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The Goodman Institute Health Blog

Wednesday Links

Posted on July 26, 2023July 26, 2023 by John C. Goodman

Lawsuit: Cigna algorithm rejects claims without a doctor even opening a patient’s records.

Report: CMS’ Medicaid inflation penalty will make generic drug shortages worse.

Virginia Medicaid paid at least $21.8 million on behalf of 12,054 enrollees after they were already dead.

An expensive trip: a medically approved, psychedelic renaissance is underway.

Did Gilead hold a promising HIV drug off the market in order to increase profits? (NYT) Economic theory would say no.

Australia has “virtually eliminated” HIV transmission in Sydney and elsewhere.

2 thoughts on “Wednesday Links”

  1. John Fembup says:
    July 26, 2023 at 1:53 pm

    The Virginia Medicaid payments were “capitation payments after enrollees’ deaths.”

    A capitation is different from a fee-for-service payment.

    A capitation is payable to the service provider based on patient enrollment with the provider. The enrollment for s patient who dies ends on the date of death. No further capitation is payable after the month in which the patient died.

    Just fyi disenrollment in general is tough for any insurer to manage. Enrollments are usually promptly reported. Not so for disenrollments even by reason of death. This is true for any type of “managed care” coverage. It was also true for indemnity-style coverage.

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  2. Bob Hertz says:
    August 1, 2023 at 1:29 am

    Claim denials are a huge problem with companies like Cigna. The blog Naked Capitalism ran a good summary on this on May 28, 2023.

    The denials aim at expensive procedures. If you are denying surgeries that cost $150,000, all it takes is 7 denials and you have saved the insurer over $1 million.

    The patients often have a hard time finding an attorney to sue the insurer — just for starters — and then will have an even harder time finding a doctor to testify against the insurer’s doctor.
    The insurers have deep pockets and can grind the patient down. Most state insurance departments are no help.

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