The Volunteer State is also being asked to provide the paperwork or refund another $370 million for improperly documented behavioral health services.
Federal auditors this week recommended that Tennessee's Medicaid program refund to the federal government $397 million in uncompensated care overpayments, and refund or provide documentation justifying another $370 million paid for behavioral health services.
TennCare Director Stephen Smith said he "strongly objects" to the findings put forward by the Department of Health and Human Services' Office of the Inspector General, calling the report "inappropriate and unreasonable."
OIG auditors examined Tennessee's $2 billion certified public expenditures for uncompensated care at public hospitals for TennCare enrollees from 2009-14. For state fiscal years 2010-13, the report found that Tennessee each year claimed the same amount -- $373.8 million – which auditors said shows that the state didn't calculate specific estimates of the CPEs for each of those years, as required.
The audit said that Tennessee did not comply with federal requirements for claiming CPEs for public hospital unreimbursed costs.
"Of the $2 billion in CPEs that Tennessee claimed during our audit period, $909.4 million was allowable and supported," OIG said. "However, the remaining $1.1 billion ($767.5 million federal share) exceeded the amount allowed. This amount included $482.1 million ($337.5 million federal share) of excess CPEs that Tennessee claimed but did not return after calculating actual CPEs."
OIG said Tennessee calculated another $609.4 million ($430 million federal share) above the allowable amount, which included $522.3 million ($370.1 million federal) of unsupported net costs of caring for uninsured behavioral health patients, $53.6 million ($37.9 million federal) of unallowable net costs of caring for TennCare behavioral health patients ages 21-64, and $33.5 million ($22 million federal) of overstated costs because of faulty math.
OIG recommended that Tennessee: Refund $397.4 million in overpayments for CPEs that exceeded the allowable amount; provide documentation or a refund for $370 million in improperly documented money for behavioral healthcare; and establish procedures to ensure compliance with federal requirements.
Tennessee 'Strongly Obects'
In a response included with the audit, TennCare Director Smith said the state "strongly objects" to OIG's methodology that relies on "an audit process that dates back 12 years (and) is fundamentally flawed and places the state in the impossible position of having to refute findings without key documents or historical knowledge of key agreements – both formal and informal - from individuals responsible for decisions and actions from both the state agency and the federal government."
In addition, Smith said TennCare has "provided completely acceptable and auditable documentation" that adheres to federal guidelines for the $370 million in claims for behavioral health services.
"If OIG applied this clear federal guidance and the language of the demonstration as intended by CMS, the total findings would immediately be reduced by more than half," Smith said.
One-third of rural older adults had at least one virtual visit in 2020, compared with nearly half of seniors in suburban and urban areas.
About 16% of doctor's visits by seniors were done remotely, either by phone or online over the past two years, but the rural elderly appear to be behind the curve, according to a new analysis of telehealth visits billed to Medicare.
The total number of virtual visits – the kind focused on evaluating a medical condition or symptom and making a plan for managing it – didn't rise from 2019 to 2020, the analysis shows, despite concerns that widespread access to telehealth because of the COVID-19 pandemic would lead to an increase in the total number of such visits.
However, the data showed that one-third of rural older adults had at least one virtual visit in 2020, compared with nearly half of seniors in suburban and urban areas. Researchers from the University of Michigan say the data suggest that policymakers need to find a way to improve telehealth access among the rural elderly.
"Before the pandemic, Medicare's telehealth provisions focused mainly on rural areas, to increase access to specialists through virtual visits originating from their local physician's office, but uptake was low," said study lead author Chad Ellimoottil, MD, an assistant professor of urology at Michigan Medicine.
"In the pandemic era, coverage for telehealth has led to a steady percentage of evaluation and management appointments being conducted virtually. For the most part, these visits have been a substitute for in-person care," he said.
At the height of the first pandemic surge in April 2020, about half of Medicare participants' appointments to evaluate a medical concern and get a treatment recommendation took place online or over the phone. That declined to between 13.5% and 18.3% for the rest of 2020, the data showed.
However, the overall number of evaluation and management appointments didn't rise past the median number of such visits in 2019. In fact, seniors had fewer such appointments for all of 2020, which the researchers said suggests that telehealth visits are being used as a substitute for in-person care, not an add-on, and that some adults are avoiding care.
NavigateNOW is being touted as "a simpler, more convenient experience at approximately 15% less premium cost than traditional benefit plans."
UnitedHealthcare is collaborating with Optum to roll out a "virtual-first health plan" in nine markets across the nation that the payer says will provide beneficiaries with greater access to remote and in-person customized care.
Minnetonka, Minnesota-based United is touting NavigateNOW as "a simpler, more convenient experience at approximately 15% less premium cost than traditional benefit plans."
Enrollees in the new plan will have access to 24/7 care from Optum providers for primary, urgent and behavioral healthcare services, backed by UnitedHealthcare's national network of providers.
They will pay $0 for virtual and in-person primary care and behavioral health visits, virtual urgent care and most generic medications, with unlimited chat, online scheduling and on-demand, same-day appointments.
They will also have access to a wearable device well-being program that incentivizes them to earn more than $1,000 per year by meeting daily activity targets, such as for walking, cycling, swimming and strength training.
Rhonda Randall, MD, CMO, UnitedHealthcare Employer & Individual, said the collaboration with Optum provides "a more integrated and coordinated healthcare system that uses technology and personal support to help encourage whole-person health, which may help prevent and detect disease before it starts."
"UnitedHealthcare and Optum will continue working together to modernize our approach to health benefits and care delivery, using technology and data to help make it more convenient for our members to access various types of medical care to support their physical and mental well-being," Randall said
NavigateNOW is offered to employers in Little Rock, Ark.; Fort Myers, Fla.; Pittsburgh; Springfield, Mass.; Minneapolis/St. Paul, Minn.; Richmond, Va.; Indianapolis; Dallas; and Houston.
The program matches enrollees' health profiles and existing medical conditions with personalized care teams led by a dedicated primary care provider who will coordinate virtual and in-person visits with Optum providers and other providers as needed.
For instance, during virtual primary care appointments, Optum providers will have the ability to connect the UnitedHealthcare member with behavioral health services within the virtual platform as needed to facilitate virtual or in-person behavioral health appointments, including therapy, medication management and additional care coordination with other health services.
Kristi Henderson, CEO, Optum Virtual Care, says the new product is a response to "patients (who) want more options for getting care that is convenient for them and their lives."
"Our work with UnitedHealthcare is designed to help make it simpler for patients and members to interact with their care providers by bringing together our digital resources and national clinical footprint to provide a more seamless, connected experience," she said.
The care-at-home platform specializes in remote patient monitoring and telehealth.
Best Buy announced Tuesday that it will buy Current Health, a Scotland-based patient monitoring and telehealth platform, further expanding the retailer's stake in the healthcare sector.
Terms of the pending sale were not disclosed.
Best Buy says that the increasing reliance upon the consumer-friendly technology that the Minnesota-based retailer sells will play a critical role in the expansion of telehealth.
"The future of consumer technology is directly connected to the future of healthcare," Deborah Di Sanzo, president of Best Buy Health, said in a media release.
"We have the distinct expertise in helping customers make technology work for them directly in their homes and by combining Current Health's remote care management platform with our existing health products and services, we can create a holistic care ecosystem that shows up for someone across all of their healthcare needs," Di Sanzo said.
The deal marks another incursion into the healthcare space by Best Buy, which in August 2018 acquired seniors-focused emergency response provider GreatCall in an $800 million deal, and in 2019 acquired Critical Signals Technologies, a Michigan-based remote monitoring service.
Leveraging clinical algorithms that can be tailored to the individual patient, Current Health claims its technology can identify when a patient needs clinical attention, allowing providers to manage care remotely or coordinate in-home care using its integrated service partners.
"Best Buy has unparalleled physical reach, world-class supply chain logistics, and trusted support services–allowing us to provide a high-touch consumer experience, at scale," said Current Health CEO Christopher McCann.
Hospital and nursing home job losses were partially offset by gains in the ambulatory care sector.
The healthcare sector reported 18,000 job losses in September, according to a disappointing employment report issued Friday by the Bureau of Labor Statistics.
Nursing homes accounted for 38,000 job losses, followed by hospitals with 8,000 job losses. Those losses were partially offset by 28,000 job gains in ambulatory care for the month, BLS reported.
The BLS report accounts for employment in mid-September and can be subject to considerable revision.
The healthcare sector has shed 524,000 jobs since the start of the pandemic in February 2020, with hospitals accounting for 93,300 job losses, and nursing homes accounting for 425,700 job losses. Ambulatory services lost 4,700 jobs in that span.
There were 15.9 million people attached to the healthcare sector workforce in September, BLS said.
The larger economy created 194,000 new jobs in September, down from the 235,000 jobs created in August, as the unemployment rate ticked down 0.4 percentage point to 4.8% for the month and the number of unemployed people fell to 7.7 million, BLS reported.
Nonfarm employment has grown by 17.4 million jobs since a April 2020 but is down by 5 million, or 3.3%, from its pre-pandemic level in February 2020.
The bureau also noted that 13.2% of employees teleworked in September because of the coronavirus pandemic, little changed from August.
Mortality was nearly 200 deaths per 100,000 prisoners over a one-year span, versus 80 deaths per 100,000 in the U.S. population.
Inmates in the nation's prisons were more than three times as likely to contract COVID-19 and more than twice as likely to die from it during the first year of the pandemic, when compared with the overall U.S. population, a new research letter shows.
Writing this week in JAMA, University of California at Los Angeles researchers looked at COVID-19 cases and deaths among U.S. federal and state prisoners for 52 weeks from April 5, 2020, to April 3, 2021 and compared these rates with the overall U.S. population.
The findings showed that 394,066 COVID cases and 2,555 deaths had been documented in U.S. prisons in that 52-week span.
The cumulative incidence rate per 100,000 prisoners for the period was 30,780 cases, compared with 9,350 cases for the U.S. population.
The standardized mortality rate per 100,000 prisoners over the same one-year span was 199.6 prisoner deaths versus nearly 80 deaths for the U.S. population.
In December 2020, at the peak of the epidemic inside prisons, prisoners were five times as likely to contract COVID-19, and nearly three times as likely to die from it, the research found.
"While COVID-19 incidence and mortality rates peaked in late 2020 and early 2021 and have since declined, the cumulative toll of COVID-19 has been several times greater among the prison population than the overall US population," the study said.
The funding provides reimbursements for telecommunications services, information services, and connected devices needed for telehealth during the pandemic.
The Federal Communications Commission has approved another 72 applications for funding commitments totaling $41.1 million for its second round of funding for its COVID-19 Telehealth Program.
The funding provides hospitals and other healthcare venues reimbursements for telecommunications services, information services, and connected devices needed for telehealth during the COVID-19 pandemic.
The new money follows the nearly $42 million awarded in August to healthcare providers in each state, territory, and the District of Columbia.
"The FCC has now approved a total of over $83 million in funding applications for Round 2 of its COVID-19 Telehealth Program," said Acting Chairwoman Jessica Rosenworcel. "From community health clinics in urban city centers to hospitals serving rural communities across the country, these funds will support efforts to help our neighbors remain in the care of their doctors, nurses, physician assistants and trusted healthcare providers during this pandemic."
Round 2 is a $250 million federal initiative that builds on the $200 million program established as part of the CARES Act. As outlined in the Round 2 Report, when $150 million has been committed, the FCC's Wireline Competition Bureau will give all remaining applicants a chance to supplement their applications.
For a detailed list of providers who received Round 2 funds, click here.
A new J.D. Power survey suggests that service limitations, access hurdles, and quality-of-care issues dampen consumer enthusiasm.
The telehealth sector has seen broad expansion during the first 18 months of the coronavirus public health emergency, but that surge has been accompanied by growing pains, one survey shows.
J.D. Power's newly released 2021 U.S. Telehealth Satisfaction Study identified service limitations, access hurdles, and quality-of-care issues have dampened consumer enthusiasm for telehealth.
The survey showed that while 36% of the more than 4,600 respondents said they'd used telehealth in the past year – up from 9% in 2020 and 7% in 2010 -- overall satisfaction with both direct-to-consumer and payer-sponsored telehealth services decline in 2021 from 2020.
The top annoyances among consumers included limited services (24%); lack of awareness of costs (15%); confusing technology requirements (15%); and lack of information about providers (15%).
"It's impossible to ignore that 36% of the healthcare customers we measure within our research have used telehealth services this year—which is four times higher than a year ago," said James Beem, managing director of global healthcare intelligence at the Troy, Michigan-based consumer data analytics firm.
"However, digging deeper into the research, it's clear that customer satisfaction has declined during the same period, with many users citing limited access to the services they need and inconsistencies in the care they receive," he said. "As the industry grows, it is critical to address these challenges."
Among the findings in the new survey:
Telehealth adoption spikes across all generations in 2021: Overall, 36% of patients have accessed telehealth services during the past year, up from just 9% in 2020 and 7% in 2019. Usage is consistent across all generational groups, with the highest usage among members of Generation Y and Pre-Boomers.
Convenience, speed and safety drive utilization: The top reasons for telehealth utilization are convenience (57%); ability to receive care quickly (47%); and safety (36%).
Patient satisfaction declines as pain points emerge: Overall satisfaction with both direct-to-consumer and payer-sponsored telehealth services decline in 2021 from 2020. The most frequently cited barriers encountered by patients are limited services (24%); lack of awareness of costs (15%); confusing technology requirements (15%); and lack of information about providers (15%).
Uneven care for higher-risk patients: Overall satisfaction is 85 points lower (on a 1,000-point scale) among patients with the lowest self-reported health status than among patients who consider themselves to be in excellent health. Similarly, healthier patients are more likely than less healthy patients to understand the information provided during the visit; say they receive clear explanations; perceive that their visits are highly personalized; and obtain high-quality diagnoses.
Telehealth Providers Ranked
Among the major providers of telehealth, Teladoc was ranked highest in customer satisfaction among direct-to-consumer brands, with a score of 874. MDLIVE (868) ranks second and MyTelemedicine (859) ranks third.
UnitedHealthcare ranks highest among payers of health plan-provided telehealth services with a score of 868. Humana (865) and Kaiser Foundation Health Plan (865) rank second in a tie.
The survey, now in its third year, measures customer service, consultation, enrollment, and billing and payment, and is based on responses of 4,676 consumers in July and June who used a telehealth service within the past year.
The new plan -- Align powered by Sanford Health Plan – covers Medicare Advantage enrollees in South Dakota, North Dakota and western Minnesota.
Sanford Health Plan announced Monday that it has launched a Medicare Advantage health insurance plan for beneficiaries in three states.
Enrollment runs from October 15 – December 7, 2021, and coverage starts on January 1, 2022.
Described by the Sioux Falls, South Dakota-based payer as an "all-in-one bundled health insurance option,Align powered by Sanford Health combines Medicare Part A and Part B "with more tailored, comprehensive health benefits and prescription drug coverage."
"What makes our offering stand out from other options on the market is that seniors will be able to join a Medicare Advantage plan that is backed by a network of Sanford Health providers working together to deliver personalized care," said John Snyder, president of Sanford Health Plan.
"As a health plan that is part of Sanford Health's comprehensive system of care, we provide members with innovative services and supplemental benefits to improve health and manage chronic conditions," Snyder said.
The plan -- offered in North Dakota, South Dakota, and western Minnesota – is touted by Sanford as meeting the comprehensive needs of beneficiaries while remaining affordable and, in some cases, offer $0 premiums and copays.
The plan will include personal health "navigators" who can help members schedule appointments, set up transportation, arrange for a trusted partner to attend appointments alongside members, and coordinate follow-up care.
Other benefits include: PPO plans; In-network and out-of-network benefits; access to an integrated network of local Sanford Health providers; visitor and travel benefits; virtual care; pharmacy; dental; vision; hearing; OTC allowance; gym memberships; and meals.
The rule lays out how payers and providers will resolve billing disputes under the No Surprises Act.
The Centers for Medicare & Medicaid Services on Thursday released its interim final rule on surprise medical billing, and payers and providers gave the long-awaited provisions decidedly different receptions.
In short: Hospitals Hate it. Payers are delighted.
The key point of contention in the final rule – which take effect on January 1, 2022 -- is the independent dispute resolution process for some out-of-network billing, which presumes that the payer's out-of-network reimbursement is the starting point for negotiations.
The disputing stakeholders will have a 30-day "open negotiation" to determine a payment. If they're still at loggerheads, they can open the dispute resolution process, which is conducted by a jointly select a "certified independent dispute resolution entity" that's been authorized by CMS.
CMS says the dispute resolution process – mandated by the No Surprises Act -- creates a process "that will take patients out of the middle of payment disputes, provides a transparent process to settle out-of-network rates between providers and payers, and outlines requirements for healthcare cost estimates for uninsured (or self-pay) individuals."
CMS Administrator Chiquita Brooks-LaSure said the final rule requires "healthcare providers and healthcare facilities to provide uninsured patients with clear, understandable estimates of the charges they can expect for their scheduled healthcare services."
Stacey Hughes, executive vice president of the American Hospital Association, called the rule "a windfall for insurers."
"The rule unfairly favors insurers to the detriment of hospitals and physicians who actually care for patients," Hughes said in prepared remarks. "These consumer protections need to be implemented in the right way, and this misses the mark."
Federation of American Hospitals President and CEO Chip Kahn called the final rule "a total miscue" that goes against the intent of Congress when it passed the law.
"It inserts a government standard pricing scheme arbitrarily favoring insurers," Kahn said. "For two years, hospitals and other stakeholders stood shoulder to shoulder with lawmakers to develop legislation that would protect patients from surprise medical bills and last December, Congress passed a bill with a fair and balanced payment dispute resolution process. This regulation discards all of that hard work, misreads Congressional intent, and essentially puts a thumb on the scale benefiting insurers against providers and will over time reduce patient access."
Matt Eyles, president and CEO of America's Health Insurance Plans, said the final rule "signals a strong commitment to consumer affordability and lower healthcare spending through an independent dispute resolution process that should encourage more providers to join health plan networks."
"We are particularly encouraged to see the rules conform to the intent of the No Surprises Act and direct that arbitration awards must begin with a presumption that the appropriate out-of-network reimbursement is the qualified payment amount," Eyles said.
"This is the right approach to encourage hospitals, health care providers, and health insurance providers to work together and negotiate in good faith. It will also ensure that arbitration does not result in unnecessary premium increases for businesses and hardworking American families."
Justine Handelman, senior vice president of policy and representation for the Blue Cross Blue Shield Association, called the IFR "a win for patients and a step toward building a more affordable and equitable healthcare system.
"We commend the administration for protecting patients and using an independent resolution process that focuses on affordability. This was Congress’ intent, and we will continue to work with Congress and the administration to create a more transparent, affordable and equitable health system," Handelman said.
Docs hate it too
The IFR is also getting panned by the American Medical Association, which called it "a surprise gift to the insurance industry."
Like the hospital associations, the AMA says the IFR "ignores congressional intent and flies in the face of the Biden Administration's stated concerns about consolidation in the health care marketplace."
"It disregards the insurance industry's role in creating the problem of surprise billing at the expense of independent physician practices whose ability to negotiate provider network contracts continues to erode,” said AMA President Gerald A. Harmon, M.D.
"Congress appreciated the negative consequences of national price setting for healthcare services and spent considerable time and effort developing a robust independent dispute resolution process to maintain market balance and preserve access to care, which the Administration apparently ignored,” Harmon said.
"It also is apparent that the Administration failed to appreciate the importance of creating an accessible and impartial dispute resolution processes as a backstop against even greater insurer abuses," he said.
Thursday's final rule is the third in a series of implementations of the No Surprises Act put forward by the Departments of Health and Human Services, Labor, Treasury and the Office of Personnel Managment.
