Anthem Criticized For Denying Claims For Patients Who Go To ER For ‘Non-Emergency’ Ailments
Patients, doctors and hospitals are publicly criticizing the insurer over the tactic. Anthem says its policy aims to reduce use of emergency departments to rein in health care costs. In other marketplace news: The Wall Street Journal examines the behind-the-scenes role of Ramesh “Sunny” Balwani at Theranos; and Aetna wants back documents being used in a whistleblower suit against CVS Caremark.
The New York Times:
As An Insurer Resists Paying For ‘Avoidable’ E.R. Visits, Patients And Doctors Push Back
Anthem denied thousands of claims last year under its “avoidable E.R. program,” according to a sample of emergency room bills analyzed by the American College of Emergency Physicians. The program, which Anthem has been rolling out in a handful of states in recent years, reviews claims based on the final diagnosis of patients. Emergency room physicians say that, last year, the company did not routinely request medical records for denied patients, and therefore could not review the symptoms that brought them to the emergency room. Anthem says it is now reviewing such records before issuing denials. (Abelson, Sanger-Katz and Creswell, 5/19)
The Wall Street Journal:
Theranos Inc.’s Partners In Blood
Much of the attention has focused on Theranos founder Elizabeth Holmes. But another character played a central role behind the scenes in the alleged fraud: Ms. Holmes’s boyfriend, Ramesh “Sunny” Balwani, according to more than three dozen former Theranos employees who interacted with Mr. Balwani extensively over a number of years. Mr. Balwani, who met Ms. Holmes when she was a teenager, jointly ran the company with her for seven years as president and chief operating officer and enforced a corporate culture of secrecy and fear until his departure in the spring of 2016, the former employees say. Unlike Ms. Holmes and Theranos, who reached a settlement with the SEC to resolve the agency’s civil charges in March without admitting or denying wrongdoing, Mr. Balwani has denied separate charges the SEC filed against him in a parallel action and is fighting them in a California federal court. (Carreyrou, 5/18)
Stat:
Aetna Pressures Whistleblower Who Alleged CVS Caremark Ripped Off Medicare
Aetna wants an employee to return or destroy documents that formed the basis of a whistleblower lawsuit she filed against CVS Caremark, alleging that the pharmacy benefit manager improperly reported generic drug prices to the federal government, according to a source familiar with the matter. At the same time, CVS Caremark is seeking to redact key portions of the lawsuit, which is currently under seal, before it is made available to the public (although you can read it here). The lawsuit, which STAT first reported last month, revolves around the complicated contracts between pharmacy benefit managers and Medicare Part D plans, as well as the pricing that must be reported to the Centers for Medicare and Medicaid Services. (Silverman, 5/18)