As many as 50% of some appeals prompt health insurers to reverse their decisions, according to a report from the Government Accountability Office. Insurers frequently deny claims due to billing errors, missing information or judgments on whether the care or service is appropriate, the investigative arm of Congress said in a report released Wednesday. These denials can be based on mistakes like an incorrect code on a claim submitted by a doctor's office, said Nancy Davenport-Ennis, CEO of Patient Advocate Foundation, a not-for-profit that helps people appeal claims denials. "You've got a lot of people in America who are ultimately paying a bill they don't owe because they don't realize it's an incorrect code," said Davenport-Ennis, who wasn't involved in the government study. The GAO studied health insurer rejection rates at the request of Congress, which wanted a better picture of the issue as part of the health care overhaul it passed last year.
Blue Shield of California's decision to cancel a big rate hike for nearly 200,000 people followed mounting pressure from the public and political leaders. But an unforeseen factor may have made the retreat easier for the company to accept: It's paying out less for medical claims than it had anticipated. And it's not just Blue Shield. Major insurers including WellPoint Inc. and Aetna Inc. also say that medical spending has been lower than projected recently, saving the companies millions of dollars in payouts. Company officials say that is largely because people are going to the doctor less. Many have switched to cheaper policies that require them to shoulder a greater share of the cost—and that has them thinking twice about discretionary visits. That trend could bolster the arguments of some healthcare experts who contend that Americans overuse medical services because they generally don't have to pay much for them, and that the only way to bring rising healthcare costs under control is to shift more of the expense to patients.
Tufts Medical Center nurses are ratcheting up their heated contract dispute with the Boston teaching hospital. Nurses planned to follow a flash mob at South Shore Plaza with picketing from 4 to 6 p.m. Wednesday outside the hospital in Chinatown. Nurses say that recent cuts in staff and other changes in how they deliver care mean that nurses are caring for more patients at one time on nearly every unit. These changes, they say, have transformed the hospital from one of the best staffed in Boston to the worst. For example, according to figures derived from a public database posted by the Massachusetts Hospital Association, each Tufts nurse in pediatrics cares for at least 1.4 critical care patients, compared with 1.03 patients at Massachusetts General Hospital, the nurses union says. To compensate for chronic understaffing, Tufts is forcing nurses to work overtime and to "float" from one area of the hospital to another where they might not be competent, according to the Massachusetts Nurses Association. The group represents 1,200 nurses at the hospital and is trying to prohibit these practices in a new contract.
In November, the prestigious Cleveland Clinic hailed a "scar-less" weight-loss surgery as one of the top 10 medical innovations expected this year. Developed by a company aptly called Satiety Inc., the procedure shrinks the stomach by using a stapler inserted through the mouth, rather than by cutting open a person's belly. But when the results of a clinical trial came in, the procedure resulted in the shedding of far fewer pounds for patients than the company had hoped. Venture capitalists who had invested $86 million in Satiety over a decade shut the company down. The failure of the procedure, called transoral gastroplasty, pushes back the availability of any incision-less procedure to millions of obese Americans for several years, a disappointment to companies trying to find the next best thing to major surgery. The setback also further restricts options for those who are overweight, because it is occurring on top of federal rejections of a new generation of diet pills.
Several workers at University of Iowa Hospitals and Clinics have filed complaints alleging their supervisor hid a baby monitor to listen in on their conversations. Workers union representative John Stellmach, president of AFSCME Local 12, said two secretaries and three clerks in the Department of Urology discovered a baby monitor hidden in their office Monday morning. Stellmach said the workers thought the monitor, which they said was plugged in and turned on, had been hidden with the knowledge of their direct supervisor, a HR representative and an administrative assistant. Stellmach said the workers, whom he declined to identify, think the monitor was put in place to determine if they were talking too much on the job. "Instead of just being rational and coming and talking to them, apparently the manager had talked with the HR person and they decided to put a baby monitor so they could hear what was going on," Stellmach said. "But what they failed to realize is that's very illegal."
A New York City hospital executive who has been accused of bribery in a federal corruption investigation has been ousted by his board and replaced by his second in command, the board announced. The executive, David P. Rosen, 63, CEO of MediSys Health Network, was among eight people, including two state legislators, charged last week by federal authorities in Manhattan with participating in bribery schemes. In his case, prosecutors said the scheme revolved around getting favorable treatment from state officials for his healthcare organization. In a statement, the board of MediSys—the nonprofit sponsor of four hospitals, three nursing homes and several neighborhood health centers in Queens and Brooklyn—said it voted to appoint Rosen's second in command, Bruce J. Flanz, to take over Rosen's job as CEO. Flanz, 59, had been the COO at MediSys.