
UnitedHealthcare of New England reports that it has approximately 173,000 members in Massachusetts and Rhode Island, but the insurer does not report its self-insured members.

MHA Flags UnitedHealth Group's Move as Anti-Competitive

UnitedHealth Group (UHG), which owns the big insurer UnitedHealthcare (see above story) is attempting to purchase Change Healthcare, and MHA, in a letter to Attorney General Maura Healey says the merger raises serious anticompetitive questions.
Under the plan, UHG would acquire Change Healthcare and consolidate it under its competitor, Optum, which is also owned by UHG. Change and Optum are technology companies that essentially control and process the data that insurance companies use to determine reimbursements, claims, revenue cycle decisions, and clinical decision support services.
“Because Optum’s parent, UHG, also owns the largest health insurance company in the United States – UnitedHealthcare – the combination of these data sets would affect (and likely distort) decisions about patient care, claims processing, and claims denials to the detriment of consumers, healthcare providers, and even other health plans,” MHA wrote Healey. “Eliminating an important rival would stifle competition and extend UHG’s already massive market power to other markets in the healthcare system and presents significant antitrust concerns.”
If Change Healthcare is insurer controlled through Optum/UHG, as opposed to existing independently, then, MHA told the AG, “Optum could exploit its significantly reinforced and expanded data and data analytics capabilities across a variety of products and services as a healthcare ‘clearinghouse’ to favor its UnitedHealthcare subsidiary. Optum also will have strong financial incentives to use competitive payers' data to inform its reimbursement rates and set its competitive clinical strategy, which will reduce competition among payers and harm hospitals and other providers. For example, Optum could share pricing information from competitor claims that pass through its clearinghouse to help inform UnitedHealthcare's negotiations with providers.”
The American Hospital Association has also objected to the merger, telling the U.S. Department of Justice, “Change’s independence from payers and its function as an ‘honest broker’ is another critical element of competition. The loss of a key independent competitor that is similar in size to Optum in these essential services will likely result in higher prices for providers and in lower quality clinical outcomes for patients.”

Surprise Billing: Make Sure Regulations Match Law’s Intent

The “No Surprises Act” that passed as part of the Consolidated Appropriations Act of 2021 was hailed at the time as one of the few pieces of bipartisan legislation that came out of an increasingly fractious Congress. The law, spearheaded by Rep. Richard Neal (D-Mass.), took patients out of surprise billing disputes and created an independent dispute resolution (IDR) process for settling provider-insurer payment disputes, as opposed to creating benchmark, government-imposed rates.
Now, as the Biden Administration begins the rulemaking process to create the specifics of how the law will be carried out, including the details of the IDR process, members of Congress are circulating a letter reminding the rule makers of Congress’s intent regarding surprise billing.
The letter from Thomas R. Suozzi (D-N.Y.) and Brad Wenstrup, DPM (R-Ohio) to the Secretaries of Health & Human Services, Treasury, and Labor stresses that Congress intended for an IDR process “that captures the unique circumstances of each billing dispute and does not cause any single piece of information to be the default one considered.” That means that a certified IDR entity should assess all of the following: median in-network rates; provider training and quality of outcomes; market share of parties; patient acuity or complexity of services; teaching status, case mix, and scope of services of the facility; demonstrations of previous good faith efforts to negotiate in-network rates; and prior contract history between the two parties over the previous four years. MHA and the Massachusetts Medical Society have voiced support for the letter, as have many other provider organizations.
“The dispute resolution process established in the No Surprises Act prevents artificially low payment rates that would incentivize insurance companies to keep providers out of their networks,” Suozzi and Wenstrup write. They also remind the rule makers that the No Surprises Act gives consumers access to tools to navigate through the care system.
“It is critical that our intent is recognized as you implement the transparency and consumer protection provisions of the law,” they wrote. “One such tool, the advanced explanation of benefits, will give patients access to information about the expected cost of their treatment and the network status of the provider before they go in for a procedure. The requirements for insurance companies to offer patients up-to-date provider networks, price comparison tools, and clearly print in- and out-of-network deductibles and out-of-pocket maximums on insurance cards will make patients more informed in their healthcare decision-making.

Extending COVID-19 Flexibilities

The state of emergency in Massachusetts brought on by the pandemic ends tomorrow, and with it goes many of the regulatory flexibilities that were ordered to allow a robust response to COVID-19.
Governor Baker's administration and the State Senate, however, took actions last week to preserve or enhance some of the COVID orders that were proven to have worked in fighting the virus or in assisting businesses that were harmed by the economic downturn.
Senate bill S.2467, An Act relative to extending certain COVID-19 measures adopted during the state of emergency, passed the chamber last Thursday and now moves to the House. The bill, through an amendment from Harriet Chandler (D-Worcester) allows employers of physician assistants (PA) to designate a PA supervisor, which will allow providers to better respond to care needs during states of emergencies. Another amendment form Patricia Jehlen (D-Somerville) extends the suspension of regulations controlling staffing requirements for assisted living residences and training requirements for employees of assisted living residences. An amendment MHA fought hard for, from Eric Lesser (D-Longmeadow), extends healthcare provider license reciprocity. This means providers licensed in good standing in one state can practice in the commonwealth until the state's public health emergency is over or until April 2022 -- whichever is later. The caregivers can practice either in person in the commonwealth or across state lines using telemedicine. 
In a related development, DPH’s Public Health Council met last Wednesday and voted to approve a new Public Health Emergency, which allows the DPH Commissioner to issue emergency orders. While the State of Emergency will end tomorrow, the Public Health Emergency will continue indefinitely. Following the health council meeting, the state announced the orders that will stay and which ones will be rescinded.
For example, MHA and hospitals had asked for an extension of the order that allows hospitals to use alternate space within a facility or near a facility to treat or test COVID-19 patients. Another extension allows the Board of Registration in Medicine to continue its policy of recognizing emergency temporary physician licenses through September 15, 2021. Nursing graduates and senior nursing students will still be allowed to practice through September 15. Policies that will be rescinded include those that imposed visitation restrictions in hospitals and other healthcare settings, allowed flexible reassignment of physician assistants, and relaxed the Determination of Need requirements that facilities have to follow regarding COVID-19 expenditures.

In-Person Meetings Required for Telehealth? That Doesn’t Make Sense

The tMed Coalition, which MHA convenes to advance telehealth, is concerned with certain provisions of the Consolidated Appropriations Act of 2021 that affect how telemedicine can be delivered.
The Act made great strides in expanding Medicare coverage and reimbursement for telehealth services for mental health disorders by removing the current geographic and originating site restrictions. But the same Act says Medicare will provide coverage and reimbursement for telehealth mental health services only if the clinician has conducted an in-person consult with the patient in the prior six months and continues to conduct in-person exams – at a frequency to be determined by U.S. Health and Human Services.
"We are concerned that such requirements at the federal level would preclude the advances in health equity that telehealth offers,” the Coalition wrote in a recent letter to the Massachusetts Congressional delegation. “Mandating in-person visits for continued telehealth services could cause patients to forego behavioral health services altogether, which would lead to worse overall health outcomes. … Requiring a patient to be seen in person, even if it’s not for every visit, could result in a no-show and discontinuance of medically necessary therapy.”
The tMED Coalition also said it does not understand the logic behind requiring in-person visits for telebehavioral health visits, but not for other forms of telehealth visits. It wrote: “The Coalition is concerned that in-person visits solely for telebehavioral health services could perpetuate stigma surrounding the care and treatment of behavioral health conditions. The tMED Coalition is unaware of any studies or clinical standards which indicate that behavioral health patients have better clinical outcomes solely because they are assessed by a clinician every six months in-person. Instead, this in-person requirement could frame behavioral health disorders, care, and treatment as being different than the care and treatment for other medical disorders.” 

Happy Juneteenth!

MHA offices will be closed this Friday, June 18, in recognition of Juneteenth, the holiday that celebrates the emancipation of enslaved African-Americans in the United States. The origin of the celebration is traced to the June 19, 1865, announcement of General Order No. 3 by Union Army General Gordon Granger, proclaiming freedom from slavery in Texas. The oft-quoted first part of that order reads: “The people of Texas are informed that, in accordance with a proclamation from the Executive of the United States, all slaves are free. This involves an absolute equality of personal rights and rights of property between former masters and slaves, and the connection heretofore existing between them becomes that between employer and hired labor.” The second part shows why the struggle continues: “The freedmen are advised to remain quietly at their present homes and work for wages. They are informed that they will not be allowed to collect at military posts and that they will not be supported in idleness either there or elsewhere.”

MHA Executive Insights Webinar Series: A New System, A New Normal

Wednesday, June 23, 8-8:30 a.m.

Join MHA's Executive Insights Series, which throughout 2021 will feature candid interviews of hospital leaders. We welcome you to pour a cup of coffee and start your day with us as we hear directly from the CEOs who help power our world-class healthcare community. 
Kevin Tabb, M.D., president and CEO of Beth Israel Lahey Health, will join us on Wednesday, June 23 to discuss his journey as a healthcare leader and the transformative care that the state’s newest health system is providing to patients in the commonwealth.
Click here to register

John LoDico, Editor