by Kristin Rowan | Mar 7, 2025 | Clinical, CMS, Medicare Advantage, Regulatory
Easier Access to Home Health
Prior authorization requirements can be cumbersome, delaying or even preventing care in some cases. Patients who need prior authorization to get he care they need also generally have form after form to fill out or to have completed by their PCP or hospital physician, who doesn’t have time for adequate visits, much less more paperwork.
As part of their ongoing efforts to reduce prior authorization volume by 10%, UnitedHealthcare has just announced a change in their home health services requirements.
Limits on Where Changes Apply
Beginning April 1, 2025, UHC will no longer require prior authorization or concurrent reviews for home health services managed by Home & Community (formerly naviHealth). This is the next step in an ongoing effort to modernize the authorization process and simplify health care for its members and providers.
These changes will apply to Medicare Advantage and Dual Special Needs Plan (D-SNP) beneficiaries in 36 states and the District of Columbia.
- Alabama
- Alaska
- Arkansas
- California
- Colorado
- Connecticut
- Florida*
- Georgia
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Nebraska
- Nevada
- New Mexico
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- Tennessee*
- Texas
- Utah
- Virginia
- Washington
- Wisconsin
- Wyoming
- Washington, D.C.
*In Florida and Tennessee, the changes will not apply to D-SNP plans that are not managed by Home & Community.
Prior Authorization Additional Information
You should continue to request prior authorization and concurrent review through March 31, 2025. UHC reminds all providers that following CMS guidelines for providing home health care services is still required. And in states where a Medicare denial is required to get Medicaid prior authorizations, providers should submit their requests through the UHC provider portal.
The available information on this pending change is limited. We will provide updates should they become available. Please contact UHC directly through the provider portal if you have specific questions.
Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com
©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
by Kristin Rowan | Dec 12, 2024 | Breaking News, Medicare Advantage, Regulatory
As most of the U.S. now knows, last week, UnitedHealthcare CEO Brian Thompson was shot and killed outside a hotel in Manhattan just hours before the UnitedHealth Group Investor Event. The Rowan Report provided the breaking news story with the information available at the time.
According to reports, after the shooting, a man fled the scene on foot and then rode an e-bike toward Central Park. Police were in pursuit based on early descriptions of the shooter and later on video footage of the shooting. The suspect was wearing a hoodie in the images of the shooting. Further investigation found a photo of the suspect in the lobby of a hostel where it is believed he stayed, smiling. Police followed the suspect into Central Park, where it is believed he got into a taxi and left the park.
He was later spotted at a bus station near the George Washington bridge.
Images obtained of the suspect taken inside the hotel show a man appearing to be in his 20s, wearing a dark jacket with the hood up and a black face mask resting under his chin. An image of the suspect at a nearby Starbucks puts the suspect in a dark jacket with a black mask covering his mouth. Twenty minutes after the shooting, he is spotted getting into a taxi wearing a black jacket and a white surgical mask covering his mouth and nose. Conspiracy theories about why he would change his mask started circulating quickly.
A video shows the suspect entering the bus station near the George Washington Bridge. There is no video of him exiting the station. Police believe he got on a bus.
Meanwhile, police found a backpack in Central Park they believe belonged to the suspect. The investigation also discovered a cell phone that may be linked to the shooting. Early on Monday, December 9, police returned to Central Park with dive crews to search for evidence.
Delay Deny Defend by Jay M. Feinman is a book criticizing health insurance companies. The sub-title, “Why Insurance Companies Don’t Pay Claims and What YOu can Do About It,” supports the description of the book indicating that Feinman explains how to be more custios when shopping for policies and what to do when you have a disputed claim. Feinman also includes a play for the legal reforms he feels are needed to end the abuse.
NYPD officers found writing on the three shell casings left at the scene of the shooting. Initially reported as “Deny, Defend, & Depose”, police have now clarified that the permanent marker found on the casings read “Deny, Delay, & Depose.”
Former FBI agent Brad Garrett said he believes the shooter is “trying to send a message.” Police have not commented on what they think the words might mean. Meanwhile, “Deny Defend Depose merchandise appeared overnight, followed quickly by the corrected “Deny Delay Depose.”
Around the time the dive crews arrived to search for clues in Central Park, a man entered a McDonald’s in Altoona, PA, nearly 280 miles away. An employee recognized him as the man from the photos and alerted local police. The person of interest, now identified as Luigi Nicholas Mangione, had a weapon, a mask, and writings that linked him to the shooting. The writings suggest he has issues with corporate America in general, and named several other people in the document in addition to Brian Thompson. He also had a fake ID that matches the one used to check in to the hostel in New York. Mangione has now been charged with Thompson’s murder.
Mangione was taken into custody by local police. Several members of the NYPD were later seen entering the police station in Altoona. As of Monday afternoon, Mangione was refusing to talk to police and did not have an attorney.
A DNA swab was taken and will be compared with DNA from a Starbucks cup found near the scene. Reports indicate Mangione will be extradited to New York. Mangione was denied bail and will remain in the Pennsylvania prison while he and his attorney fight the extradition to New York.
Additional information about Mangione surfaced on December 11. Mangione’s grandfather founded Lorien Health Services. The company, based in Maryland, operates six ALFs and eight nursing homes. Mangione often volunteered with the company in high school. Additionally, Mangione’s former roommate said in an interview that Mangione recently had surgery that was “heinous” and left him with multiple screws in his body.
The customary sentiments of comfort, sympathy, and condolences were pointedly absent in the days after Thompson’s death. Instead, stories of denied claims, limitations on access to care, and other frustrations with the industry flooded social media. Of the 60,000 reactions to the UnitedHealth Group post about Thompson’s death, 57,000 were laugh emojis.
Many industry professionals noted that the incident has brought up bigger issues with healthcare insurance in general. The Rowan Report previously wrote about UnitedHealthcare using AI in place of medical professionals to determine medical necessity. This resulted in a much higher than expected denial rate and more than 90% reversal of denials on appeal.
For more information on how healthcare might change after the shooting death of Brian Thompson, please see our complimentary article this week, “Will Thompson’s death change healthcare?”
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
by Kristin Rowan | Dec 12, 2024 | Advocacy, Editorial, Medicare Advantage, Regulatory
Will Thompson's death change healthcare?
On the same day that Brian Thompson died, Blue Cross Blue Shield announced a reversal of an earlier planned policy change. In November, the insurance giant announced it would change its process for anesthesia claims. The change would start in three states and begin on February 1st, 2025. The new process would limit the amount of time the company would cover anesthesia for surgeries and other procedures that called for anesthetization.
The announcements said the company would deny any claim for a surgery or procedure needing anesthesia that goes beyond the time limit they established. Reportedly, the policy would not apply to people under 22 or any maternity related care. A press release from the American Society of Anesthesiologists criticized the policy. It said BCBS “will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, regardless of how long the procedure takes.”
The new policy was confusing. Some reports indicated there would be a time limit set by the insurer and all claims over that time limit would be denied. Another interpretation said the company would initially approve the claim but would only cover the anesthesia up to a point, leaving the balance to the insured. Yet another report implied BCBS shield would still pay for the surgery, surgeon, and facility, but not for any of the anesthesia.
Though the initial announcement received backlash from anesthetists, surgeons, insured patients, and Connecticut Senator Chris Murphy, the policy was not widespread news. That is, until the shooting of Brian Thompson shed light on all health insurance company policies. Citing “misinformation” the company announced on Thursday, December 4, that it would not proceed with the policy change.
To be clear, it never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services. The proposed update to the policy was only designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines.
Anthem Blue Cross Blue Shield
The New York Times referred to the reactions to Thompson’s death as “morbid glee.” Comments on social media posts, videos, and news stories include:
“Thoughts and deductibles to the family.”
“Unfortunately my condolences are out-of-network.”
“I pay $1,300 a month for health insurance with an $8,000 deductible. When I finally reached that deductible, they denied my claims. He was making a million dollars a month.”
“Cause of death: Lead poisoning! It’s a pre-meditated condition. Payout denied.”
UnitedHealth Group Responds
UnitedHealth Group CEO Andrew Witty called the media interest in Thompson’s death “aggressive” and “frankly offensive.” In a video to UnitedHealth Group employees, Witty said, “I’m sure everybody has been disturbed by the amount of negative and in many cases citriolic media and commentary…particulary in the social media environment.” Witty noted there were few poeple who had a “bigger positive effect” on the U.S. healthcare system than Thompson.
Witty’s leaked internal video compounded the negativity towards health insurance companies. Witty decryied the media and public vitriol. He then praised Thompson’s impact on healthcare and defended the company policy.
“Our role is a critical role, and we make sure that care is safe, appropriate, and is delivered when people need it,” Witty said, “What we know to be true is the health system needs a company like UnitedHealth Group.” Witty followed his seemingly innocuous statement with, “We guard against the pressures that exist for unsafe care or for unnecessary care to be delivered in a way which makes the whole system too complex and ultimately unsustainable.” Public outcry was amplified after the video was leaked, with insured persons using this as proof that the company’s policy is to deny care.
Ron Culp, a public relations consultant at DePaul University said if the attack is related to health insurance policies it “could cause companies in the sector to make some changes,” noting that, “empathy and potential alternative solutions will play greater roles.”
Fortune predicts that the incident will cause fewer people to aim for the corner office.
While disgruntlement with corporate America is not new, The Wall Street Journal said this incident is “tinged with class rage and anti-corporate venom….[The] current outpouring is on a grander scale….”
Loss of Faith in Insurance Stock
Between close of business on Tuesday, December 3, the day before Thompson’s shooting, and Tuesday, December 10, major insurance stocks have dropped more than 6%. This includes UnitedHealth, CVS Health, and Cigna, three of the largest private health insurers in the country.
Jared Holz, a health-care equity strategist, said the stock performance appears to be in response to the rhetoric condemning health insurance business models that include denied claims in deference to higher profits.
After just one week, the public is still uncovering and pronouncing issues with the healthcare insurance industry. The long-term health insurance impact regarding company policies, denial rates, or anything else remains to be seen. The Rowan Report will never condone violence against another person. However, if Thompson’s death brings about changes in the corruption of for-profit insurance companies, we will all be the better for it.
This is an ongoing story. The Rowan Report will continue to provide updates as they become available.
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
by Kristin Rowan | Dec 4, 2024 | Admin, Breaking News
United Health CEO in NY for Investor Event
On November 26, UnitedHealth Group announced it would host its annual Investor Conference for analysts and institutional investors in New York City on Wednesday, December 4, 2024. The purpose of Investor Day, according to the press release, was to discuss long-term growth priorities and the company’s efforts to advance high-quality health care, including expanding value-based care.
This morning, Wednesday, December 4, 50-year-old Brian Thompson, CEO of UnitedHealth Group’s insurance unit, arrived in midtown Manhattan in advance of the Investor Conference.
Mr. Thompson made his way to the Hilton Hotel for the meeting at approximately 6:45 a.m. The suspect had arrived on foot about five minutes prior. Several people recall passing him as he waited for Thompson to arrive. When Thompson approached the hotel, the suspect stepped from behind a car, approaching Thompson from behind, and fired several rounds. Thompson was struck at least once in the back and once in the leg. Reports state the suspect’s gun malfunctioned after the initial shots before he fired again.
The New York Police Department called it “a brazen, targeted attack.”
I want to be clear at this time, every indication is that this was a pre-meditated, pre-planned, targeted attack. This does not appear to be a random act of violence.
Police Commissioner, New York Police Department
NYPD Officers stand near the entrance of the hotel where Brian Thompson was reportedly shot and killed in Midtown, New York City, December 4, 2024.
Shannon Stapleton / Reuters
NYPD Officers responded to a call that a man had been shot outside the hotel. Officers arrived within 2 minutes of the call. When they arrived, they found Thompson on the sidewalk with gunshot wounds.
Emergency medical services arrived and transported Thompson to Roosevelt Hospital. He was pronounced dead at 7:12 a.m. ET.
UnitedHealth Group cancelled the Investor Day event immediately after the shooting.
Lorie Burleson, Provider Advocate Account Manager at UnitedHealthCare, issued a statement on LinkedIn about the fatal shooting.
“This morning, we learned of the devastating loss of our CEO, Brian Thompson, who was tragically taken from us,” she wrote. “This is an unimaginable loss for UnitedHealth Group and for everyone who knew him.
“To my UHC family, my heart is with each of you during this incredibly difficult time. Let us come together to honor Brian’s legacy and support one another as we navigate this tragedy.”
In a statement Wednesday, UnitedHealth Group said it was “deeply saddened and shocked at the passing” of Thompson. The company called him a “highly respected colleague and friend to all who worked with him.”
According to Daily Mail, Brian Thompson’s annual salary was $10 million. However, several outlets report he exercised more than $20 million worth of stock units in early 2024. Thompson had a net worth close to $43 million, according to multiple outlets.
Brian Thompson, 20 year veteran of UnitedHealthCare, is survived by his wife Paulette Thompson and their two children. Paulette indicated that Brian had received threats related to his job but that it did not deter him from maintaining his travel schedule.
This is an ongoing breaking story and The Rowan Report will continue to follow additional news.
UnitedHealth Group, which owns Optum, which owns LHC group, is among the nation’s largest healthcare companies and provides health insurance, pharmacy benefits and healthcare services. The company is currently trying to acquire Amedisys as well, but has been held up by DOJ inquiries.
UnitedHealthcare provides coverage for more than 29 million U.S. individuals, according to their website. In 2024, United Healthcare ranked number 8 on the Fortune Global 500, and its parent company, UnitedHealth Group employs 439,000 people, generating $379.5 billion in revenue in 2024, according to Forbes.
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
by Kristin Rowan | Sep 20, 2024 | CMS, Medicare Advantage, Regulatory
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.
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.
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.”
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.
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!
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
by Tim Rowan | Dec 6, 2023 | CMS, Regulatory
by Tim Rowan, Editor Emeritus
MA Plans Continue to Exaggerate Patient Conditions for Profit
As we reported in October (More MA Plans Caught Inflating Patient Assessments, 10/11/23), insurance companies operating Medicare Advantage plans routinely pad the patient assessments that set their monthly revenue from the Medicare Trust Fund. Worse, CMS bowed to industry pressure earlier this year and agreed not to extrapolate the amount of the fraudulent payments, as it does with Home Health and Hospice overpayments (Government Lets Health Plans That Ripped Off Medicare Keep the Money, 2/22/23).
Now, we hear that the HHS OIG has totaled its 2023 audits and announced it found over $213 million in padded Medicare Advantage overpayments so far this year. In its latest semiannual report, covering fraudulent patient assessments between April and September, the OIG said it recovered $82.7 million. Total recoveries would have been higher except for that CMS ruling that prevents the agency from extrapolating payments before contract year 2018.
Will SEC Allow Cigna/Humana Marriage?
Early last month, Bloomberg broke the news that Cigna was in talks to sell its Medicare Advantage business to Health Care Service Corporation, the parent company of BCBS in Illinois, Texas, New Mexico, Montana and Oklahoma. Should that sale be approved, it would remove an obstacle to Cigna’s rumored desire to merge with Humana.
Though approval is uncertain — the SEC has squashed more than one similar attempt under both the current and former Presidents — it would create what Axios called “another Titan” that would rival UnitedHealth Group and CVS Health in size. CVS acquired Aetna in 2018. It would also combine two Pharmacy Benefit Managers, giving the new entity control of a third of the market, which would be equal to the market share owned today by CVS.
In 2017, a proposed merger between Cigna and Elevance Health, formerly Anthem, was struck down in court. A proposed merger between Humana and Aetna was also canceled in a federal court the same year. Large, powerful insurers, and the PBMs they own, have come under increased scrutiny from federal regulators.
The Biden administration has already launched a warning shot, indicating it will be scrutinizing private equity acquisitions in health care. In September, the Federal Trade Commission sued private equity firm Welsh, Carson, Anderson & Stowe after it bought up nearly all of the anesthesiology practices in Texas and then, with competition removed, began to jack up prices. FTC chair Lina Khan made it clear the suit was intended to send a message to all consolidation attempts that might harm patients.
United to Change Prior Authorization Policy
According to a November 27 policy update from UnitedHealthcare (UHC), the payer is updating its Home Health prior authorization and concurrent review process for services that are delegated to Home & Community Care, the payer’s home care division.
The updated policy, which are set to take effect January 1, will affect United’s Medicare Advantage and Dual Special Needs plans in 37 states, a UnitedHealthcare news release stated.
In Summary
- Start of care visits still do not require prior authorization.
- Providers must notify Home & Community Care of the initiation of home care services. UHC encourages providing notice within five days after the start of a care visit to help avoid potential payment delays.
- Before the 30th day, providers must request prior authorization for days 30 to 60, by discipline, and provide documentation to Home & Community Care.
- For each subsequent 60-day period, providers must request prior authorization, by discipline, and provide documentation to Home & Community Care during the 56- to 60-day recertification window.
UHC says it will respond to questions about the prior authorization approval process at HHinfo@optum.com
In related news, in its annual investor conference call, the company projected “revenues of $400 billion to $403 billion, net earnings of $26.20 to $26.70 per share and adjusted net earnings of $27.50 to $28.00 per share” for 2024. Cash flows from operations are expected to range from $30 billion to $31 billion.
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
©2023 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
