Jeffrey Sippel, MD, MPH, discusses the trend of insurance claim denials related to non-invasive ventilators for patients with ALS.
There has been a trend of denied insurance claims for non-invasive ventilators (NIVs) by Medicare Advantage plans, particularly affecting individuals with amyotrophic lateral sclerosis (ALS), according to Jeffrey Sippel, MD, MPH, the associate director of Inpatient Clinical Services and associate professor of Clinical Medicine in the Pulmonary Sciences and Critical Care Medicine Division at the University of Colorado School of Medicine. In an interview with the American Journal of Managed CareⓇ (AJMCⓇ) he emphasized the adverse impact on patient outcomes and the financial shortsightedness of the carriers' approach, as appropriate admissions could potentially save significant health care costs in the long run.
Transcript
Could you shed light on the larger trend among Medicare Advantage plans? Why do you think this trend is emerging, and what are the consequences for patients?
So there are trends here that we've observed, and I would just say that United [Healthcare], by example, is the leader of the pack here, but there are absolutely other carriers that are following. And so, when we see trends for denials, one thing we need to ask ourselves is, “Are they right? And are these services medically indicated or not?” And they're telling us that they're not—I respectfully disagree.
They have a legalistic interpretation of a written document that's just not reality based. And so I think the main driver here—in fact, I know the main driver here—is cost. Back of the napkin, NIV machines might cost $15,000 to $20,000. The RAD (respiratory assist device) devices might cost $2000 to $3000. I get it. However, here's also the rest of the story. The DME company contracts for the NIV machines allow them to appropriately provide really good in home respiratory support. The bilevel devices get supported like CPAP—they just quite literally send patients masks and say, “Hey, try these, let us know which ones you like,” that's not appropriate. And when there are troubleshooting problems, they don't have the resources, because their contracts have much lower support for the bilevel devices, the RAD devices, they just don't provide the enhanced support.
So it's driven by money. It's driven by a lack of appreciation of how dynamic these patients are, and how quickly they can change from sort of stable to doing quite poorly. And then the final thing that they don't appreciate is that when we admit these patients appropriately, the costs associated with that admission are huge. They could have saved an admission and saved themselves tens of thousands of dollars. It's a short-sighted approach to making this quarter's profit statement look better.
Tackling Health Inequality: The Power of Education and Experience
April 30th 2024To help celebrate and recognize National Minority Health Month, we are bringing you a special month-long podcast series with our Strategic Alliance Partner, UPMC Health Plan. Welcome to our final episode of this limited series and our conversation with Janine Jelks-Seale, MSPPM, director of health equity at UPMC Health Plan.
Listen
A new federal rule will enable thousands of immigrants in the Deferred Action for Childhood Arrivals (DACA) program to obtain health care through the Affordable Care Act; a forthcoming CMS rule is expected to lower home-based care wait times and raise caregiver wages; the HHS Office for Civil Rights has finalized 2 rules that strengthen the ACA’s health care discrimination ban.
Read More
Examining Low-Value Cancer Care Trends Amidst the COVID-19 Pandemic
April 25th 2024On this episode of Managed Care Cast, we're talking with the authors of a study published in the April 2024 issue of The American Journal of Managed Care® about their findings on the rates of low-value cancer care services throughout the COVID-19 pandemic.
Listen
Shelly Lanning on How Employers Can Reduce Costs by Bridging Gaps in Women's Health Care
May 3rd 2024In a presentation at the Greater Philadelphia Business Coalition on Health Women’s Health Summit, Shelly Lanning, cofounder and president of Visana Health, addressed the need for comprehensive approaches in women’s health care and their coverage options.
Read More