A global shortage of medical isotopes is expected to get worse in two weeks as supplies run down after nuclear reactor closings. The Petten nuclear reactor in the Netherlands closed for scheduled maintenance. Together with a Canadian reactor in Chalk River, Ontario, that was shut down in May because of a leak, the idled reactors account for two-thirds of the world's supply of molybdenum-99. In response to the shutdown of the Canadian reactor, the Society of Nuclear Medicine reported in June that 91% of 375 surveyed members had been affected, with 60% of doctors postponing procedures and 31% canceling some.
The pharmaceutical industry has remained relatively unscathed so far in Washington?s effort to overhaul the nation's healthcare system. But despite the much publicized 10-year, $80 billion cost-saving promise the drug industry made to President Obama and the chairman of the Senate Finance Committee, some House leaders do not think the drug makers have given enough. President Obama seemed to agree during a nationally televised news conference focused on healthcare reform. He praised the pharmaceutical industry for making a hard commitment, but added "we might be able to get $100 billion out of them, or more."
An initiative by the Maryland Hospital Association will provide $15.5 million over the next five years to 17 nursing schools across the state to help increase the number of students in the programs and alleviate a predicted shortage of nurses. The plan will be financed through donations from healthcare providers, insurers, and individuals.
The Lewin Group is a consulting firm whose research has been widely cited by opponents of a public insurance option in the healthcare reform debate. Lewin produced one of the most widely cited statistics of the healthcare debate: Under a particular version of a public option, the number of people with private, employer-sponsored coverage would decline by more than 100 million.
The legal fisticuffs between Bayonne (NJ) Hospital Center and Horizon Blue Cross Blue Shield of New Jersey went to the second round today when for-profit BHC filed a federal lawsuit claiming that the Garden State's largest health insurer is using "egregious and unethical business practices" in a campaign to scare emergency patients away from the out-of-network hospital.
"We want them to stop intimidating our patients," says Daniel Kane, CEO at BHC. He adds the intimidation includes harassing telephone calls, egregious and arbitrary coverage and claims denials, and using couriers to instruct patients to leave in mid-treatment.
"When patients come to the ED and require hospitalization, as soon as Horizon becomes aware of the admission, they send couriers to the hospital telling the patient that they have determined that the patient is stable and the patient needs to be transferred to an in-network hospital, or there is no need for them to go to the hospital and they should go home, or that the patient is going to incur all these financial obligations if they continue to be in the hospital," Kane says. "It's not uncommon for them to not even speak with the patients' physicians. We've had couriers trying to deliver letters to patients in the ICU telling them that they are stable."
BHC's suit, filed in U.S. District Court in Newark, comes two months after Horizon filed its own lawsuit accusing BHC of fraud and alleging that the 278-bed, acute-care hospital had begun charging "exorbitant" fees for emergency care after it terminated its network agreement with Horizon on Feb. 7. Since leaving the network, Horizon claims that BHC has more than doubled its aggregate per-day charges, from $13,000 in 2008 to $29,000 in 2009. In addition, Horizon says BHC isn't collecting out-of-network fees owed by Horizon members, thereby over-billing Horizon.
Horizon today denied the allegations in the new Bayonne suit. "Horizon BCBSNJ has not taken any improper actions in dealing with Bayonne or in communicating with our members regarding the hospital," according to the insurer's statement. "The root cause of this dispute is money—Bayonne wants to increase its revenues on the backs of Horizon BCBSNJ members. In addition to recent labor contract disputes and leaving the hospital networks of most major health insurers, Bayonne has been charging exorbitant fees and misrepresenting its fees for those services."
Kane says Horizon's "artificially" low reimbursements are threatening the viability of the only emergency care option in Bayonne, which emerged from bankruptcy in February 2008. He says Horizon hopes to become a for-profit, public company and it is low-balling reimbursements to New Jersey hospitals–half of which are already losing money–to pad its bottom line, making it more attractive to investors.
"Ultimately, Horizon's attacks are not on hospitals, but on the communities they serve," Kane says. "Their relentless assault on patients, doctors and hospitals for the sake of their own profits is a prime reason that New Jersey ranks last in the country for emergency rooms per capita. Neither this hospital nor the people of Bayonne will be bullied by Horizon. BHC filed this case to fight for patients' rights for quality healthcare and hopes that other hospitals will do the same in their conflicts with Horizon."
Joining the BHC suit as a plaintiff is John Godinsky, MD, a Horizon policyholder, who sought emergency treatment at BHC for an irregular heartbeat. While in the hospital, Horizon allegedly told Godinsky and BHC that his stay was denied coverage because Horizon erroneously claimed it was a pre-existing condition. Against physicians' advice, Godinsky left the hospital fearing he'd be saddled with a large bill.
The Obama administration has made it clear that cracking down on healthcare fraud and abuse is a priority, and the latest version of the America's Affordable Health Choices Act of 2009 includes language that will further increase funding to ensure that government money is not lining the pockets of fraudsters.
That increase in enforcement will be essential if more people are covered under a government system, according to Robert A. Wade, Esq., partner at Baker & Daniels, LLP, in South Bend, IN.
Wade says he would expect an uptick in fraud and abuse cases if the reform passes simply because there will be more people covered and more money being funneled through the system. If more people are covered under a federal program, more claims would fall under the False Claims Act and Stark Law.
Some opponents of a government-run healthcare system cite the high level of fraud and abuse in the Medicare and Medicaid programs as a sign that the government is incapable of running an efficient system. However, experts argue that government programs are no more susceptible to fraud and abuse than private insurers.
"If a physician or [healthcare] entity has the capacity to commit fraud, they will do it regardless of which bucket they are taking from," said Wade.
A report from the George Washington University Medical Center in Washington D.C. titled Health Insurance Fraud: An Overview concurs.
"What is absolutely clear from virtually every reliable source on the subject is that health care fraud is a systemic problem affecting public and private insurers alike, in the individual market, the employer-sponsored group market, and public programs," the report stated.
Authors of the report, Sara Rosenbaum, Nancy Lopez, and Scott Stifler, said the reason the public is more aware of Medicare and Medicaid fraud is because the government is required to tell taxpayers where their money is going. Most recently, Office of Inspector General Chief Counsel Lewis Morris told Congress that the United States lost $60 million to healthcare fraud in 2008, which was 3% of the government's budget.
Private insurance companies are not obligated to release such numbers so fraud involving those companies stay out of the headlines. The amount of money private insurers lost to fraud is reported to the board of trustees, not the public.
"[Healthcare fraud enforcement] has been a theme we have seen in the president's budget and Medicare rule making," says Ed Dougherty, senior vice president of B&D Consulting.. "I would say regardless of what happens in healthcare reform, there will be increased focus in all sites of service."
Those who use the Internet as an ad medium outnumber those who use TV or radio, according to a LinkedIn Research Network/Harris poll. But as advertising shifts online, consumers don't necessarily welcome it, the poll found.
Hospitals will see that RAC technical denials can have a large impact on their bottom line, said Levitt. And many times they are completely avoidable.
Technical denials can result when a RAC denies a claim for insufficient documentation—for instance, if the RAC never receives requested medical records from a provider.
CMS considers technical denials to be payment errors, because it has paid for care that cannot be substantiated, Levitt said.
"Documentation to support a service is required to meet medical necessity, and technical denials are similar to that," said Levitt. "If you don’t have the documentation written down and available, it doesn't support the care that has been done and you’ll get a denial."
Pay attention to the remark codes on your remittance advice to know whether your denial was a technical one, Levitt advised. N102 indicates requested medical records were not received (or not received on time), whereas N432 is for the adjustment based on a Recovery Audit.
If you do find an N102, you may be able to speak to your RAC during the discussion period about turning in additional documentation in certain circumstances. Some RACs have indicated during outreach sessions that they will accept missing documentation after the initial submission deadline. RACs may choose to accept relevant information that providers originally neglected to file.
While providers should do their best to avoid technical denials, Levitt knows firsthand that any hospital can slip up. At her former hospital, Levitt discovered they submitted incomplete documentation to a RAC after a copy service didn't realize the hospital charted on both sides of its paper medical records. The service copied the records as if there was only information on one side.
"When I would get 150 pages of a chart, I’d assume everything was there," said Levitt. But when she looked more closely she discovered the error. "I can’t tell you the amount of work that created, plus the costs added up. And it can delay your appeals."
But whenever possible, limit the possibility of a technical denial by meticulously tracking all deadlines for record submissions and by being careful and thorough when submitting records to ensure documentation is complete. Few hospitals can afford unnecessary loss.
During the current recession, marketers have learned that interactive marketing is more effective and advertising less effective per dollar spent, according to a five-year interactive marketing forecast by Forrester Research. Six out of ten marketers surveyed said they agreed with the statement "We will increase budget for interactive by shifting money away from traditional marketing." Just 7% said they have no plans to increase their marketing budget.
Hispanic consumers are more optimistic about their financial future than non-Latinos, but the recession is sharply eroding Hispanics' traditional brand loyalty and fondness for advertising, according to a report. Just 31% surveyed said "advertisements help me decide what to buy," a 16% drop from the number of respondents who agreed with that statement a year ago, according to the report from Forrester Research.
