The no good, very bad week for the payors

Plus: Popular weight loss drugs face lawsuit over stomach paralysis claims

Aug 04, 2023

Good morning and happy Friday. Welcome to Fulcrum Strategies’ and FLATLINING.net’s weekly e-newsletter. Keep reading for the latest headlines in the healthcare world plus and update on our podcast and the healthcare news from the war in Ukraine.

In the headlines:

Cigna sued over PXDX system

You may recall that our own president and CEO Ron Howrigon was interviewed by ProPublica for a report they were doing on Cigna’s use of software that routinely denies claims, including medically necessary claims. That software is called PXDX and a group of physicians this week announced a class action lawsuit against the healthcare giant for instantly denying claims instead of having them be reviewed by a medical director. Cigna is also facing intense scrutiny from the House Energy and Commerce Committee over the report. Read more from Healthcare Dive.

LIVE Cigna stock price: CI 0.00%↑

UnitedHealth Group sued over denied claims

The US Department of Labor has filed a lawsuit against a UnitedHealthcare subsidiary, UMR, which manages claims for the insurance giant, for denying claims for thousands of emergency room visits and drug screenings. The denials were caused solely by diagnosis codes rather than a “prudent layperson” which the plan documents require, the federal government alleged. Read more in the StarTribune.

LIVE UnitedHealth Group stock price: UNH 0.00%↑

Payors are refusing to pay IDR claims, doctors say

Axios is reporting that physicians who have taken claims that fall under the No Surprises Act to the independent dispute resolution (IDR) process have received letters from the payors saying they will not pay the claims because they view them as “unenforceable” and “not binding.” The physicians submit claims to the IDR process when they think they have been underpaid and an arbitrator determines what the correct amount should be. They are enforceable and binding under the No Surprises Act. It comes as the rulings in the Texas Medical Association cases against the federal government are expected any day now. Read more from Axios.

A decade-long look at how Big Insurance profiteers American taxpayers and the sick.

The FLATLINING Podcast

As the 2024 presidential campaign heats up, Ron and I have been having discussions on the podcast about various proposals that have made their way through different committees or at least been introduced as at least a few of them will end up as talking points on the campaign trail.

Last week, we talked about a plan to deregulate Health Savings Accounts (HSA) in a way that will not help anyone; I predict that you can expect to hear a lot about HSAs from Republicans in this election cycle. We also talked about the Biden administration's attempts to roll back Trump-era policies that made short-term insurance plans not so short-term.

This week, we continued this discussion by talking about a Democratic bill that has been introduced in the Senate that speeds up the Medicare drug price negotiations created in the Inflation Reduction Act. We also discussed a concept floating around to see that physicians who see patients at hospitals or offices are billing in the same way.

Listen to the FLATLINING Podcast wherever you listen to podcasts by clicking one of the links below or clicking the red button to listen here on FLATLINING.net.

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Ukraine

Some American physicians have taken leaves from their full-time jobs in the United States to work at clinics in hospitals in war-torn Ukraine. Since the Russian invasion in February 2022, hundreds of healthcare facilities have been bombed and destroyed, crippling the country’s critical care infrastructure. One Virginia doctor just returned from spending three weeks performing neurosurgeries in Dnipro and he shared his story with CBS6 News Richmond. Read more from CBS6 News Richmond WTVR.

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Final Thought

Next week on the FLATLINING Podcast, Ron and I are having a short discussion on a recent claim made by Senator Bernie Sanders (I-VT). He claimed that there are millions of Americans that can’t find a doctor or have to wait months to receive primary care. In this FLATLINING Podcast Short, we discussed how accurate that claim is and the answer may surprise you. Subscribe to the podcast now so you don’t miss it.

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

Have a good weekend,

Matthew