The Health Shopper

The Wisconsin Association of Health Plans announced that many of the state's carriers will provide plan members with tools to estimate out-of-pocket costs before seeking treatment. Anthem Blue Cross Blue Shield, Humana, and UnitedHealthCare Wisconsin are among the 17 participating insurance carriers that will be rolling out this program by September 1. Association officials note that providing these estimates is becoming increasingly important as more people move to high deductible plans.

Consumerist has a useful item for health consumers about how to appeal denied insurance claims. After getting the exact reason for the denial, the industry expert suggests:

• Asking for a "1 time ‘pay and educate' exception," where the insurance company will pay for the claim on this one occasion.
• If the insurer says that the policy has an exclusion that prevents it from covering the expense, ask for the company to clearly point out the policy exclusion in writing.
• Work with your doctor and the office staff to collect evidence that you believe supports your position and present this evidence to your insurance company.

As the piece notes, following these steps and others listed in the piece can help consumers make sure they receive a fair hearing when interacting with their insurance companies.

California's Department of Managed Health Care has proposed rules that would prevent physicians from billing patients for additional charges beyond the costs of in-network care covered by insurance. Typically, billing disputes arise when patients go to in-network hospitals or emergency rooms for treatment but are inadvertently treated by an out-of-network physician who has not accepted the HMO's negotiated price. Physicians, in a process called balanced billing, can then directly bill the patient for the difference between the two fees.

According to the Los Angeles Times the department has been trying to work out a compromise between physician groups and HMOs on the issue for two years, but ultimately has proposed the rules to protect consumers from increased out-of-pocket spending. Under the proposal, consumers would not have to pay for any difference in billing. Instead, physician groups and insurance companies would have to resolve the disputes on their own.

Several insurance companies are placing restrictions on CT scans for policyholders and in many instances are requiring plan members to receive pre-authorizations before undergoing the scans. Insurers are following the lead of Medicare, which announced and then retracted restrictions on CT scans, due to limited clinical evidence supporting their use. At the time of Medicare's reversal, the New York Times noted that "The proposal to curtail payments met with fierce resistance from doctors who perform these scans and companies that make the equipment" who "strongly defended the scans." Medicare alone spent as much as $50 million on the scans in 2006, and in the past six years, their use has been increasing 13 percent annually.

Evidence in favor of their widespread use remains weak, however. A few months ago, Consumer Reports listed CT Scans as one of the ten most overused medical treatments in the United States. A month later, a group of researchers writing in the New England Journal of Medicine found that approximately one third of CT scans were unnecessary, exposing "perhaps 20 million adults and, crucially, more than 1 million children per year in the United States" to a radiation dose roughly equal to 85 to 200 chest x-rays.

The good news is that requiring pre-authorizations seems to work. According to a study by the Robert Wood Johnson Foundation's Center for Health System Change, a health plan that required pre-authorization of the scans successfully reduced the growth rate on scans while denying only 1.5 percent of scan requests. As one insurer said, "We're not saying ‘No' that much, but because people have to now justify what difference the test is going to make, they aren't requesting it as much."

Blue Cross Blue Shield of South Carolina has begun to seek partnerships with international hospitals in order to encourage policyholders to seek more cost-effective treatments abroad. The insurer has already established agreements with seven overseas hospitals and hopes to add another five within the year. Blue Cross officials are hoping that encouraging medical tourism for planned medical care will help control costs, since, as Business Week notes, "An insurance company could waive all deductibles and co-pays, offer to cover travel costs for the patient and family members, even throw in a cash incentive, and still save tens of thousands of dollars" without sacrificing quality.

Aetna has announced that it will be unveiling a set of online tools in August that combine personal health information with diagnostic tools to help plan members better understand their medical conditions. For example, the Wall Street Journal's health blog notes, a patient whose doctor had diagnosed him with a history of sinusitis would be told that a headache suggested sinus problems rather than something more serious, and would tools to let the user search for in-network ear, nose and throat doctors. Aetna's hope is that the tools, called SmartSource, will allow plan members to get more personalized information about their health status than they could find in standard online searches.

Humana has announced that it will launch a pilot program in Florida to improve care coordination for chronically ill seniors. The program, which will be offered through Medicare Advantage and is an extension of a Medicare pilot, employs social workers, nurses and other health professionals to help individuals manage chronic diseases and avoid the hospital. Under the early Medicare pilot, for example, a nurse visited a 95 year old patient with mobility problems who had been leaning heavily on walls and furniture to get around the house. The nurse arranged to have a bench installed in the patient's house-paid for by the insurer-to prevent falls that could lead to health problems. The program also aims to help patients with multiple chronic health problems manage their conditions.

In response to some of the recent controversy surrounding policy rescissions, America's Health Insurance Plans has started circulating a proposal to create independent state review boards to review policy rescissions. Under the proposal, the review boards would be staffed by health care professionals and lawyers, and their decisions regarding policy rescissions would be final. The proposal has drawn praise from Consumer's groups and activists, and will be considered at a meeting of the National Association of Insurance Commissioners next month.

Los Angeles City Attorney Rocky Delgadillo has filed a lawsuit against Health Net claiming that the insurer illegally rescinded policies of 1,600 policyholders who submitted expensive claims. Specifically, the lawsuit claims that applications for individual policies were complicated and ambiguous, allowing the insurer to rescind policies on the grounds that individuals had supposedly filled them out incorrectly. The city attorney is also considering criminal charges against Health Net employees.

In addition, the suit claims that the insurer improperly delayed paying for medical care, resulting in delays in medical care for thousands of patients.  The suit is part of a larger citywide effort to crack down on insurance companies, as last week, the city created a website, Protect the Insured, to allow city residents to report grievances against insurers.

A Health Net spokesperson denied the charges and noted that the company paid out more than $200 million in claims last year for people with individual insurance policies, and noted that the company has an independent board to review cancellations in order to protect policyholders.

Cigna has taken a lot of heat in the past few weeks for refusing to pay for a liver transplant for a 17 year old girl, Nataline Sarkisyan, who was suffering from complications due to leukemia and a bone marrow transplant. The insurer determined that the transplant was experimental and did not offer a sufficient chance of survival, and as such denied the operation and only reversed it after Sarkisyan was too sick to undergo the transplant. Her family, now, has begun campaigning with John Edwards and has suggested that Cigna be charged with murder in the girl's death.

Now, a number of prominent health writers have jumped to Cigna's defense, arguing that Sarkisyan's doctors and the media may have overstated the potential benefits and that Cigna's denial may have been justified. Sarkisyan's doctors at UCLA gave the operation a 65% chance of extending Sarkisyan's life for six months-a number that may be questionable-and as Cigna's defenders have pointed out, if UCLA officials truly believed in the necessity of the operation, they could have performed the transplant and written the case off as charity or continued to negotiate with Cigna.

In contrast, critics of the insurer have pointed out that calling an operation "experimental" is a standard tactic to deny care, and that "a 65% chance of surviving six months does not preclude a 50% survival at five years."