UnitedHealth Group Acquisition of Amedisys Under Fire by DOJ

by Kristin Rowan | Nov 15, 2024 | CMS, M&A, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Justice Department Sues

In September of 2023, UnitedHealth Group made a bid to purchase Amedysis. That acquisition has been under scrutiny since last year. When the bid was announced, the Department of Justice began an inquiry, asking for additional information. At the time, Amedysis indicated that they anticipated the inquiry.

Now, more than a year later, the Department of Justice, along with the Attorneys General of Maryland, New York, New Jersey, and Illinois, have filed an antitrust lawsuit to block the acquisition. The proposed $3.3 billion acquisition would eliminate competition between the two companies. It would also give too much control to UnitedHealth Group, according to the suit.

Statement from the Department of Justice

The DOJ and the Attorneys General stated that the merger is illegal. The two companies own so much of the market share in the space already that combining the two would mean less choice for patients and fewer employment options for nurses seeking competitive pay and benefits.

UnitedHealth Group already acquired Amedisys’s biggest home health and hospice rival, LHC Group. Since that acquisition, UnitedHealth Group and Amedisys have been two of the largest providers of home health and hospice care in the United States.

American healthcare is unwell. Unless this $3.3 billion transaction is stopped, UnitedHealth Group will further extend its grip to home health and hospice care, threatening seniors, their families and nurses.

Jonathan Kanter

Assistant Attorney General, Justice Department anti-trust division

Surprisingly, the former CEO and current board chairman of Amedisys acknowledged the problems. He said that the competition between the two companies has helped keep them honest. He also said it has driven better quality to the benefit of their respective patients. The former CEO went on to say that the companies also compete for nurses and the merger may threaten the benefits nurses receive. It seems even the heads of the companies involved know this is a bad idea.

UnitedHealth Group's Proposed Solution

In response to the concerns voiced by the DOJ, UnitedHealth proposed to divest some of its facilities to VitalCaring Group. UnitedHealth said this would prevent the monopoly the merger creates. The DOJ responded to that proposal somewhat harshly.

The complaint alleges that the UnitedHealth Group’s market share would be illegal in home health markets in 23 states and the District of Columbia. It would also be illegal in hospice markets in 8 states, and in the nurse labor market in 24 states.

UnitedHealth’s proposed divestiture would only alleviate the monopoly in a few areas. This leaves hundreds of markets across the U.S. in jeopardy. Further, VitalCaring Group has poor quality scores and is facing its own legal judgement of close to half a billion dollars. Allegedly, the current CEO of VitalCaring Group was the CEO of a competitor while running VitalCaring behind the scenes.

Good News for Home Health and Hospice

The complaint describes home health and hospice services as “critically important parts of the American healthcare system….Patients rely on the skill and expertise of home health and hospice nurses, who must effectively treat patients at home.

Millions of patients depend on United and Amedisys to receive home health and hospice care in the comfort of their homes. The Department’s lawsuit demonstrates our commitment to ensuring that consolidation does not threaten quality, affordability, or wages in these vital healthcare markets.

Benjamin C. Mizer

Principal Deputy Associate Attorney General

Attorney General Merrick B. Garland said, “We are challenging this merger because home health and hospice patients and their families experiencing some of the most difficult moments of their lives deserve affordable, high quality care options. The Justice Department will not hesitate to check unlawful consolidation and monopolization in the healthcare market that threatens to harm vulnerable patients, their families, and health care workers.”

Final Thoughts

Mister Attorney General, please turn your attention to CMS and Medicare Advantage, as they continue to threaten the safety and well-being of patients, families, and caregivers with increasingly low reimbursement rates and denials of coverage.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Medicare Advantage Stock Prices After Trump Elected

by Kristin Rowan | Nov 15, 2024 | Clinical

by Kristin Rowan, Editor

Will the Change in Leadership Usher in a Change in Reimbursement Rates?

As in any election year, we have been bombarded with promises, predictions, and pandering from senate and house hopefuls as well as presidential candidates from every party. Each of them found platform issues that resonated with their followers. In turn, they have accused their opponents of all manner of sin.

Now that the election has passed and the lame duck session of congress has begun, analysts have started looking to January and how election results may impact different industries. Analysts believe Trump, along with congressional Republicans, will aggressively push Medicare Advantage. One researcher predicts that traditional Medicare will “wither on the vine.”

Privatization

Opposition to our current health care and insurance system often advocate for a single-payer system that is seen in places like England and Canada. Naysayers refer to this as the “socialization” of medicine, referring to socialist and communist governments. Privatization, on the other hand, moves healthcare out of the hands of the government and into the hands of privately held, usually for-profit, health insurance companies. Medicare Advantage has quietly moved more than 50% of all Medicare eligible patients to a privatized system. Senior policy analyst at Paragon Health Institute, Joe Alabanese believes that the Trump administration and a republican Congress would be “more friendly” to the idea of privatized health care.

Insurer Stock Prices

Whether the stock prices just before and after election day are predictive of things to come remains to be seen. For now, the information before us is this:

- Between Nov 1 and Nov 7, Humana Inc. had the largest increase in stock prices at 10.7%
- UnitedHealth Group Inc. rose 5.1% in the same time period
- Both companies had greater stock increases than the average across S&P
- Elevance Health was in keeping with the rest of the S&P with an increase of 3.6%
- Molina Healthcare, Inc. and The Cigna Group dropped 0.2% and 0.4%, respectively

Analysts say the jumps are in keeping with expectations that Republican control in Congress and in the White House will be beneficial for Medicare Advantage

Final Thoughts

It’s no secret that The Rowan Report is not a fan of Medicare Advantage. Specifically, the sales tactics used on the elderly and infirmed are predatory and the denial rate is criminal. The more eligible patients sign up for Medicare Advantage the less they will receive the care they need. Further, the more Medicaid has to supplement the cost of Medicare Advantage, the more home care agencies will suffer. Nationally, the more CMS regulates payment rates, pre-authorizations, and denial rates by privatizing Medicaid, the worse off our entire healthcare system will be.

With the state and national associations, we will continue to advocate on behalf of care at home agencies and their patients. And we hope you will too, regardless of who is in office. We have support at the federal level and we will continue to fight the good fight.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Here We Go Again

by Tim Rowan | Nov 8, 2024 | Clinical, CMS, Editorial, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

OIG Accuses Medicare Advantage Providers of Padding Patient Assessments...Again

“Hello, this is your Medicare Advantage company calling. I am one of their clinicians and it is time for us to update your health assessment. If you will agree to a home visit, we will send you a $50 gift card to CVS.”

This phone call my brother received is typical, increasingly common, and not necessarily on the up-and-up, according to a new report to CMS from the Department of Health and Human Services Office of the Inspector General (OIG). OIG found that these home visits, known in the insurance industry as “Health Risk Assessments,” (HRA) when coupled with HRA-related claims data, increased Medicare Trust Fund payments to MA companies $7.5 billion in 2022 and twice that in 2023. Most of it went to the top 20 companies.

The October 2024 report, “Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions,” accuses the industry as a whole of improperly padding payments by “finding” new health conditions during these HRA’s that may indicate the need for additional care at additional cost to the company. It questions the use of MA plan employees doing these assessments instead of relying on the customer’s primary care physician’s reports.

OIG references CMS’s own report, “Part C Improper Payment Measure (Part C IPM) Fiscal Year 2023 (FY 2023) Payment Error Rate Results,” to determine that gross overpayments to Medicare Part C plans in 2023 amounted to just over six percent of total payments, or $14.6 billion. The net increase to MA plans, after adjusting for underpayments, brought the percentage to 4.62. Total 2023 payments to MA plans came to $275,605,962,817.

The report also points out that identifying additional customer need during an HRA does not necessarily translate into the insurance company paying for additional care.

OIG Recommendations

In addition to implementing prior OIG recommendations, the new report asks CMS to:

- Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments,
- Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews, and
- Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies.

CMS concurred with OIG’s third recommendation but rejected the other two.

While the entire 38-page report is well-worth reading, OIG has also published a one-page summary.

At this year’s annual conference of The National Alliance for Care at Home, the new merger of NAHC and NHPCO, a number of education sessions were devoted to teaching Home Health agency owners how to negotiate with Medicare Advantage plans in order to minimize losses and better care for patients who chose those plans. Comments included the high rate of care denial, unreasonable prior authorization policies, and slow payments as compared to traditional Medicare. Other healthcare entities have chosen a potentially more effective response: Just Say No.

Hospital systems have had enough

According to a roundup of recent decisions by large and small healthcare systems in Becker’s Hospital CFO Report (10/25/24), no fewer than 30 healthcare providers are severing their relationships with one or more MA plans, with another 60 who told Beckers they are seriously considering the same move.

States Have as Well

A sister publication, Becker’s Payer Issues, reported in its October 23 edition that more and more states are issuing fines against MA plans for violations ranging from excessive denied claims to collection of co-pays when none was required.

How Much Longer?

All of this demands a serious question. How much longer will Home Health continue to tolerate abuse by these giant, for-profit payers now that a different path forward has been paved by hospital systems and state regulatory arms? The loudest voice for Home Health to join the “Just Say No” movement over the last few years has been that of Bruce Greenstein, CTO of LHC Group. Following his company’s acquisition by UnitedHealth’s Medicare Advantage division, Optum, his less loud message is to work with MA plans to teach them what Home Health is and what it can do for them.

Statement from Dr. Landers

In his inaugural address to The Alliance last month, new CEO Dr. Steven Landers called for our entire industry and everyone taking a paycheck from it to join him in advocacy. We fully support that call to action, recognizing that no national association can influence lawmakers and CMS regulators without member support, but he was referring to Medicare rules and payment structures. As we know, that includes less than half of Medicare beneficiaries today. Thanks to deceptive TV ads during open enrollment every year, that number will continue to shrink.

Widespread Advocacy

We need to turn at least part of our advocacy focus to the dominant payers, the MA divisions of insurance companies. Read the Beckers report on the 30 healthcare systems that have torn up their MA contracts. Read the companion report about the epidemic of care denials. Yes, it is a David vs. Goliath story, with even the largest organizations in Home Health dwarfed by the size of the payers. As so many hospital systems have shown, however, it is possible to switch from begging for a few more cents per visit to forcing a plan to beg you to take their patients.

It will only work though if everyone does it. We have already lost LHC Group, and Optum is in the final stages of adding Amedisys to their stable. Out of 11,000 HHAs, there is still a chance we have a united voice loud enough to be heard and taken seriously.

Final Thoughts

One of their improper cost-cutting tactics is routine care denial. For example, the Labor Department alleged that UnitedHealth subsidiary UMR denied all urine drug screen claims from August 2015 to August 2018 without determining whether a claim was medically necessary. In my brother’s case, following his wife’s HRA by her MA company, with no additional care offered, he made the tough choice to put her on in-home hospice care. The assessing nurse immediately detected she had a UTI and ordered the appropriate antibiotics. She responded quickly and may be discharged from hospice soon. Hospice care, of course, is paid by traditional Medicare, not Medicare Advantage.

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com or contact Tim at Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

UnitedHealth Study: Is Medicare Advantage Killing Seniors

by Tim Rowan | Oct 25, 2024 | CMS, Editorial, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

Is Medicare Advantage Killing Us?

Dr. Steve Landers has long been eloquent in his speaking and writing about the importance of Home Health over the years. Though I was already impressed, I gained a new level of respect this week. Simultaneously with his debut as CEO of the new Alliance, Dr. Landers released an article about a recent study on the impact of Medicare Advantage on Medicare beneficiaries.

It is an article that everyone in our healthcare sector should read.

In “Home Health Cuts and Barriers are Life and Death Issues for Medicare Beneficiaries,” Dr. Landers points readers toward a study conducted by Dr. Elan Gada of UnitedHealthcare’s Optum Group. The results are disturbing. That the findings were released by a Medicare Advantage company is surprising.

Yes, Virginia, Home Healthcare Really Does Save Lives

Landers cited the study’s primary finding. “Medicare Advantage beneficiaries in their plan who did not receive needed home health care after hospitalization were 42% more likely to die in the 30 days following a hospital stay than those who received the prescribed care.” If a drug proved to be as effective as post-discharge home healthcare in saving lives, Landers wrote, “it would dominate the news, restricting access would be considered immoral, and health officials would be pushing its adoption.”

Medicare Advantage Enrollees Go Without

There are a number of reasons a hospital discharged patient might not receive home healthcare, including system issues and patient refusal. However, Dr. Gada’s study also discovered that MA customers go without post-discharge home health at a higher rate than traditional Medicare beneficiaries. Traditional Medicare beneficiaries go without in-home care about 25% of the time. Medicare Advantage beneficiaries 38% of the time. Landers notes that this data is a few years old and that the denial rate for MA customers is likely higher today.

Stop the Killing

We know the life-saving impact of post-hospital home healthcare. The question becomes: how does our little corner of the U.S. healthcare system help regulators and payers to know it as well as we do? At this week’s inaugural conference of the National Alliance for Care at Home, at least three education sessions discussed Medicare Advantage. All three offered strategies for negotiating with insurance companies and surviving under their oppressive rate structures and their frequent care denials.

UnitedHealth Group Medicare Advantage Landers

These Are Bandages, Not Cures

In previous opinion pieces, I have quoted revelations in government lawsuits against MA divisions of insurance companies. These prove the program that was originally launched to extend the lifespan of the Medicare Trust Fund actually costs CMS 118 percent of what traditional Medicare costs. At the same time, insurance company reports to shareholders proudly point out that their MA division is their most profitable.

One of last week’s most read stories was the report from UnitedHealth Group on their astounding Q3 growth.

In the Long Run

Learning to cope with MA care denials and below-cost visit payments is fine for those focused on making next month’s payroll. An entirely different tactic is needed for those focused on the care needs of their elderly parents or who are approaching age 65 themselves. The question must be asked, “Why does Medicare Advantage exist?”

Medicare Advantage Lobbyists

AHIP is the insurance company lobby. It put extreme pressure on Congress in 2009 when the Affordable Care Act was being written. That pressure resulted in then-President Obama removing a core plank from his bill. Obama struck the public option healthcare insurance plan in order to win enough votes to get the bill to his desk.

More $ Makes More $

That lobbying effort continues today precisely because MA is so profitable. How does it bring in so much cash? One after another, all of the large insurance companies have been caught padding patient assessments, the very fraud Home Health is so often accused of. Their monthly checks are determined by how much care they predict their covered lives will need, and they exaggerate it. Later, when it comes time to treat these same customers, MA plans deny care that would have been covered by traditional Medicare. They book profits at both ends, and they gladly pay the minimal fines when the practice is exposed.

The Reality of Medicare Advantage Fraud

To make each covered life more profitable, MA plans have begun calling customers to offer “free” nurse visits. These are essentially re-assessments where the MA staffer is rewarded for “finding” additional illnesses. This is not theoretical. My brother was offered a $50 gift certificate to CVS if he would allow his wife’s MA plan representative to drop in and chat with her, to “make sure she was getting all the benefits she was entitled to.”

Dr. Steven Landers: Call for Advocacy

In his article and in his speeches this week, Dr. Landers made it quite clear what must be done. EVERY person whose livelihood depends on the Medicare Trust Fund must make their voice heard. Letters and phone calls to Congress, to the Senate, to CMS, and to the Secretary of Health and Human Services, telling them you do not want to happen to your community what happened in Maine. After years of negative profit margins, in a state where MA adoption is at two-thirds, Andwell Health Partners ceased business in a wide swath of the northern regions of the state. Andwell was the only Home Health provider there.

The combined advocacy strength of NAHC and NHPCO is not enough to tip the scales. Your input is crucial.

Here's How it Works:

Your letter explaining the damage coming from shrinking CMS reimbursement and MA care denials will be opened by a Congressional staffer.
The staffer will read only enough of your letter to see its topic and which side of that topic you are on.
No need to be lengthy or eloquent
Put your topic and your position in your first paragraph
The staffer will add a checkmark in the pro or con side of their Home Health ledger.
The Congressperson, Senator, HHS Secretary will see a one-page summary of the numbers.
When the numbers are small, the summary goes into a file
When the numbers are large, the elected or appointed official will pay attention
In rare cases, you may even get a phone call

UnitedHealth Group Advocacy Medicare Advantage

Dr. Landers, in His Own Words

The article Dr. Landers wrote detailing all of these includes wording suggestions for your message in your letter and/or call. For convenience, I have included one paragraph below,* but I urge you to spend three minutes reading the entire inspiring and frightening piece. In person, he explained all this in an emotional appeal. He said he cannot emphasize enough the importance of universal participation in our new organization’s advocacy effort. Based on what we have learned about post-hospital nursing care in the home, your letters and phone calls are a matter of life and death.

Excerpt

*To save lives and avoid unnecessary suffering, Medicare officials must reverse their plans to cut Traditional Medicare home health payments for 2025 and ensure payments are stable after adjusting for the dramatically increased healthcare labor cost inflation experienced over the past 5 years. Additionally, Medicare officials and lawmakers must study and address the possibility of the disproportionate administrative and financial barriers to home health in Medicare Advantage.

We are fortunate to have leaders in Congress like Senator Debbie Stabenow, Senator Susan Collins, Representative Terri Sewell, and Representative Adrian Smith who are working to champion a comprehensive bi-partisan legislative fix. Our leaders in Washington must act swiftly, before the end of the year, to save lives and avoid further destabilizing home health services for Medicare beneficiaries.

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

An Interview with Dr. Steven Landers, Part 2

by Kristin Rowan | Oct 25, 2024 | Advocacy, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage is Killing Us...Literally

This is part 2 of 2 in the interview with Dr. Steven Landers. You can read part 1 here.

Medicare Advantage article by Dr. Landers

Earlier this week, Dr. Landers published an article in the NAHC Report. The article cited three studies and analyses on the number of enrollees in both Medicare and Medicare Advantage who do not receive the care to which they are entitled. During our recent interview with Dr. Landers, he addressed this article.

Dr. Steven Landers: On the Record

The Rowan Report:

You wanted to address something you recently wrote. Is this the same topic you mentioned the opening session, or is this something else?

Dr. Steven Landers:

No, this is a focused piece on the emerging research that we’re seeing around when people miss out on home health. It’s a life and death issue. I want to be sure that we, as an alliance, I, as a physician, and us, as advocates, that we are conveying that these issues around home health cuts and barriers are potentially deadly. This is not a trivial matter. It’s not an administrative or technical financial issue. It’s about people’s lives.

RR:

The article mentioned a study that said that the numper of people not getting the home care that they’re entitled to is almost double with Medicare Advantage enrollees over traditional Medicare.

Steve:

That was from a study that’s referenced there from a few years ago. The Partnership for Quality Home Health Arcadia Analysis that came out this year actually showed that those trends are worsening. We know that they’re not getting the needed care in Medicare Advantage and traditional Medicare.

In both cases it’s too high, but it’s higher in Medicare Advantage. It’s more common that people don’t get the prescribed care in Medicare Advantage. And we also know that that’s going up in both traditional Medicare and Medicare Advantage. The access has gotten worse because of the Medicare home health policy and because of the way that Medicare Advantage has grown and handled these issues.

Interviewer:

I guess the big giant question is what do we do, especially when margins for both traditional Medicare and Medicare Advantage are so low?

Steve:

One, we’ve got to start improving access to home healthcare. And the way that we do that is we end this march of payment cuts that are being set forward by Medicare. I mean, right now the leaders of Medicare are in their rulemaking process and they have choices to make. They can either do things that reverse this trend and put us on a path to better access or I think continuing these cuts will hurt beneficiaries.

And the other piece is the Medicare advantage front. We need more scrutiny and evaluation and potentially oversight here to make sure Medicare Advantage beneficiaries have access to high quality home healthcare.

“The results of this study demonstrate that among MA members referred to home health after acute hospitalization, those who did not receive home health services experienced higher mortality and lower readmissions than those who received these services.”

Unfulfilled Home Health Referrals Lead to Higher Mortality Among Medicare Advantage Members

Elan Gada, MD, Paul Pangburn, MHA, Chris Sahr, MS, MBA, Chad P. Schaben, MPH, Richard Young, MS

RR:

Where does the problem lie?

Steve:

People don’t get home health when it’s prescribed and mortality rates are substantially higher. There could be [anecdotal] reasons that this is happening. I’ve tried to think of them. I can’t really come up with them when you see it in three different analyses, especially one done within the Medicare Advantage plan. They have great data. It was well thought out and this is serious business and it really should be a kitchen table discussion for families like ‘what’s going here?,’ because obviously home healthcare is a beloved service that families care deeply about.

We’ve seen home care become a presidential campaign issue because it’s good policy and also because the folks running, Vice President Harris, who brought it up, and former President Trump, who chimed in sort of a me too, being enthusiastic about the concept. They’ve got to know that this polls well, that the families care about this stuff.

Editor Emeritus Tim Rowan provides an analysis of the study from UnitedHealth Group here.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

UnitedHealth Group Sees Q3 Growth

by Kristin Rowan | Oct 18, 2024 | CMS, M&A, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

UnitedHealth Group Earnings Show Strong Q3 Revenue Growth

For most of 2024, and even going back into 2023, The Rowan Report has written about UnitedHealth Group and its acquisitions, its over diagnosing patients for financial gain, its dropping of Medicare Advantage plans, and, of course the Change Healthcare cyberattack.

Despite all the negativity, UnitedHealth Group continues to grow. The company’s revenue grew more than 9% over last year’s Q3 numbers. Even after the cyberattack, Optum grew by more than $2 billion. According to UnitedHealth Group CFO John Rex, the growth is due to an increase in both the number and type of care services offered. Optum operates three subsidiaries, OPtum Health, OptumRx, and OptumInsight, with total revenue of $63.9 billion.

CyberAttack did not Impact Earnings

According to the Q3 financial statement, per share earnings of $6.51 include the cyberattack impacts. The annual adjusted net earnings outlook for 2024 is between $27.50 and $27.75, in line with earlier projections. The 2024 net earnings outlook reflects both the selling of South American properties and the impacts from the Chnage Healthcare cyberattack. Net earnings outlook is $15.50 to $15.75 per share.

More UnitedHealth Group Acquisitions on the Horizon

UnitedHealth Group CEO Andrew Witty said the company is using a five pillar growth strategy. They will continue to spend money acquiring companies for United Healthcare, value-based care, pharmacy businesses, financial services, and what he called “technology-ed opportunities.

Meanwhile...

While UnitedHealth Group and Optum post higher revenue and cash flow and their shareholders se an increase in per share earnings, subscribers to UnitedHealth insurance plans are losing. Monthly premiums and annual deductibles for Medicare Part B increased from 2023 to 2024. Part B standard premiums are expected to increase by almost 6% in 2025. For seniors with higher income, the adjustment amount will go up to $74 per month, making monthly premiums jump to $259. The base beneficiary premium for Part D also increased in 2024 and will again for 2025.

Keeping it in the Family

Effective September 1, 2024, UnitedHealthcare started requiring prior authorization for Medicare Advantage member to receive PT, OT, and ST services when performed outside of the home. Not surprisingly, United Health owns multiple practices that offer PT, OT, and ST at home. Those services don’t require prior authorization. UnitedHealth Group is enjoying higher revenue, higher net income, and is funneling the money from insurance premiums back into its own pocket.

Go for the Gold

This announcement came just after UHC announced a gold card program to reduce prior authorization requirements. The gold card program started October 1st and was supposed to reduce the prior authorization request volume for provider groups. Providers groups who are in-network, have a minimum number of prior authorizations for two years, and have at least a 92% approval rate qualify for gold status.

Final Thoughts

Home health agencies are struggling to survive with lower payment rates from Medicare plans and operating in the negative under Medicare Advantage plans. Physician practices, surgery centers, urgent care, and pharmacy benefit managers are operating under UHC for even greater profits. More patients are seeing delays in care due to increased prior authorization requirements, unless the patient is seeing a caregiver owned by UHC. Shareholders are getting increased per share revenues. Perhaps there’s a solution hidden in the math there somewhere.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

CMS Ransomware Attack: Breach of PII

by Kristin Rowan | Sep 27, 2024 | Admin, Breaking News, CMS, Regulatory

by Kristin Rowan, Editor

CMS Ransomware Attack

In mid-2023, a planned file transfer went awry when Clop claimed to have breached hundreds of companies that they later listed on a data leak site. Among the companies listed were Shell, UnitedHealthcare Student Resources, The University of Georgia, and Putnam Investments. Also compromised were government entities including the U.S. Department of Energy. According to Clop, data from military sources, children’s hospitals, and other .gov sites was also copied. The ransomware group alleges they deleted all information from government, military, and children’s hospital sites.

Unfortunately, there is no way to confirm whether all that information was indeed deleted. Earlier this year, Change Healthcare suffered a similar widespread breach that caused massive payment delays for months. CMS provided guidance during those delays.

Underreporting of Attack

Many of the companies impacted by this attack chose to disclose the breach rather than negotiate with the ransomware attackers to retrieve the stolen data. When Bleeping Computer reached out to those companies immediately following the attacks, a number of them indicated that only a small number of people were effected and that no financial or identifiable information had been stolen. It seems, now, though that not all companies involved in the attack were on the initial list.

Wisconsin Physicians Service (WPS) health insurance corporation was among the companies not listed when news of this attack was first published. WPS provides Medicare administrative services to CMS, including handling Medicare Part A/B claims. In the first week of September, nearly 3-1/2 months after the attack, CMS and WPS started notifying beneficiaries whose protected health information (PHI) or other personally identifiable information (PII) may have been stolen during the attack.

1,000,000 Notifications

On July 28, 2023, CMS estimated 612,000 Medicare beneficiaries may have had PHI and/or PII exposed in the breach. That number has increased to almost 1 million. CMS and WPS are sending notifications to more than 950,000 people whose information has been compromised. The letter explains further:

May 31, 2023, MOVEit disclosed the breach to the public and released a patch.

June 2, 2023, WPS notified CMS of a data breach that occurred sometime between May 27 and May 31, 2023.

According to WPS, they applied the patch but did not observe any evidence of any files having been copied.

July 28, 2023 CMS sends an initial letter to beneficiaries whose information may have been affected.

May 2024, WPS acted on new information that led them to discover copied files from before the patch was deployed.

Of the portion of breached files that WPS studied, none were found to have personal information.

June 8, 2024, a different portion of the files showed personal information was contained in those files. This information includes:

Name
Social Security Number or Individual Taxpayer Identification Number
Date of Birth
Mailing Address
Gender
Hospital Account Number
Dates of Service
Medicare Beneficiary Identifier (MBI) and/or Health Insurance Claim Number

Note: in the initial letter sent to beneficiaries in July of 2023, CMS also listed Healthcare Provider, Prescription Information, Insurance Claims, Policy Information, Subscriber Information, Health Benefits, and Enrollment Information as possibly having been leaked. These items were removed from the list in the September 2024 version of the same letter.

For those who received this notification, CMS and WPS offered a complimentary year of credit monitoring from Experian. CMS also advised members to request their free credit report from each of the credit reporting companies.

The letter also informed members that they would soon receive a new Medicare card with a new Medicare Number. 946,801 people received this notice.

CMS Ransomware Attack Victims Not Notified

On September 24, 2024, Bleeping Computer reported that on the same day CMS sent more than 900,000 letters to members, they also reported to the Department of Health and Human Services that the total number of people with information stolen was 3,112,815. CMS explains the difference by saying the larger number includes Medicare beneficiaries, people who are deceased, and people who were covered by other providers but whose information was included in WPS data collection used for provider audits in their role as Medicare Administrative Contractors (MACs).

New MBIs and What it Means For You

According to a blog post dated September 26, 2024 from SimiTree, starting in mid-October, CMS will issue new Medicare cards with new Medicare Beneficiary Identifiers to the 946,801 Medicare beneficiaries who were previously identified as at risk and were notified of the breach. This may cause undue delays and other issues for home health and hospice providers.

Claim Rejection

If these beneficiaries use their existing MBI after the new one has been issued, providers could see rejections on NOAs, NOEs, OASIS submissions, and claims.

Urgent Reverification

Providers will need to reverify eligibility and update patient records in their EMR systems. Because providers were not notified of which beneficiaries were impacted, agencies will need to verify MBIs for every Medicare patient.

Possible Disruption

The full impact of reassigning MBIs to nearly 1 million Medicare beneficiaries is not yet known. Medicare has not clarified what will happen with claim processing for patients whose MBIs change during the claim processing for active patients. There are possibilities for delayed processing, delayed payments, and incorrect denial of services or payments due to the volume of MBIs changing at once.

How to Prepare

Our friends at SimiTree have some suggestions for how home health and hospice providers can prepare in advance for the MBI change coming around October 15-16, 2024.

Take Immediate Action – start reverifying eligibility for all Medicare patients now
Update Systems – ensure your EMR and other solutions in your tech stack are updated and ready to handle the changes
Train your Staff – make sure everyone on your team knows this change is coming and teach them new verification procedures so their patients aren’t left without care

CMS has not issued a statement about the impact of the MBI changes, but this story is ongoing and we will continue to monitor and report on any updates from WPS and CMS as well as look for additional information on the changes expected with the new MBIs.

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Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

BREAKING NEWS: Blumenauer Proposes Hospice Overhaul

by Rowan Report | Sep 27, 2024 | Breaking News, Partner News, Regulatory

FOR IMMEDIATE RELEASE

Contact: Portland District Office
503-231-2300

blumenauer proposes overhaul to hospice benefit

If enacted, the legislation would be the single most significant update to the hospice benefit and payment structure since its inception in 1982

WASHINGTON, D.C., SEPTEMBER 26, 2024 – Today, Congressman Earl Blumenauer (D-OR), a senior member of the Ways and Means Committee, introduced the Hospice Care Accountability, Reform and Enforcement Act (Hospice CARE Act) to modernize Medicare’s hospice benefit, which has remained largely unchanged since its inception in 1982. The proposal comes as egregious reports of fraud and abuse within the benefit persist, despite action from Centers for Medicare & Medicaid Services (CMS). The legislation is the product of years of collaboration between stakeholders, lawmakers, and industry leaders. It builds on Blumenauer’s decades-long commitment to ensure the federal government supports families at a time of great stress and vulnerability: the end of life.

“The United States spends significantly more on health care than other developed nations for worse outcomes. Nowhere is this more egregious than in the hospice industry,” said Congressman Earl Blumenauer. “Patients and families deserve better. We need a reset. It is past time for Congress to act to end the fraud, waste, and abuse within the hospice benefit and bring it into the 21^st century.”

To protect patients and taxpayers, the Hospice CARE Act would institute a number of long overdue reforms to crackdown on fraud while incentivizing high-quality care. Critically, it would:

- Reform the payment structure: The underlying hospice per-diem payment structure—which generally pays hospices for each day of care regardless of if care is provided on a given day—rewards bad actors who exploit the benefit for financial gain. The legislation revises the payment structure to ensure that providers are incentivized to deliver high-quality care and meet the current needs of individuals and their families.
- Bolster program integrity: Additional safeguards and oversight is needed to prevent fraudulent providers from enrolling in Medicare, especially for new hospices. That includes temporarily preventing new hospices from enrolling in Medicare, with exceptions where additional access to care is needed, increasing survey frequency, and increasing ownership transparency

A one-page fact sheet can be found here. Bill text here.

“The hospice benefit, while unique, is ripe for change. This legislation is a first-of-its-kind opportunity to improve it,” said Katie Smith Sloan, president and CEO, LeadingAge, the association of nonprofit providers of aging services, including hospice, on the Hospice Care Accountability, Reform and Enforcement (CARE) Act of 2024. “Revising a benefit that has not been altered significantly since its creation in 1982 is a formidable undertaking – but a necessary one. Done right, changes will expand the benefit to support the realities of modern-day hospice care and address vulnerabilities that are currently being exploited. There is more work to do and we look forward to continuing our productive partnership to ensure this bill achieves these goals.”

“The National Partnership for Healthcare and Hospice Innovation (NPHI) is thankful for the work of Congressman Blumenauer, his staff, and the Ways and Means Committee staff who worked with the hospice and advanced illness community to put forward the Hospice Care Accountability, Reform, and Enforcement (CARE) Act. This legislation is an encouraging and unique opportunity to consider reforms that would strengthen the Medicare hospice benefit by ensuring it continues to support patients, families, and the non-profit providers who were the original foundation of hospice care,” said Tom Koutsoumpas, CEO and founder of NPHI. “We look forward to continuing to work closely with Congress and relevant stakeholders on efforts to modernize the hospice benefit and improve care of those at the end-of-life.

“The Coalition to Transform Advanced Care (C-TAC), truly appreciates the introduction of the Hospice Care Accountability, Reform, and Enforcement (Hospice CARE) Act. We commend Representative Earl Blumenauer (D-OR-3rd) for this important work and for his decades of support for compassionate end-of-life care and for bringing policies to the national stage with bi-partisan support,” stated Jon Broyles, C-TAC CEO. “We have had the privilege to work with the Congressman, his staff, Ways & Means Committee staff and other advocates on this bill and it is an important starting point for ideas that will lead to modernizing the hospice program and improving the lives of people with serious illness and their family caregivers.”

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This press release was issued by the office of U.S. Congressman Earl Blumenauer, representing the 3rd district of Oregon. The original press release can be found here. The Rowan Report has reached out to The Alliance for Care at Home for comment.

Another One Bites the Dust

by Kristin Rowan | Sep 20, 2024 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Essentia Drops Medicare Advantage

Essentia Health is an integrated health system with locations in Minnesota, North Dakota and Wisconsin. The health system offers 285 different services across more than 1,700 locations. They employ more than 2,700 doctors. Essentia also includes 14 hospitals, emergency care, same-day care for mental health crises, and multiple specialties.

This is all to say that Essentia Health is not a small player. They contract with the largest payers in the industry.

Re-Evaluation

Recently, the health system began re-evaluating its participation in some Medicare Advantage plans. According to the chief medical officer for population health at Essentia, Cathy Cantor, M.D., M.B.A., too often deny or delay care. Cantor said in a statement:

“This was not a decision we made lightly. The frequent denials and associated delays negatively impact our ability to provide the timely and appropriate care our patients deserve. This is the right thing to do for the people we are honored to serve.”

Essentia informed patients that they will no longer be an in-network provider for MA plans through UnitedHealthcare (UHC) or Humana beginning January 1, 2025. The health system claims that UHC and Humana delay and deny approval of care at more than twice the rate of other Medicare Advantage plans. They are encouraging its patients to choose a different plan during open enrollment that is in-network with Essentia.

UHC Responds

UnitedHealthcare responded to the press release that Essentia issued. According to their statement, the two parties extended their contract just this past July. Negotiations included a number of items on which they agreed to collaborate, but Medicare Advantage was not specified among them.

“Essentia Health didn’t raise concerns regarding its participation in our Medicare Advantage network until last week. We have since met with Essentia on Sept. 9 and are committed to working with the health system to explore solutions with the goal of renewing our relationship. We hope Essentia shares our commitment toward reaching an agreement.”

Following Suit

Essentia’s departure from Medicare Advantage is just one in a recent mass exodus.

Sanford Health of South Dakota ended its Humana MA participation due to “ongoing challenges and concerns that negatively effect patients including ongoing denials of coverage and delays in accessing care.”

HealthPartners out of Minnesota announced over the summer that “UnitedHealthcare delays and denies approval of payment for MA claims at an exceptionally high rate…up to 10 times higher than other insurers…. After over a year of being unable to persuade UnitedHealthcare to change their practices, we’ve determined that we can no longer participate in the UnitedHealthcare Medicare Advantage network.”

Mercy, the official medical provider of the St. Louis Cardinals, announced its year-end departure from the Anthem Blue Cross Blue Shield network. This includes all Medicare Advantage, ACA marketplace, and managed Medicaid plans. They cited administrative tasks that create a barrier to timely, appropriate patient care. Mercy also complained that Anthem has raised its rates for patients and employers, increased its profits, and still has not raised reimbursement rates to providers. Like Essentia, Mercy is encouraging its patients to consider whether the health care plan they choose during open enrollment will list Mercy as one of its in-network providers.

Final Thoughts

CMS reimbursement rates, Medicare Advantage denials, payment delays, and other interruptions are impeding patient care. As Tim mentions in his editorial this week, we are in an election year and we urge you to research how each party might impact our industry.

If more providers and payors continue to drop Medicare Advantage from their offerings, will we see more patients returning to traditional Medicare plans with an affordable Medicare Supplement or MediGap coverage? One can only hope!

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Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

More Rural Providers Say ‘No’ to MA

by Tim Rowan | Aug 23, 2024 | Artificial Intelligence, Caring for the Caregiver, Clinical, CMS

by Tim Rowan, Editor Emeritus

O

ne just does not know whom to believe anymore. This week, we were sent three opinions of the pros and cons of Medicare Advantage programs. One says they reduce costs and improve patient satisfaction for rural residents. Another says rural hospitals are turning away MA customers at a growing rate. The third says MA customers utilize healthcare services at a lower rate than traditional Medicare beneficiaries. Let’s take a look at each opinion.

The Pro

Better Medicare Alliance is a non-profit advocacy group that promotes Medicare Advantage. They describe themselves and the genesis of their recent report this way:

“Better Medicare Alliance engaged ATI Advisory to understand Medicare beneficiaries who live in rural areas and how they are served across Medicare Advantage and Fee-for-Service (FFS) Medicare. Understanding geographic differences in beneficiary experiences is important to both the Medicare Advantage and FFS Medicare program. This research can help policymakers and stakeholders identify opportunities to improve access to and quality of rural health care.”

That sounds good so far. Let’s look at their conclusions.

- 30 percent fewer MA client live in rural areas compared to cities and suburbs
- rural MA enrollees are more likely to be Black or LatinX but health needs are consistent across all rural demographics
- satisfaction is the same between rural MA clients and traditional Medicare beneficiaries, though MA enrollees use preventive services more and outpatient services less
- rural MA enrollees spend less in premiums and out of pocket costs than traditional Medicare beneficiaries

Rural Hospitals Tell a Different Story

Healthcare Uncovered, an online publication with a patient advocacy slant, describes BMA as “an active front group for the health insurance industry and perhaps the country’s greatest champion of Medicare Advantage plans.” and “with a well-stocked, industry-financed war chest to promote insurers’ premier product.”

Writing for Healthcare Uncovered, longtime healthcare journalist Trudy Lieberman added perspective to the BMA-sponsored report:

More places say no to medicare advantage

There was evidence last fall that Medicare Advantage was under attack when several hospitals announced they were reviewing their arrangements with Advantage plan sellers and were not accepting some or all plans. The CEO of the Brookings Hospital system in Brookings, South Dakota, told me, “The difference between original Medicare and Medicare Advantage is vast. Advantage plans pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services.”

In 2023, Becker’s Hospital Review began reporting on hospitals that were dropping some or all of their contracts with Advantage plans. The August 20, 2024 update indicates 18 more hospitals have or will drop MA plans this year.

Ms. Lieberman went on to report that MA plans frequently limit in-plan physicians. When they eliminate a physician in a rural community, patients often must travel miles to reach an approved doctor.

“Another damning report, this one issued by the Nebraska Rural Health Association, also revealed the pitfalls of joining an Advantage plan. The report warned that Nebraskans with Advantage plans ‘have created such a financial burden for rural residents’ that when they get sick, those with Medicare Advantage coverage ‘represent the largest growing segment of charity care for Nebraska’s rural hospitals.’ I’d bet few if any seniors are told they may end up on charity care if they choose an Advantage plan.”

A hospital in 23,000-resident North Platte, Nebraska has stopped accepting all MA patients. CEO Ivan Mitchell told Ms. Lieberman that transfers to nursing home and Home Health are denied 13 percent of the time. “Hospital stays are 40 percent longer for MA patients. They are stuck in the hospital two or three days waiting for approval to be transferred, and we need those beds for sicker patients.”

Home Health Weighs In

The Research Institute for Home Care awarded a grant to Tami M. Videon, PhD, and Robert J. Rosati, PhD, of the VNA Health Group, the honored Home Health not-for-profit in New Jersey. The researchers divided beneficiaries into three groups: Traditional Medicare, MA with a premium, and MA without a premium. Their findings resonated with the experiences of rural hospitals more than those of the MA advocacy group.

Research Findings

- Traditional Medicare (TM) beneficiaries were more likely to utilize outpatient, inpatient, and home health care services than beneficiaries in Medicare Advantage (MA) plans, regardless of whether the plan had a monthly premium or not.
- Beneficiaries who reported being in zero premium MA plans were substantially less likely to use dental, hearing, and vision services compared to other beneficiaries.
- Rates of utilization of hearing and dental services were relatively similar for beneficiaries reporting they were in MA plans with a premium and those enrolled in TM. Access to vision services was greatest among beneficiaries reporting being in MA plans with a premium.

In their research briefing, the researchers stated:

“Consistent with the literature, this study found beneficiaries enrolled in MA plans had lower utilization for services required to be covered by Medicare (outpatient visits, inpatient admission, and home health care use) than beneficiaries enrolled in TM. The observed lower rate of home health care utilization among MA beneficiaries may result from restrictions in inpatient care. However, prior research indicates when analyses are restricted to similar patient populations (a subset of diagnostic codes), MA beneficiaries are less likely to receive home health care than TM beneficiaries.”

Where Does the Money Go?

We have often reported on the lawsuits that various federal departments have lodged against the largest health insurance companies for their Medicare Advantage practices. With their payments from the Medicare Trust Fund based on patient assessments, they have been caught exaggerating illnesses, adding chronic conditions that do not exist, and conducting periodic home visits to “update” their data on the health condition of their customers. These nurse visits to the home frequently “identify” serious health conditions that the person did not know they had, or in most cases did not have at all.

As a consequence of this practice, coupled with denying care that Traditional Medicare would have covered, the program has been determined by government audits to cost 119 percent of what Traditional Medicare costs.

Final Thoughts

Should Home Health follow the lead of so many rural hospitals and begin to Just Say No? Our guess is that this will be a prominent topic at this October’s NAHC Conference in Tampa.

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Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com Tim@RowanResources.com ©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com