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Expectant Mom Needed $15,000 Overnight to Save Her Twins

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by Renuka Rayasam
Thu, 27 Apr 2023 09:00:00 +0000

It was Labor Day 2021 when Sara Walsh, who was 24 weeks pregnant with twins, began to experience severe lower-back pain.

On Wednesday, a few days later, a maternal-fetal specialist near her home in Winter Haven, Florida, diagnosed Walsh with twin-to-twin transfusion syndrome, a rare complication that occurs when fetuses share blood unevenly through the same placenta. The doctor told her that the fetuses were experiencing cardiac issues and that she should prepare for treatment the following day, Walsh said.

Her OB-GYN told her that, without immediate surgery, her twins had a high chance of perinatal death, and she could also die.

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Both referred Walsh to a fetal surgeon about four hours away, describing him as an expert on the .

As Walsh prepared to , she received a call from the surgeon's practice, the Fetal Institute. Walsh said a billing representative told her that before surgeon Ruben Quintero would see her, she needed to pay in full for the consultation, surgery, and postoperative care — a total estimate of $15,000.

Although Walsh had insurance, the biller said the surgeon was not in any private insurance networks nor did he offer payment plans.

“I burst into tears,” Walsh said. “'I don't want to lose these babies.'”

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Her mother agreed to give her money, and Walsh also called her insurer, who advised her to apply for a waiver that could allow them to reclassify the care as in network.

Late Wednesday, Walsh and her husband checked into a hotel near the practice's office in Coral Gables. The next morning, she handed her credit card and then her mother's credit card to the clerk at the Fetal Institute. Quintero said her case had advanced to stage 3, meaning there were problems that could cause heart failure in one or both fetuses.

He performed surgery later that day at a hospital about 90 minutes away. On Friday morning, she traveled back to his office for a follow-up. In the following weeks, she had two more consultations.

About five weeks after the surgery, Walsh gave birth to twin girls. They were premature but otherwise healthy.

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Then she waited for her insurance reimbursement to .

The Patient: Sara Walsh, 39, is covered by Blue Cross and Blue Shield of through her employer, a national newspaper publisher.

Medical Service: Fetoscopic laser surgery for treatment of twin-to-twin transfusion syndrome, as well as pre- and postoperative evaluations and X-rays.

Service Provider: The Fetal Institute in Coral Gables, Florida, a practice that specializes in treating rare pregnancy complications.

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Total Bill: $18,610 over multiple visits for surgery; pre- and post-surgical consultations; and two follow-up consultations for potential complications that didn't ultimately require more treatment. Walsh ended up putting $14,472.35 on her and her mother's credit cards. Her health plan eventually paid the Fetal Institute $5,419.44. Walsh was later partially reimbursed but ultimately paid more than $13,000 out-of-pocket.

What Gives: Walsh's case falls into a gray area of medical billing between emergency and elective care. Despite being insured, Walsh paid most of the full charges upfront and out-of-pocket for care that three doctors said she urgently needed to save her twins. And she knew the surgeon was an out-of-network provider.

Within 20 hours, Walsh gathered the thousands of dollars she was told she needed to pay before the surgeon would meet with her and prepared to undergo surgery in an unfamiliar hospital. “That 20 hours was just insanity,” she said.

When Walsh called BCBS before her procedure, a representative told her that Quintero was in its network at a few facilities but not at his private practice, where he would evaluate her. Laura Kersey, a billing representative with the Fetal Institute, confirmed to KFF Health News that the practice accepts Medicaid — which covers nearly half of all births in Florida — but does not contract with private insurance.

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“Our highly specialized practice sees from across the globe,” Quintero said in a statement to KFF Health News. “It would be impractical to join all health plans. If any patient is unable to pay in full for a procedure, we offer them CareCredit or an alternative payment plan, on a case by case basis.”

Neither option was available to Walsh. Approval for CareCredit, a medical credit card, would not have come in time for her next-morning procedure. Walsh said the Fetal Institute denied her request to pay half the bill upfront and the rest over time.

Kersey said requiring upfront payment is the Fetal Institute's “normal practice.” She said they are transparent about their billing practices and disclose them to potential patients ahead of time. If someone cannot pay, she said, the Fetal Institute sends the person back to the referring physician to find another option.

Walsh said the BCBS representative advised her to complete a waiver intended for patients who receive urgently needed care from an out-of-network provider when it is not feasible to see an in-network provider. Walsh did not have the days or even weeks needed to undergo the insurer's formal preauthorization process, which could have told her in advance whether BCBS would cover the claim.

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Walsh and her mother had paid the Fetal Institute nearly $13,000 related to her surgery, hopeful that BCBS would reimburse them.

In the weeks before Walsh gave birth, the specialist in Winter Haven sent her back to Quintero twice. Both times Quintero evaluated Walsh and sent her home without further treatment. She paid nearly $1,475 more for those visits.

Walsh said she had trouble getting all the documentation BCBS said she needed. In early November, she received the letter of medical necessity explaining the diagnosis.

The letter, signed by Quintero, said that twin-to-twin transfusion syndrome, when left untreated, results in pregnancy loss in 95% of patients.

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But Walsh's situation didn't count as the type of emergency that could have qualified her for federal billing protections, said Erin Fuse Brown, a professor and the director of the Center for Law, Health & Society at Georgia State University.

Walsh sought care that was “knowingly out of network, even though there was a figurative gun to her head,” Fuse Brown said, referring to the potential loss of her twins or even her own life.

The federal No Surprises Act, which took effect last year, months after Walsh's surgery, protects patients who receive emergency services inadvertently from out-of-network providers and only in certain settings — particularly emergency departments and urgent care centers. It also covers nonemergency services received from out-of-network providers, but only at in-network facilities.

Federal laws requiring public access to emergency services apply only to hospitals, not individual providers in their offices, Fuse Brown said. Physicians generally can refuse new patients and charge what they want, if they are transparent about costs, she added.

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“It's not a surprise medical bill if it's not a surprise,” Fuse Brown said.

Only about 30 to 40 hospitals nationwide can perform fetoscopic laser surgery to treat twin-to-twin transfusion syndrome, Yale Medicine estimates.

Walsh said the specialist who referred her for a next-day surgical appointment gave her just two options for providers in the region, only one of whom practiced in her state. That was Quintero, who is renowned for his work on the condition. He is credited with pioneering the procedure Walsh needed and, with his colleagues, also developed a way to assess the condition's severity, known as the Quintero staging system.

But it turns out there was another option in Florida. Neither the specialist nor BCBS told Walsh about the possibility of getting care at the University of South Florida, she said. At the time, USF was the only other facility in her state that could have performed the procedure, according to Alejandro Rodriguez, a maternal-fetal medicine physician and an assistant professor at the USF Health Morsani College of Medicine in Tampa. Rodriguez said that USF accepts private insurance, Medicaid, and Medicare and doesn't require patients to pay upfront for care.

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“There was no mention of shopping around,” Walsh said. And with her doctors telling her the lives of her children — and potentially her own — were urgently at stake, she said it seemed her only option was to pay up.

“No parent should face the choice of ‘How much money can I raise in the next 12 hours and is it enough to save the lives of my children?'” Walsh said.

Walsh has spent more than a year to get reimbursed by her health plan, repeatedly explaining her complicated case as representatives tried to sort out the proper billing codes for the rare, newer treatment. “No one understood how a doctor charged me more than $10,000 upfront to treat me,” she said.

Walsh also reached out to a medical advocate, who she said concluded that Quintero had billed correctly.

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Walsh's insurance covered Wellington Regional Medical Center, the in-network hospital where Quintero performed the procedure.

The Fetal Institute also filed claims for Walsh's care with BCBS, telling her they were filing on her behalf. BCBS processed the claims — for Quintero's surgical services at the in-network hospital — as out-of-network care and reimbursed Walsh for just a fraction of the more than $18,000 charged.

Her “explanation of benefits” documents stated that Walsh was on the hook for the balance between what Quintero's practice charged and the $5,419.44 that BCBS paid.

Walsh said BCBS covered her pregnancy-related visits to other, in-network providers, adding that her plan fully covers all diagnostic and laboratory maternity care.

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In early 2022, the Fetal Institute forwarded Walsh a check for about $1,282. According to the practice's records shared with KFF Health News, the check corrected an overpayment on the full charges, totaling $18,610 — which Walsh's payments and BCBS' reimbursements had together fulfilled.

Walsh said she had not received any other reimbursement.

BCBS declined to comment on Walsh's case, citing privacy concerns even though Walsh waived federal health privacy protections, which would allow the insurer to speak to a reporter about the case.

After a KFF Health News reporter contacted the insurer, Walsh said, a BCBS representative called to inform her that her claims had been “escalated,” but eventually determined that the reimbursement was “appropriate” because the provider was out of its network.

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The insurer said that the full amount of her balance doesn't apply toward out-of-pocket maximums in her plan.

The Takeaway: Federal billing protections are not designed to protect patients who choose out-of-network care, even when they find themselves in an urgent situation with few options and little time for comparison shopping.

And often only a handful of specialized providers can treat rare conditions. While that dearth of options raises ethical questions about whether it is OK for a doctor to demand payment upfront for lifesaving surgery, it is legal to do so, experts say. Many Americans would be challenged to raise $15,000 overnight.

“The patient did everything she could,” said Fuse Brown.

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Worse, still, she said: When a patient pays upfront, there's little incentive for providers and insurers to negotiate a fair payment or even cooperate to help patients get reimbursement.

The case shows how consumer protections are still lacking in many situations. “This could still happen tomorrow,” Fuse Brown said.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

By: Renuka Rayasam
Title: Expectant Mom Needed $15,000 Overnight to Save Her Twins
Sourced From: kffhealthnews.org/news/article/expectant-mom-needed-15000-overnight-to-save-her-twins/
Published Date: Thu, 27 Apr 2023 09:00:00 +0000

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Kaiser Health News

After a Child’s Death, California Weighs Rules for Phys Ed During Extreme Weather

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Samantha Young
Wed, 15 May 2024 09:00:00 +0000

LAKE ELSINORE, Calif. — Yahushua Robinson was an energetic boy who jumped and danced his way through life. Then, a physical education teacher instructed the 12-year-old to run outside on a day when the temperature climbed to 107 degrees.

“We lose loved ones all the time, but he was taken in a horrific way,” his mother, Janee Robinson, said from the family's Empire home, about 80 miles southeast of Los Angeles. “I would never want nobody to go through what I'm going through.”

The day her son died, Robinson, who teaches phys ed, kept her elementary school inside, and she had hoped her children's teachers would do the same.

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The Riverside County Coroner's Bureau ruled that Yahushua died on Aug. 29 of a heart defect, with heat and physical exertion as contributing factors. His death at Canyon Lake Middle School came on the second day of an excessive heat warning, when people were advised to avoid strenuous activities and limit their time outdoors.

Yahushua's family is supporting a bill in California that would require the Department of Education to create guidelines that govern physical activity at public schools during extreme weather, including setting threshold temperatures for when it's too hot or too cold for students to exercise or play outside. If the measure becomes , the guidelines will have to be in place by Jan. 1, 2026.

Many states have adopted protocols to protect student athletes from extreme heat during practices. But the California bill is broader and would require educators to consider all students throughout the school day and in any extreme weather, whether they're doing jumping jacks in fourth period or playing tag during recess. It's unclear if the bill will clear a critical committee vote for May 16.

“Yahushua's story, it's very touching. It's very moving. I think it could have been prevented had we had the right safeguards in place,” said state Sen. Melissa Hurtado (D-Bakersfield), one of the bill's authors. “Climate change is impacting everyone, but it's especially impacting vulnerable communities, especially our children.”

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Last year marked the planet's warmest on record, and extreme weather is becoming more frequent and severe, according to the National Oceanic and Atmospheric Administration. Even though most heat deaths and illnesses are preventable, about 1,220 people in the United States are killed by extreme heat every year, according to the Centers for Disease Control and Prevention.

Young children are especially susceptible to heat illness because their bodies have more trouble regulating temperature, and they rely on adults to protect them from overheating. A person can go from feeling dizzy or experiencing a headache to passing out, a seizure, or going into a coma, said Chad Vercio, a physician and the division chief of general pediatrics at Loma Linda University Health.

“It can be a really dangerous thing,” Vercio said of heat illness. “It is something that we should take seriously and figure out what we can do to avoid that.”

It's unclear how many children have died at school from heat exposure. Eric Robinson, 15, had been sitting in his sports medicine class learning about heatstroke when his sister arrived at his high school unexpectedly the day their brother died.

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“They said, ‘OK, go home, Eric. Go home early.' I walked to the car and my sister's crying. I couldn't believe it,” he said. “I can't believe that my little brother's gone. That I won't be able to see him again. And he'd always bugged me, and I would say, ‘ me alone.'”

That morning, Eric had done Yahushua's hair and loaned him his hat and chain necklace to wear to school.

As temperatures climbed into the 90s that morning, a physical education teacher instructed Yahushua to run on the blacktop. His friends told the family that the sixth grader had repeatedly asked the teacher for water but was denied, his parents said.

The school district has refused to release video footage to the family showing the moment Yahushua collapsed on the blacktop. He died later that day at the hospital.

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Melissa Valdez, a Lake Elsinore Unified School District spokesperson, did not respond to calls seeking comment.

Schoolyards can reach dangerously high temperatures on hot days, with asphalt sizzling up to 145 degrees, according to findings by researchers at the UCLA Luskin Center for Innovation. Some school districts, such as San Diego Unified and Santa Ana Unified, have hot weather plans or guidelines that call for limiting physical activity and providing water to kids. But there are no statewide standards that K-12 schools must implement to protect students from heat illness.

Under the bill, the California Department of Education must set temperature thresholds requiring schools to modify students' physical activities during extreme weather, such as heat waves, wildfires, excessive rain, and flooding. Schools would also be required to up with plans for alternative indoor activities, and staff must be trained to recognize and respond to weather-related distress.

California has had heat rules on the books for outdoor workers since 2005, but it was a latecomer to protecting student athletes, according to the Korey Stringer Institute at the University of Connecticut, which is named after a Minnesota Vikings football player who died from heatstroke in 2001. By comparison, Florida, where Gov. Ron DeSantis, a Republican, this spring signed a law preventing cities and counties from creating their own heat protections for outdoor workers, has the best protections for student athletes, according to the institute.

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Douglas Casa, a professor of kinesiology and the chief executive officer of the institute, said state regulations can establish consistency about how to respond to heat distress and save lives.

“The problem is that each high school doesn't have a cardiologist and doesn't have a thermal physiologist and doesn't have a sickling expert,” Casa said of the medical specialties for heat illness.

In 2022, California released an Extreme Action Heat Plan that recommended state agencies “explore implementation of indoor and outdoor heat exposure rules for schools,” but neither the administration of Gov. Gavin Newsom, a Democrat, nor lawmakers have adopted standards.

Lawmakers last year failed to pass legislation that would have required schools to implement a heat plan and replace hot surfaces, such as cement and rubber, with lower-heat surfaces, such as grass and cool pavement. That bill, which drew opposition from school administrators, stalled in committee, in part over cost concerns.

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Naj Alikhan, a spokesperson for the Association of California School Administrators, said the new bill takes a different approach and would not require structural and physical changes to schools. The association has not taken a position on the measure, and no other organization has registered opposition.

The Robinson family said children's lives ought to outweigh any costs that might come with preparing schools to deal with the growing threat of extreme weather. Yahushua‘s death, they say, could save others.

“I really miss him. I cry every day,” said Yahushua's father, Eric Robinson. “There's no one day that go by that I don't cry about my boy.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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——————————
By: Samantha Young
Title: After a Child's Death, California Weighs Rules for Phys Ed During Extreme Weather
Sourced From: kffhealthnews.org//article/california-weighs-heat-climate-school-rules-physical-education-child-death/
Published Date: Wed, 15 May 2024 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/medicaid-unwinding-decried-as-biased-against-disabled-people/

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Kaiser Health News

Medicaid ‘Unwinding’ Decried as Biased Against Disabled People

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Daniel Chang
Tue, 14 May 2024 09:00:00 +0000

Jacqueline Saa has a genetic that leaves her unable to stand and walk on her own or hold a job. Every weekday for four years, Saa, 43, has relied on a home aide to help her cook, bathe and dress, go to the doctor, pick up medications, and accomplish other tasks.


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Have you or someone you know with disabilities unexpectedly lost Medicaid benefits since April 2023? Tell us about it here.

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She received coverage through Florida's Medicaid program until it abruptly stopped at the end of March, she said.

“Every day the anxiety builds,” said Saa, who lost her home health aide for 11 days, starting April 1, despite being eligible. The state has since restored Saa's home health aide service, but during the gap she leaned on her mother and her 23- and 15-year-old daughters, while struggling to regain her Medicaid benefits.

“It's just so much to worry about,” she said. “This is a health care system that's supposed to help.”

Medicaid's home and community-based services are designed to help people like Saa, who have disabilities and need help with everyday activities, stay out of a nursing facility. But people are losing benefits with little or no notice, getting bad advice when they call for information, and facing major disruptions in care while they wait for the issue to get sorted out, according to attorneys and advocates who are hearing from patients.

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In Colorado, Texas, and Washington, D.C., the National Health Law Program, a nonprofit that advocates for low-income and underserved people, has filed civil rights complaints with two federal agencies alleging discrimination against people with disabilities. The group has not filed a lawsuit in Florida, though its attorneys say they've heard of many of the same problems there.

Attorneys nationwide say the special needs of disabled people were not prioritized as states began to review eligibility for Medicaid enrollees after a pandemic-era mandate for coverage expired in March 2023.

“Instead of monitoring and ensuring that people with disabilities could make their way through the , they sort of treated them like everyone else with Medicaid,” said Elizabeth Edwards, a senior attorney for the National Health Law Program. Federal law puts an “obligation on states to make sure people with disabilities don't get missed.”

At least 21 million people nationwide have been disenrolled from Medicaid since states began eligibility redeterminations in spring 2023, according to a KFF analysis.

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The unwinding, as it's known, is an immense undertaking, Edwards said, and some states did not take extra steps to set up a special telephone line for those with disabilities, for example, so people could renew their coverage or contact a case manager.

As states prepared for the unwinding, the Centers for Medicare & Medicaid Services, the federal agency that regulates Medicaid, advised states that they must give people with disabilities the help they need to benefit from the program, specialized communications for people who are deaf or blind.

The Florida Department of Children and Families, which verifies eligibility for the state's Medicaid program, has a specialized team that processes applications for home health services, said Mallory McManus, the department's communications director.

People with disabilities disenrolled from Medicaid services were “properly noticed and either did not respond timely or no longer met financial eligibility requirements,” McManus said, noting that people “would have been contacted by us up to 13 times via phone, mail, email, and text before processing their disenrollment.”

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Allison Pellegrin of Ormond Beach, Florida, who lives with her sister Rhea Whitaker, who is blind and cognitively disabled, said that never happened for her family.

“They just cut off the benefits without a call, without a letter or anything stating that the benefits would be terminating,” Pellegrin said. Her sister's home health aide, whom she had used every day for nearly eight years, stopped service for 12 days. “If I'm getting everything else in the mail,” she said, “it seems weird that after 13 times I wouldn't have received one of them.”

Pellegrin, 58, a sales manager who gets health insurance through her employer, took time off from work to care for Whitaker, 56, who was disabled by a severe brain injury in 2006.

Medicaid reviews have been complicated, in part, by the fact that eligibility works differently for home health services than for general coverage, based on federal regulations that give states more flexibility to determine financial eligibility. Income limits for home health services are higher, for instance, and assets are counted differently.

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In Texas, a parent in a household of three would be limited to earning no more than $344 a month to qualify for Medicaid. And most adults with a disability can qualify without a dependent child and be eligible for Medicaid home health services with an income of up to $2,800 a month.

The state was not taking that into consideration, said Terry Anstee, a supervising attorney for community integration at Disability Rights Texas, a nonprofit advocacy group.

Even a brief lapse in Medicaid home health services can fracture relationships that took years to build.

“It may be very difficult for that person who lost that attendant to find another attendant,” Anstee said, because of workforce shortages for attendants and nurses and high demand.

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Nearly all states have a waiting list for home health services. About 700,000 people were on waiting lists in 2023, most of them with intellectual and developmental disabilities, according to KFF data.

Daniel Tsai, a deputy administrator at CMS, said the agency is committed to ensuring that people with disabilities receiving home health services “can renew their Medicaid coverage with as little red tape as possible.”

CMS finalized a rule this year for states to monitor Medicaid home health services. For example, CMS will now track how long it takes for people who need home health care to receive the services and will require states to track how long people are on waitlists.

Staff turnover and vacancies at local Medicaid agencies have contributed to backlogs, according to complaints filed with two federal agencies focused on civil rights.

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The District of Columbia's Medicaid agency requires that case managers help people with disabilities complete renewals. However, a complaint says, case managers are the only ones who can help enrollees complete eligibility reviews and, sometimes, they don't do their jobs.

Advocates for Medicaid enrollees have also complained to the Federal Trade Commission about faulty eligibility systems developed by Deloitte, a global consulting firm that contracts with about two dozen states to design, implement, or operate automated benefits .

KFF Health found that multiple audits of Colorado's eligibility system, managed by Deloitte, uncovered errors in notices sent to enrollees. A 2023 review by the Colorado Office of the State Auditor found that 90% of sampled notices contained problems, some of which violate the state's Medicaid rules. The audit blamed “flaws in system design” for populating notices with incorrect dates.

Deloitte declined to comment on specific state issues.

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In March, Colorado paused disenrollment for people on Medicaid who received home health services, which includes people with disabilities, after a “system update” led to wrongful terminations in February.

Another common problem is people being told to reapply, which immediately cuts off their benefits, instead of appealing the cancellation, which would ensure their coverage while the claim is investigated, said attorney Miriam Harmatz, founder of the Florida Health Justice .

“What they're being advised to do is not appropriate. The best way to protect their legal rights,” Harmatz said, “is to file an appeal.”

But some disabled people are worried about having to repay the cost of their care.

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Saa, who lives in Davie, Florida, received a letter shortly before her benefits were cut that said she “may be responsible to repay any benefits” if she lost her appeal.

The state should presume such people are still eligible and preserve their coverage, Harmatz said, because income and assets for most beneficiaries are not going to increase significantly and their conditions are not likely to improve.

The Florida Department of Children and Families would not say how many people with disabilities had lost Medicaid home health services.

But in Miami-Dade, Florida's most populous county, the Alliance for Aging, a nonprofit that helps older and disabled people apply for Medicaid, saw requests for help jump from 58 in March to 146 in April, said Lisa Mele, the organization's director of its Aging and Disability Resources Center.

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“So many people are calling us,” she said.

States are not tracking the numbers, so “the impact is not clear,” Edwards said. “It's a really complicated struggle.”

Saa filed an appeal March 29 after learning from her social worker that her benefits would expire at the end of the month. She went to the agency but couldn't stand in a line that was 100 people deep. Calls to the state's Medicaid eligibility review agency were fruitless, she said.

“When they finally connected me to a customer service representative, she was literally just reading the same explanation letter that I've read,” Saa said. “I did everything in my power.”

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Saa canceled her home health aide. She lives on limited Social Security disability income and said she could not afford to pay for the care.

On April 10, she received a letter from the state saying her Medicaid had been reinstated, but she later learned that her plan did not home health care.

The following day, Saa said, advocates put her in touch with a point person at Florida's Medicaid agency who restored her benefits. A home health aide showed up April 12. Saa said she's thankful but feels anxious about the future.

“The toughest part of that period is knowing that that can happen at any time,” she said, “and not because of anything I did wrong.”

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Have you or someone you know with disabilities unexpectedly lost Medicaid benefits since April 2023? Tell KFF Health News about it here.

KFF Health News correspondents Samantha Liss and Rachana Pradhan contributed to this report.

——————————
By: Daniel Chang
Title: Medicaid ‘Unwinding' Decried as Biased Against Disabled People
Sourced From: kffhealthnews.org/news/article/medicaid-unwinding-people-with-disabilities-home-health-benefits/
Published Date: Tue, 14 May 2024 09:00:00 +0000

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https://www.biloxinewsevents.com/nursing-homes-wield-pandemic-immunity-laws-to-duck-wrongful-death-suits/

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Nursing Homes Wield Pandemic Immunity Laws To Duck Wrongful Death Suits

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Fred Schulte, KFF Health News
Tue, 14 May 2024 09:00:00 +0000

In early 2020, with reports of covid-19 outbreaks making dire headlines, Trever Schapers worried about her father's safety in a nursing home in Queens.

She had delighted in watching her dad, John Schapers, blow out the candles on his 90th birthday cake that February at the Lawrence Care Center in the New York City borough. Then the home went into lockdown.

Soon her father was dead. The former union painter spiked a fever and was transferred to a hospital, where he tested positive for covid, his daughter said, and after two weeks on a ventilator, he died in May 2020.

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But when Trever Schapers sued the nursing home for negligence and wrongful in 2022, a judge dismissed the case, citing a New York hastily passed early in the pandemic. It granted immunity to medical providers for “harm or damages” from an “act or omission” in treating or arranging care for covid. She is appealing the decision.

“I feel that families are being ignored by judges and courts not recognizing that something needs to be done and changed,” said Schapers, 48, who works in the medical field. “There needs to be accountability.”

The nursing home did not return calls seeking comment. In a court filing, the home argued that Schapers offered no evidence that the home was “grossly negligent” in treating her father.

More than four years after covid first raged through many U.S. nursing homes, hundreds of lawsuits blaming patient deaths on negligent care have been tossed out or languished in the courts amid contentious legal battles.

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Even some nursing homes that were shut down by health officials for violating safety standards have claimed immunity against such suits, court show. And some families that allege homes kept them in the dark about the health of their loved ones, even denying there were cases of covid in the building, have had their cases dismissed.

Schapers alleged in a complaint to state health officials that the nursing home failed to advise her that it had admitted covid-positive patients from a nearby hospital in March 2020. In early April, she received a call telling her the facility had some covid-positive residents.

“The call I received was very alarming, and they refused to answer any of my questions,” she said.

About two weeks later, a social worker called to say that her father had a fever, but the staff did not test him to confirm covid, according to Schapers' complaint.

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The industry says federal health officials and lawmakers in most states granted medical providers broad protection from lawsuits for good faith actions during the health emergency. Rachel Reeves, a senior vice president with the American Health Care Association, an industry trade group, called covid “an unprecedented public health crisis brought on by a vicious virus that uniquely targeted our population.”

In scores of lawsuits, however, family members allege that nursing homes failed to secure enough protective gear or tests for staffers or residents, haphazardly mixed covid-positive patients with other residents, failed to follow strict infection control protocols, and brazenly misled frightened families about the severity of covid outbreaks among patients and staff.

“They trusted these facilities to take care of loved ones, and that trust was betrayed,” said Florida attorney Lindsey Gale, who has represented several families suing over covid-related deaths.

“The grieving process people had to go through was horrible,” Gale said.

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A Deadly Toll

KFF Health News found that more than 1,100 covid-related lawsuits, most alleging wrongful death or other negligent care, were filed against nursing homes from March 2020 through March of this year.

While there's no full accounting of the outcomes, court filings show that judges have dismissed some suits outright, citing state or federal immunity provisions, while other cases have been settled under confidential terms. And many cases have stalled due to lengthy and costly arguments and appeals to hash out limits, if any, of immunity protection.

In their defense, nursing homes initially cited the federal Public Readiness and Emergency Preparedness Act, which Congress passed in December 2005. The law grants liability protection from claims for deaths or injuries tied to vaccines or “medical countermeasures” taken to prevent or treat a disease during national emergencies.

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The PREP Act steps in once the secretary of Health and Human Services declares a “public health emergency,” which happened with covid on March 17, 2020. The emergency order expired on May 11, 2023.

The law carved out an exception for “willful misconduct,” but proving it occurred can be daunting for families — even when nursing homes have long histories of violating safety standards, infection controls.

Governors of at least 38 states issued covid executive orders, or their legislatures passed laws, granting medical providers at least some degree of immunity, according to one consumer group's tally. Just how much legal protection was intended is at the crux of the skirmishes.

Nursing homes answered many negligence lawsuits by getting them from state courts into the federal judicial system and asking for dismissal under the PREP Act.

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For the most part, that didn't work because federal judges declined to hear the cases. Some judges ruled that the PREP Act was not intended to shield medical providers from negligence caused by inaction, such as failing to protect patients from the coronavirus. These rulings and appeals sent cases back to state courts, often after long delays that left families in legal limbo.

“These delays have been devastating,” said Jeffrey Guzman, a New York City attorney who represents Schapers and other families. He said the industry has fought “tooth and nail” to “fight these people getting their day in court.”

Empire State Epicenter

New York, where covid hit early and hard, is ground zero for court battles over nursing home immunity.

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Relatives of residents have filed more than 750 negligence or wrongful death cases in New York counties since the start of the pandemic, according to court data KFF Health News compiled using the judicial reporting service Courthouse News Service. No other area comes close. Chicago's Cook County, a jurisdiction where private lawyers for years have aggressively sued nursing homes alleging poor infection control, recorded 121 covid-related cases.

Plaintiffs in hundreds of New York cases argue that nursing homes knew early in 2020 that covid would pose a deadly threat but largely failed to gird for its impact. Many suits cite inspection reports detailing chronic violations of infection control standards in the years preceding the pandemic, court records show. Responses to this strategy vary.

“Different judges take different views,” said Joseph Ciaccio, a New York lawyer who has filed hundreds of such cases. “It's been very mixed.”

Lawyers for nursing homes counter that most lawsuits rely on vague allegations of wrongdoing and “boilerplate” claims that, even if true, don't demonstrate the kind of gross negligence that would override an immunity claim.

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New York lawmakers added another wrinkle by repealing the immunity statute in April 2021 after Attorney General Letitia James noted the law could give nursing homes a free pass to make “financially motivated decisions” to cut costs and put patients at risk.

So far, appeals courts have ruled lawmakers didn't specify that the repeal should be made retroactive, thus stymying many negligence cases.

“So these cases are all wasting the courts' time and preventing cases that aren't barred by immunity statutes from being resolved sooner and clogging up the court system that was already backlogged from COVID,” said attorney Anna Borea, who represents nursing homes.

Troubled Homes Deflect Suits

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Some nursing homes that paid hefty fines or were ordered by health officials to shut down at least temporarily because of their inadequate response to covid have claimed immunity against suits, court records show.

Among them is Andover Subacute and Rehabilitation nursing home in New Jersey, which made national headlines when authorities found 17 bodies stacked in a makeshift morgue in April 2020.

Federal health officials fined the facility $220,235 after issuing a critical 36-page on covid violations and other deficiencies, and the state halted admissions in February 2022.

Yet the home has won court pauses in at least three negligence lawsuits as it appeals lower court rulings denying immunity under the federal PREP Act, court records show. The operators of the home could not be reached for comment. In court filings, they denied any wrongdoing.

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In Oregon, health officials suspended operations at Healthcare at Foster Creek, calling the Portland nursing home “a serious danger to the public health and safety.” The May 2020 order cited the home's “consistent inability to adhere to basic infection control standards.”

Bonnie Richardson, a Portland lawyer, sued the facility on behalf of the family of Judith Jones, 75, who had dementia and died in April 2020. Jones' was among dozens of covid-related deaths at that home.

“It was a very hard-fought battle,” said Richardson, who has since settled the case under confidential terms. Although the nursing home claimed immunity, her clients “wanted to know what happened and to understand why.” The owners of the nursing home provided no comment.

No Covid Here

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Many families believe nursing homes misled them about covid's relentless spread. They often had to settle for window visits to connect with their loved ones.

Relatives of five patients who died in 2020 at the Sapphire Center for Rehabilitation and Nursing in the Flushing neighborhood in Queens filed lawsuits accusing the home's operators of keeping them in the dark.

When they phoned to check on elderly parents, they either couldn't get through or were told there was “no COVID-19 in the building,” according to one court affidavit.

One woman grew alarmed after visiting in February 2020 and seeing nurses wearing masks “below their noses or under their chin,” according to a court affidavit.

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The woman was shocked when the home relayed that her mother had died in April 2020 from unknown causes, perhaps “from depression and not eating,” according to her affidavit.

A short time later, news media reported that dozens of Sapphire Center residents had died from the virus — her 85-year-old mother among them, she argued in a lawsuit.

The nursing home denied liability and won dismissal of all five lawsuits after citing the New York immunity law. Several families are appealing. The nursing home's administrator declined to comment.

Broadening Immunity

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Nursing home operators also have cited immunity to foil negligence lawsuits based on falls or other allegations of substandard care, such as bedsores, with little obvious connection to the pandemic, court records show.

The family of Marilyn Kearney, an 89-year-old with a “history of dementia and falls,” sued the Watrous Nursing Center in Madison, Connecticut, for negligence. Days after she was admitted in June 2020, she fell in her room, fracturing her right hip and requiring surgery, according to court filings.

She died at a local hospital on Sept. 16, 2020, from sepsis attributed to dehydration and malnutrition, according to the suit.

Her family argued that the 45-bed nursing home failed to assess her risk of falling and develop a plan to prevent that. But Watrous fired back by citing an April 2020 declaration by Connecticut Gov. Ned Lamont, a Democrat, granting health care professionals or facilities immunity from “any injury or death alleged to have been sustained because of the individual's or health care facility's acts or omissions undertaken in good faith while providing health care services in support of the state's COVID-19 response.”

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Watrous denied liability and, in a motion to dismiss the case, cited Lamont's executive order and affidavits that argued the home did its best in the throes of a “public health crisis, the likes of which had never been seen before.” The operators of the nursing home, which closed in July 2021 because of covid, did not respond to a request for comment. The case is pending.

Attorney Wendi Kowarik, who represents Kearney's family, said courts are wrestling with how much protection to afford nursing homes.

“We're just beginning to get some guidelines,” she said.

One pending Connecticut case alleges that an 88-year-old man died in October 2020 after experiencing multiple falls, sustaining bedsores, and dropping more than 30 pounds in the two months he lived at a nursing home, court records state. The nursing home denied liability and contends it is entitled to immunity.

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So do the owners of a Connecticut facility that cared for a 75-year-old woman with obesity who required a lift to get out of bed. She fell on April 26, 2020, smashing several teeth and fracturing bones. She later died from her injuries, according to the suit, which is pending.

“I think it is really repugnant that providers are arguing that they should not be held accountable for falls, pressure sores, and other outcomes of gross neglect,” said Richard Mollot, executive director of the Long Term Care Community Coalition, which advocates for patients.

“The government did not declare open season on nursing home residents when it implemented COVID policies,” he said.

Protecting the Vulnerable

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Since early 2020, U.S. nursing homes have reported more than 172,000 residents' deaths, according to Centers for Medicare & Services data. That's about 1 in 7 of all recorded U.S. covid deaths.

As it battles covid lawsuits, the nursing home industry says it is “struggling to recover due to ongoing labor shortages, inflation, and chronic government underfunding,” according to Reeves, the trade association executive.

She said the American Health Care Association has advocated for “reasonable, limited liability protections that defend staff and providers for their good faith efforts” during the pandemic.

“Caregivers were doing everything they could,” Reeves said, “often with limited resources and ever-changing information, in an effort to protect and care for residents.”

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But patients' advocates remain wary of policies that might bar the courthouse door against grieving families.

“I don't think we want to continue to enact laws that reward nursing homes for bad care,” said Sam Brooks, of the Coalition for the Protection of Residents of Long-Term Care Facilities, a patient advocacy group.

“We need to keep that in mind if, God forbid, we have another pandemic,” Brooks said.

Bill Hammond, a senior fellow at the Empire Center for Public Policy, a nonpartisan New York think tank, said policymakers should focus on better strategies to protect patients from infectious outbreaks, rather than leaving it up to the courts to sort out liability years later.

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“There is no serious effort to have that conversation,” Hammond said. “I think that's crazy.”

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By: Fred Schulte, KFF Health News
Title: Nursing Homes Wield Pandemic Immunity Laws To Duck Wrongful Death Suits
Sourced From: kffhealthnews.org/news/article/nursing-home-pandemic-immunity-wrongful-death-lawsuits/
Published Date: Tue, 14 May 2024 09:00:00 +0000

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