Becker's Hospital Review

27 CFO / FINANCE Some Anthem patients afraid to use ED under discretionary policy: 6 things to know By Morgan Haefner O hio residents with Anthem insur- ance told The Plain Dealer they fear Anthem's discretionary emer- gency department policy will negatively affect them. Here are six things to know from the article. 1. Anthem rolled out its controversial ED pol- icy in Ohio Jan. 1. Under the coverage change, the insurer reviews diagnoses aer members' ED visits. If their condition is determined to be nonemergent, Anthem may not cover their ED claims, with several exceptions. 2. The Plain Dealer asked readers Feb. 22 to submit their experiences under the new policy. "Readers say they are afraid to vis- it the emergency room and potentially be saddled with expensive medical bills," the newspaper found. 3. One reader who is covered through his wife's Anthem policy, Matt Vale, told e Plain Dealer, "I wonder every day if me or my wife have a trip to the ER, will it be covered?" 4. Ohio Department of Insurance Assistant Director of Public Affairs Chris Brock told the publication the agency will continue to monitor the policy change. Mr. Brock also strongly encouraged Anthem members to review and file a complaint with the depart- ment if they have a concern about their claim. 5. Anthem has said its ED policy aims to cut the costly and improper use of EDs for nonemergent reasons. The policy is in ef- fect across Ohio, Indiana, New Hampshire, Missouri, Georgia and Kentucky. 6. The Ohio American College of Emer- gency Physicians, Ohio Hospital Associ- ation and Ohio State Medical Association are collecting ED claims Anthem denies to submit to the Department of Insurance, ac- cording to the report. n How health insurers game Medicare Advantage ratings to boost bonus payments By Ayla Ellison H umana, UnitedHealth, Aetna, Anthem and other insur- ance companies that provide Medicare Advantage plans use a tactic known as "crosswalking" to collect additional revenue from the federal government, according to an analysis of federal data by The Wall Street Journal. Here are five things to know. 1. Medicare ranks Medicare Advantage plans on a quality scale of one to five stars, and pays bonuses to plans with high ratings. When an MA plan is not set to receive a financial bonus, health insurance companies will merge those patients into plans with higher scores, which preserves the bonuses. 2. Using this tactic, health insurance companies are able to boost the ratings of Medicare Advantage plans without actually im- proving on quality measures. 3. Insurers have used this tactic over the past few years. Insurers shuffled roughly 1.45 million Medicare Advantage members into higher-rated plans for 2018, according to WSJ. 4. Paul Ginsburg, PhD, a professor at the University of Southern in Los Angeles and a member of the Medicare Payment Advisory Commission, told WSJ crosswalking "is nothing more than gam- ing the system." 5. The budget deal signed into law in February is expected to cut down on the practice of crosswalking, according to WSJ. n Mission Hospital to name cancer institute after donors of record-setting gift By Alia Paavola M ission Viejo, Calif.-based Mission Hospital Foundation received the largest gift in its 23-year history from Judi and Bill Leonard March 21. The Leonards, who requested to keep the specif- ic amount of the eight-figure gift undisclosed, are longstanding members of the Mission Hospital family. To honor the donors, the cancer institute, which is currently under construction, will be named the Judi and Bill Leonard Institute for Cancer Prevention, Treatment and Wellness at Mission Hospital. Over the past 15 years, the Leonards have donated 24 individual gifts to the hospital through their foun- dation. "We are humbled and blessed by the engagement of the Leonard family and the enduring impact they will have on the health and well-being of our com- munity," said Tarek Salaway, CEO of Mission Hospi- tal. "Their generosity will enable Mission Hospital to revolutionize cancer care to south Orange County and provide a comprehensive level of care that was previously unavailable in our community." n

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