By Susan Jaffe | Kaiser Health News

Despite interventions by Medicare officials, the number of appeals from health care providers and patients challenging denied claims continues to spiral, increasing the backlog of cases and delaying many decisions well beyond the timeframes set by law, according to a government study released Thursday.

The report from the Government Accountability Office, said the backlog “shows no signs of abating.”  It called for the Department of Health and Human Services to improve its oversight of the process and to streamline appeals so that prior decisions are taken into account and repetitive claims are handled more efficiently.

GAO investigators cited significant increases in cases filed at each of four stages of appeals. They found a 62 percent rise at the first level from 2010 through 2014, while appeals filed at the third stage — which are heard by an administrative law judge — had a nearly ten-fold increase during the same period.

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By Rachel Bluth | Kaiser Health News

The Food and Drug Administration removed an obstacle from of its “compassionate use” policy this month, eliminating some paperwork that physicians must do to obtain experimental drugs for some patients with immediately life-threatening illnesses.

Doctors will now file an application for FDA approval that contains just 11 questions, 15 fewer than the old form. They should be able to complete this new version in 45 minutes, the FDA said. The new form is simpler because it was designed for individual patients, replacing an all-purpose format that had been used by doctors acting on behalf of individuals or small or large groups of patients.

There had been concerns that doctors unfamiliar with how to submit the old form might have been deterred from applying for compassionate access, which is also known as expanded access, said FDA spokeswoman Sandy Walsh.

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HHS plans to limit the use of short-term health plans and tweak the Affordable Care Act’s risk-adjustment program for health plans to account for people who need coverage for only part of the year. The program will also now track prescription drug usage as a factor in assessing risk. (Modern Healthcare)

The government’s move would limit short-term health coverage to an individual to less than three months and bar renewal, as opposed to the almost 12-month term that some plans are offering, along with a chance to renew.(CNBC)

The moves are aimed at improving the mix of healthy and sick enrollees, known as the “risk pool.” A risk pool that has been smaller and sicker than expected has contributed to financial losses for many insurers on the marketplaces. (The Hill)

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The Future of ObamaCare Long After Obama Leaves Office

By Lisa Aliferis | Kaiser Health News

BERKELEY, Calif. — Few people have the unusual set of professional experiences that Dr. Lonny Shavelson does. He worked as an emergency room physician in Berkeley for years — while also working as a journalist. He has written several books and takes hauntingly beautiful photographs.

Now, just as California’s law aid-in-dying law takes effect this week, Shavelson has added another specialty: A consultant to physicians and terminally ill patients who have questions about how it works.

“Can I just sit back and watch?” Shavelson asked  from his cottage office. “This is really an amazing opportunity to be part of establishing policy and initiating something in medicine. This is a major change … [that] very, very few people know anything about and how to do it.”

Shavelson is the author of the 1995 book, “A Chosen Death,” which followed five terminally ill people over two years as they determined whether to amass drugs on their own and end their lives at a time of their choosing. He was present at the death of all of them.

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By Jay Hancock | Kaiser Health News

The portion of released prisoners with addiction problems who lacked medical insurance fell sharply after the health law’s Medicaid expansion took effect, but drug-treatment rates for ex-offenders barely budged, a new study shows.

Twenty-eight percent of ex-inmates with drug-use disorders were without health coverage in 2014, down from about 38 percent in the years before that, according to researchers at the Johns Hopkins Bloomberg School of Public Health. The study was published June 6 in Health Affairs, an academic journal.

The findings reflect the Affordable Care Act’s expansion of Medicaid coverage in most states, while at the same time highlighting barriers to drug treatment even when patients have a way to pay for it, authorities said.

“Once you provide coverage, it will take time for the services to be available on the street for folks,” said Steven Rosenberg, president of Community Oriented Correctional Health Services, a California-based nonprofit that works with ex-inmates. “One would not expect an immediate turnaround.” Rosenberg wasn’t involved in the research.

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By Chad Terhune| Kaiser Health News

California insurance officials are looking into whether Health Net Inc. has improperly withheld payments to addiction treatment centers for months while the company investigates concerns about fraudulent claims.

The California Department of Insurance began an inquiry after receiving numerous complaints from substance-abuse treatment facilities statewide that Health Net had not paid them since at least January, according to providers questioned by the agency. Health Net is California’s fourth-largest health insurer, acquired in March for $6 billion by Centene Corp., a St. Louis-based insurer.

Officials at the California Department of Managed Health Care, the state’s other insurance regulator, said they are reviewing a May 20 complaint about Health Net’s actions signed by executives and owners of 118 for-profit treatment centers.

The treatment providers say they can’t afford to accept Health Net patients without reimbursement, and that the insurer is harming its policyholders by limiting their access to treatment. Drug and alcohol treatment centers in Arizona have filed similar complaints about Health Net with insurance officials there.

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Blue Cross and Blue Shield joined a growing roster of health insurers Thursday that are suing the federal government to collect millions of dollars the companies say they are owed under the Affordable Care Act. (The News and Observer)

The suit, filed on Thursday in the U.S. Court of Federal Claims in Washington, D.C., says the U.S. failed to live up to obligation to pay the insurer more than $147 million owed under an ACA program known as “risk corridors,” which aimed to limit the financial risks borne by insurers entering the new health-law markets. (The Wall Street Journal)

The federal government’s failure to make full payment has exacerbated BCBSNC’s losses in the exchange market in 2014 and 2015, the insurer said, adding it has made it significantly more challenging to continue selling ACA products. (HealthcareFinance)

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Highmark Sues Government Over ACA Losses

States will be allowed to use Medicaid funding to fight the spread of the Zika virus with mosquito repellent, contraception, family planning services and other preventive measures, according to a letter the CMS sent Wednesday to state officials. (Modern Healthcare)

The five-page letter, distributed by the Centers for Medicare & Medicaid Services (CMS) on Wednesday, offers long-awaited guidance for states looking to bolster their response to the mosquito-borne virus without extra funding from Congress.  (The Hill)

The letter sent by Vikki Wachino, director of HHS’  Center for Medicaid and CHIP Services, also reminded Medicaid managed care plans that they can go beyond the required services that must by covered by Medicaid to do more to stop the spread of Zika. (USA Today)

What is Medicaid?

Fresh problems for “Obamacare”: The largest health insurer in Texas wants to raise its rates on individual policies by an average of nearly 60 percent, a new sign that President Barack Obama’s overhaul hasn’t solved the problem of price spikes. (The New York Times)

Blue Cross Blue Shield of Texas has about 603,000 individual policyholders and, unlike other insurers in the state, offers coverage in every county. In a recent filing with federal regulators, a summary of which is available on HealthCare.gov, the company said it is seeking increases averaging from 57.3 percent to 59.4 percent across its individual market plans. (The Dallas Morning News)

In a statement, Blue Cross Blue Shield of Texas said its request is based on strong financial principles, science and data. “It’s also important to understand the magnitude of the losses … experienced in the individual retail market over the past two years,” the statement said. The company says it lost $416 million in 2014 and $592 million last year. (CBS News)

Insurers in other big states also are requesting major rate hikes, suggesting that the average national rate hike for ObamaCare plans in 2017 may fall closer to 20% than 10%. Insurers in Florida recently requested a 17.7% rate hike, while Pennsylvania market participants are seeking a 24% increase. (Investor’s Business Daily)

By Chad Terhune| Kaiser Health News

UnitedHealth Group Inc. is leaving California’s insurance exchange at the end of this year, state officials confirmed Tuesday.

The nation’s largest health insurer announced in April it was dropping out of all but a handful of 34 health insurance marketplaces it participated in. But the company had not discussed its plans in California.

UnitedHealth’s pullout also affects individual policies sold outside the Covered California exchange, which will remain in effect until the end of December.

“United is pulling out of California’s individual market including Covered California in 2017,” said Amy Palmer, a spokeswoman for the state exchange.

It’s expected that UnitedHealth will continue offering coverage to employers in California and to government workers and their families through the California Public Employees’ Retirement System.

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