The numbers are all approximately the same

Cigna Carelink is a problematic arrangement between Cigna and Tufts Health Plan. All medical claims go to Cigna. For claims in most states, Cigna uses Cigna’s network and Cigna’s pricing. For claims from Massachusetts providers, Cigna uses Tufts Health Plan’s network and Tufts Health Plan’s pricing. So the claim comes in to Cigna, Cigna sends it to Tufts Health Plan to process and assign a price, and then Cigna gets the relevant info back from Tufts Health Plan and Cigna generates the EOB and sends payment.

As a Cigna Carelink customer, I can only talk to Cigna. I cannot talk to Tufts Health Plan.

Tufts Health Plan has just priced a simple claim for us three times. The billed amount was $156.00 for seeing a doctor. The first two times, Tufts Health Plan priced the claim at $90.59. The third time, Tufts Health Plan priced the claim at $138.54.

When you provide the same input, you should get the same output. This is a single claim, with no change in the patient, health care plan, date of service, location of service, provider ID, procedure code, or diagnosis code. Why are the numbers changing?

This is not the first time I’ve seen erratic pricing and processing by Tufts Health Plan. I called Cigna today and asked why the pricing by Tufts Health Plan seems to be assigning random numbers. The supervisor I spoke with at Cigna said that the pricing from Tufts Health Plan is random. Too bad we weren’t on a recorded line.

Cigna cannot speak directly to Tufts Health Plan about pricing. When Cigna sends a query to Tufts Health Plan pointing out pricing problems or processing problems, the only response they have ever received from Tufts Health Plan has been “the claim processed correctly.” Tufts Health Plan has never admitted a mistake, has never acknowledged a difference in how they are processing identical claims for different dates of service, has never even acknowledged a difference in how they are processing the same claim when they process it a second or third time. The answer is $90.59. The answer is $138.54. The answer is correct, regardless of which answer it is.

Cigna claims they cannot audit the pricing from Tufts Health Plan, because they have no way to see any of the numbers themselves. They simply have to trust that it’s correct, and in turn assure us that it’s correct. Even when it clearly isn’t.

This is separate from how the pricing interacts with our deductible and our out-of-pocket maximum. That part happens after the pricing, as part of deciding how much we pay and how much Cigna pays.

Would you get away with this at your job? Provide an arbitrary answer, change the answer whenever you feel like it, and refuse to answer any questions about it?

Cigna claims that they offer this arrangement because Tufts Health Plan has a wider network in Massachusetts, and because Tufts Health Plan gets better pricing in Massachusetts. We haven’t personally run into any providers who are in-network for Tufts Health Plan and out-of-network for Cigna, and on the rare occasion that Cigna has been willing to look up their own pricing for a claim to compare it to the Tufts Health Plan pricing, the Cigna pricing has been comparable or cheaper. So why are they really doing this?

Contract, contract, who has the contract

A patient goes to the doctor. The doctor has a list price, the doctor agrees to bill the patient’s insurance, the patient agrees to pay whatever portion insurance doesn’t pay, and the doctor (being in network) has a separate agreement with the insurance company to accept the negotiated price as payment in full.

In a normal scenario, the doctor’s list price (full billed amount listed on the chargemaster) is $300, but the negotiated price with the insurance company is $200. The insurance company pays somewhere between $0 and $200, the patient pays the rest to a total of $200, and that’s the end of it.

In a screwy scenario, the doctor’s list price is $300, but the negotiated price with the insurance company is $350. The insurance company pays somewhere between $0 and $350. What does the patient owe?

The doctor can seek payment from the insurance company, and presumably is entitled to collect up to $350 from the insurance company under the terms of the doctor’s contract with the insurance company. But what exactly entitles the doctor to seek more than $300 from the patient, if the insurance company has paid less than $300?

(In a sane world, the insurance company would never agree to pay more than the list price. We don’t live in that world.)

My feeling is that when I provide the doctor with my insurance information, I am allowing him to bill my insurance and keep whatever he collects from my insurance. But the fundamental debt is mine, and the insurance company is simply helping to cover that debt. If I can owe more than the list price simply because the insurance company has negotiated an even higher price, then my relationship with the insurance company is backwards and I’m helping to cover the insurance company’s debt.

I’ve seen this sort of too-cozy relationship with auto body shops and car insurance, where the body shop feels that the insurance company is the customer rather than the car’s owner being the customer.

Suppose that the fundamental debt is mine, and suppose that the doctor cannot seek more than $300 from me, but is allowed to keep $350 from the insurance company if the insurance company decides to pay the bill in full. What if I see the doctor twice with a list price of $300 each time, and the insurance company pays $350 for the first visit and only pays $100 for the second visit? Should the amounts be aggregated? If each visit is treated separately, then I owe $0 for the first visit and I owe $200 for the second visit. If the visits are aggregated, then I only owe $150.

You know what we need? Some sort of clear rules about how all this works. I’m surprised that I’m having so much trouble finding those rules. If we had insurance regulations, those would probably address this sort of question, wouldn’t they?

Cigna refusing to pay for Early Intervention

Summary

When Cigna refuses to pay for Early Intervention services, the taxpayers of Massachusetts get stuck with the bill. This could easily be costing Massachusetts $1 million to $2 million per year or more. We had an employer-provided health insurance plan through Cigna in 2013-2014. Our child received Early Intervention services. Despite our plan documents saying that Early Intervention services were covered, Cigna denied every single claim when it was first submitted. Our experience on more than 40 claims totaling over $8000 was that Cigna consistently lied about our plan coverage in an attempt to make Massachusetts pay instead of Cigna. After more than a year of appeals, we were able to correct our claims, but that only corrects the payments for one child out of the 36,000 who are in Early Intervention. Massachusetts should investigate how many times Cigna has pulled this scam, and stop it from continuing.

What is Early Intervention (EI)?

Early Intervention is a set of developmental services provided to children from birth to their third birthday. It includes evaluations, individual home visits by social workers and developmental specialists, and group services. Each EI agency that provides EI services in Massachusetts covers a specific town or region. You can find a lot of information about EI at http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/early-intervention/family-info/about-ei.html.

Who pays for Early Intervention in Massachusetts?

Early Intervention services are sometimes covered by health insurance. Massachusetts has a coverage mandate for EI services, but that mandate is not obligatory for self-insured plans. The Massachusetts Department of Public Health pays for any costs not covered by insurance, including co-payments and deductibles. The EI provider submits claims to health insurance when health insurance is available, and then any remaining amounts are submitted to the state for payment.

What happens when an insurer like Cigna wrongly refuses to pay for EI services?

The state gets stuck with the bill instead, while the insurer (or the employer in the case of a self-insured plan) saves money. The EI provider still gets paid, and the families still receive EI services, so the state is the only party that suffers a loss.

DPH makes EI providers report when services are not covered by a commercial plan, but that process assumes that the insurer is being truthful about whether EI services are covered. This assumption that an insurer will be truthful is a huge vulnerability which Cigna is able to take advantage of.

How much money could be involved?

The most expensive month we saw was $1207.01, while other months were typically $800 to $900. From our experience, this could easily mean costs on the order of $10,000 per year for one child. In Fiscal Year 2014, there were over 36,000 children enrolled and receiving EI services. Over 16,000 had commercial insurance. The state paid over $147,000,000 for EI services, which would be on the order of $7000 per year per child on average.

As of a few years ago Cigna covered over 10% of the people in Massachusetts with commercial insurance. That could translate into 1600 children covered by Cigna who are receiving EI services. At $7000 per year per child, if Cigna is wrongly denying even 10% to 20% of those services, that would be $1 million to $2 million per year.

How did Cigna treat Early Intervention claims for your child?

Cigna denied every single Early Intervention claim that was submitted for our child. There were over 40 EI claims over the course of a year, many covering more than one date of service, and Cigna denied every claim. Our Summary Plan Description said that Early Intervention services were covered. Whenever we called Cigna, we were told that Early Intervention services were not covered. The EI provider successfully appealed a few of these denials, but they eventually gave up and started to believe Cigna when Cigna wrongly said that EI services were not covered. After we placed many phone calls appealing these denials, persisting through repeated denials and incorrect statements from Cigna, Cigna eventually reprocessed and paid these claims.

The initial claims processing from Cigna was completely consistent: no EI claim was paid on the first submission.

Was this deliberate fraud on the part of Cigna?

When an insurer shows a pattern of denying every legitimate claim, lies about coverage whenever a customer questions the denials, ignores the statements in the Summary Plan Description, and knows that a third party will end up footing the bill instead, it certainly doesn’t look good.

Was the problem with Cigna or with Tufts?

Our self-insured plan is administered by Cigna, but the claims that Cigna receives within Massachusetts are sent on to Tufts Health Plan for processing. Cigna created the Summary Plan Descriptions, we only interacted with Cigna, and Cigna consistently refused to acknowledge that there was anything wrong with these claim denials, so it looks to me like a problem with Cigna.

(It is clear that the problem was not tied to the employer, who put together a perfectly good insurance plan and chose a major health insurance company to administer the plan.)

How would Massachusetts recover money from Cigna?

1. Identify which EI claims are being submitted to Cigna and are being denied on the basis of services not being covered by the plan. This information should be known by EI providers and by Cigna, and should be collected by DPH.
2. Total up those denied claims per child.
3. Start with the children with the largest total dollar amounts of denied claims in a year. Check the Summary Plan Description or other plan documents for each child’s plan to see which plans are supposed to cover EI services. It should rapidly become apparent how widespread this pattern is, and how much money the state stands to recover from Cigna.

Who should investigate?

The Massachusetts DPH is losing money because of Cigna. The Massachusetts Inspector General might like to save the state some money. The Massachusetts Attorney General might like to put a stop to insurance fraud that directly impacts the state’s budget.

How could state laws or regulations be changed to reduce this problem?

Whenever an insurer denies a claim for EI services, the insurer could be required to provide a copy of the actual plan documents (such as a Summary Plan Description) to DPH. DPH should check the actual plan documents for each child once per year to confirm that the denial is correct.

When an insurer wrongly denies EI claims on a repeated basis, there should be clear and significant penalties assessed. An insurer like Cigna apparently needs a financial incentive to avoid defrauding the state.

Some resources about epi pens in Massachusetts schools

The law:
https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXII/Chapter71/Section54B

DPH regulations:
http://www.mass.gov/eohhs/docs/dph/regs/105cmr210.pdf

State Dept of Education:
http://www.doe.mass.edu/cnp/allergy.pdf

2015 survey for schools about epi pen use:
https://www.surveymonkey.com/s/EpiPen2015

504 plan recommended as a mechanism for ensuring allergy safety in school:
http://www.mass.gov/eohhs/gov/departments/dph/programs/family-health/directions/chap-8/504-plan.html

(And by the way, Mass DPH issues an annual report on EpiPen use in schools which always concludes with recommending that students with allergies have a 504 plan.)

Some overall info about 504 plans from the Office for Civil Rights:
http://www2.ed.gov/about/offices/list/ocr/docs/hq5269.html

How anaphylaxis works on a cellular level:
http://luriechildrens-salubrity.tumblr.com/post/118705177170/the-science-of-anaphylaxis-an-allergic-storm

Non-negotiable points for an allergy plan:
http://foodallergyconsulting.com/top-3-non-negotiables-food-allergy-plans-2/

Not happy with our Samsung refrigerator

We have a Samsung French door refrigerator. We like it. Well, we like some things about it. It’s large, it keeps our food cold, and it turns out that we really like having the freezer on the bottom.

But it’s also a defective piece of shit, and we don’t like that side of it as much.

Nothing interesting. Flames don’t shoot out the doors when you open the fridge. It doesn’t wobble its way across the kitchen and start molesting the microwave. But the glides that let the freezer drawer open broke after a year. Samsung replaced the glides, and the replacement glides stick all the time, making it very difficult to open the freezer all the way. Samsung says it’s supposed to be that way, because who wants to open the freezer?

Oh, and the door and freezer gaskets aren’t really all that strong. And food along the back wall of the refrigerator compartment tends to freeze, so you can’t use the back couple of inches of the refrigerator, but that’s ok because the refrigerator is really deep so there’s a lot of room anyway.

But the truly annoying thing is when you go to close the left refrigerator door, the one that has the little divider flap that seals up the space between the left and right doors, and the divider flap doesn’t flip itself to the right position and your door bounces back open because the divider flap won’t let the fridge door close. Until you put everything down, hold the divider flap in the right place, and carefully close the door, because that’s convenient. Every. Time. You. Use. The. Door.

Why would that happen? Well, Samsung used a crappy little spring to manage the divider flap, and that spring lasts about 16 months before snapping into two pieces. And the plastic sleeve that it goes into also breaks apart after a bit over a year. Next week we’ll be on our third of each in less than four years. So you have to keep replacing these little pieces, and apologizing to your family and friends for your defective refrigerator until the parts arrive, and explaining that no, you really don’t recommend Samsung appliances, but you also don’t feel good about throwing out a $2000 refrigerator after just a few years, so you’re reluctantly living with it.

Samsung’s attitude is telling. A one-year warranty, because most of the refrigerator parts last at least a year. (Yay?) A one-time repair out of warranty, because that gets you in the habit of repairing your refrigerator instead of demanding a refund. And then an insistence that you start giving Samsung more and more money for repairs that don’t even hold up, with the excuse that they’ve already covered repairing their defective appliance out of warranty once, and how could you possibly expect them to keep repairing their defective appliance without bleeding you for more money? I mean, that would clearly be unreasonable, because an appliance company shouldn’t have to pay for five repairs in four years. With no acknowledgment of the fact that an appliance shouldn’t NEED five repairs in four years, and that if it does need five repairs in four years, that’s their fault and they should absolutely be on the hook for repairing it or replacing it.