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A Mom’s $97,000 Question: How Was Her Baby’s Air-Ambulance Ride Not Medically Necessary?

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Molly Castle Work
Mon, 25 Mar 2024 09:00:00 +0000

Sara England was putting together Ghostbusters costumes for Halloween when she noticed her baby wasn't doing well.

Her 3-month-old son, Amari Vaca, had undergone open-heart surgery two months before, so she called his cardiologist, who recommended getting him checked out. England assigned Amari's grandparents to trick-or-treat duty with his three older siblings and headed to the local emergency room.

Once England and the baby arrived at Natividad Medical Center in Salinas, California, she said, doctors could see Amari was struggling to breathe and told her that he needed specialized care immediately, from whichever of two major hospitals in the region had an opening first.

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Even as they talked, Amari was declining rapidly, his mother said. Doctors put a tube down his throat and used a bag to manually push air into his lungs for over an hour to keep his oxygen levels up until he was stable enough to switch to a ventilator.

According to England, late that night, when doctors said the baby was stable enough to travel, his medical team told her that a bed had opened up at the University of California-San Francisco Medical Center and that staffers there were ready to receive him.

She, her son, and an EMT boarded a small plane around midnight. Ground ambulances carried them between the hospitals and airports.

Amari was diagnosed with respiratory syncytial virus, or RSV, and spent three weeks in the hospital before recovering and returning home.

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Then the bill came.

The Patient: Amari Vaca, now 1, who was covered by a Cigna policy sponsored by his father's employer at the time.

Medical Services: An 86-mile air-ambulance flight from Salinas to San Francisco.

Service Provider: Reach Medical Holdings, which is part of Global Medical Response, an industry giant backed by private equity investors. Global Medical Response operates in all 50 states and has said it has a total of 498 helicopters and airplanes. It is out-of-network with Amari's Cigna plan.

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Total Bill: $97,599. Cigna declined to any part of the bill.

What Gives: Legal safeguards are in place to protect patients from big bills for some out-of-network care, air-ambulance rides.

Medical billing experts said the No Surprises Act, a federal enacted in 2022, could have protected Amari's family from receiving the $97,000 “balance bill,” leaving the insurer and the air-ambulance provider to determine fair payment according to the law. But the protections apply only to care that plans determine is “medically necessary” — and insurers get to define what that means in each case.

According to its coverage denial letter, Cigna determined that Amari's air-ambulance ride was not medically necessary. The insurer cited its reasoning: He could have taken a ground ambulance instead of a plane to cover the nearly 100 roadway miles between Salinas and San Francisco.

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“I thought there must have been a mistake,” England said. “There's no way we can pay this. Is this a real thing?”

In the letter, Cigna said Amari's records did not show that other methods of transportation were “medically contraindicated or not feasible.” The health plan also noted the absence of documentation that he could not be reached by a ground ambulance for pickup or that a ground ambulance would be unfeasible because of “great distances or other obstacles.”

Lastly, it said records did not show a ground ambulance “would impede timely and appropriate medical care.”

When KFF Health News asked Cigna what records were referenced when making this , a spokesperson declined to respond.

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Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation, said that even though Amari's bill isn't technically in violation of the No Surprises Act, the situation is exactly what the law was designed to avoid.

“What they're basically saying is that the should have opted against the advice of the physician,” Donovan said. “That's insane. I know ‘medical necessity' is this nebulous term, but it seems like it's becoming a catch-all for turning down patients.”

On Feb. 5, the National Association of Emergency Medical Services Physicians said that since the No Surprises Act was enacted two years ago, it has seen a jump in claim denials based on “lack of medical necessity,” predominantly for air-ambulance transports between facilities.

In a letter to federal health officials, the group cited reasons commonly given for inappropriate medical-necessity denials observed by some of its 2,000 members, such as “the patient should have been taken elsewhere” or “the patient could have been transported by ground ambulance.”

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The association urged the government to require that health plans presume medical necessity for inter-facility air transports ordered by a physician at a hospital, subject to a retrospective .

Such decisions are often “made under dire circumstances — when a hospital is not capable of caring for or stabilizing a particular patient or lacks the clinical resources to stabilize a patient with a certain clinical diagnosis,” the group's president, José Cabañas, wrote in the letter. “Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan.”

Patricia Kelmar, a health policy expert and senior director with the U.S. Public Interest Research Groups, noted, however, that hospitals could familiarize themselves with local health plans, for example, and establish protocol, so that before they call an air ambulance, they know if there are in-network alternatives and, if not, what items the plan needs to justify the claim and provide payment.

“The hospitals who and breathe and work in our communities should be considering the individuals who to them every day,” Kelmar said. “I understand in emergency situations you generally have a limited amount of time, but, in most situations, you should be familiar with the plans so you can work within the confines of the patient's health insurance.”

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England said Cigna's denial particularly upset her.

“As parents, we did not make any of the decisions other than to say, yes, we'll do that,” she said. “I don't know how else it could have gone.”

The Resolution: England twice appealed the air-ambulance charge to the insurer, but both times Cigna rejected the claim, maintaining that “medical necessity” had not been established.

The final step of the appeals is an external review, in which a third party evaluates the case. England said staff members at Natividad Medical Center in Salinas — which arranged Amari's transport — declined to write an appeal letter on his behalf, explaining to her that doing so is against the facility's policy.

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Using her son's medical records, which the Natividad staff provided, England said she is writing a letter herself to assert why the air ambulance was medically necessary.

Andrea Rosenberg, a spokesperson for Natividad Medical Center, said the hospital focuses on “maintaining the highest standards of health care and patient well-being.”

Despite receiving a waiver from England authorizing the medical center to discuss Amari's case, Rosenberg did not respond to questions from KFF Health News, citing privacy issues. A Cigna spokesperson told KFF Health News that the insurer has in-network alternatives to the out-of-network ambulance provider, but — despite receiving a waiver authorizing Cigna to discuss Amari's case — declined to answer other questions.

“It is disappointing that CALSTAR/REACH is attempting to collect this egregious balance from the patient's family,” the Cigna spokesperson, Justine Sessions, said in an email, referring to the air-ambulance provider. “We are working diligently to try to resolve this for the family.”

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On March 13, weeks after being contacted by KFF Health News, England said, a Cigna representative contacted her and offered assistance with her final appeal, the one reviewed by a third party. The representative also told her the insurer had attempted to contact the ambulance provider but had been unable to resolve the bill with them.

Global Medical Response, the ambulance provider, declined to comment.

England said she and her husband have set aside two hours each week for him to take care of their four kids while she shuts herself in her room and makes calls about their medical bills.

“It's just another stress,” she said. “Another thing to get in the way of us being able to enjoy our family.”

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The Takeaway: Kelmar said she encourages patients to appeal bills that seem inaccurate. Even if the plan denies it internally, push forward to an external review so someone outside the company has a chance to review, she said.

In the case of “medical necessity” denials, Kelmar recommended patients work with the medical provider to provide more information to the insurance company to underscore why an emergency transport was required.

More from Bill of the Month

Doctors who write a letter or make a call to a patient's insurer explaining a decision can also ask for a “peer-to-peer review,” meaning they would discuss the case with a medical expert in their field.

Kelmar said patients with employer-sponsored health plans can ask their employer's human resources department to advocate for them with the health plan. It's in the employers' best interest since they often pay a lot for these health plans, she said.

No matter what, Kelmar said, patients shouldn't let fear stop them from appealing a medical bill. Patients who appeal have a high likelihood of winning, she said.

Patients with government health coverage can further appeal insurance denials by filing a complaint with the Centers for Medicare & Medicaid Services. Those who believe they have received an inappropriate bill from an out-of-network provider can call the No Surprises Act help desk at 1-800-985-3059.

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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!

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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——————————
By: Molly Castle Work
Title: A Mom's $97,000 Question: How Was Her Baby's Air-Ambulance Ride Not Medically Necessary?
Sourced From: kffhealthnews.org/news/article/medical-necessity-rsv-infant-air-ambulance-surprise-bill/
Published Date: Mon, 25 Mar 2024 09:00:00 +0000

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Kaiser Health News

Millions Were Booted From Medicaid. The Insurers That Run It Gained Medicaid Revenue Anyway.

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Phil Galewitz, KFF News
Fri, 26 Apr 2024 13:55:00 +0000

Private Medicaid health plans lost millions of members in the past year as pandemic protections that prohibited states from dropping anyone from the program expired.

But despite Medicaid's unwinding, as it's known, at least two of the five largest publicly traded companies selling plans have continued to increase revenue from the program, according to their latest earnings reports.

“It's a very interesting paradox,” said Andy Schneider, a research professor at Georgetown University's McCourt School of Public Policy, of plans' Medicaid revenue increasing despite enrollment drops.

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Medicaid, the -federal health program for low-income and disabled people, is administered by states. But most people enrolled in the program get their health care through insurers contracted by states, UnitedHealthcare, Centene, and Molina.

The companies persuaded states to pay them more money per Medicaid enrollee under the assumption that younger and healthier people were dropping out — presumably for Obamacare coverage or employer-based health insurance, or because they didn't see the need to get coverage — leaving behind an older and sicker population to , their executives have told investors.

Several of the companies reported that states have made midyear and retrospective changes in their payments to plans to account for the worsening health status of members.

In an earnings call with analysts on April 25, Molina CEO Joe Zubretsky said 19 states increased their payment rates this year to adjust for sicker Medicaid enrollees. “States have been very responsive,” Zubretsky said. “We couldn't be more pleased with the way our state customers have responded to rates be commensurate with normal cost trends and trends that have been influenced by the acuity shift.”

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Health plans have faced much uncertainty during the Medicaid unwinding, as states began reassessing enrollees' eligibility and dropping those deemed no longer qualified or who lost coverage because of procedural errors. Before the unwinding, plans said they expected the overall risk profile of their members to go up because those remaining in the program would be sicker.

UnitedHealthcare, Centene, and Molina had Medicaid revenue increases ranging from 3% to 18% in 2023, according to KFF. The two other large Medicaid insurers, Elevance and CVS Health, do not break out Medicaid-specific revenue.

The Medicaid enrollment of the five companies collectively declined by about 10% from the end of March 2023 through the end of December 2023, from 44.2 million people to 39.9 million, KFF data shows.

In the first quarter of 2024, UnitedHealth's Medicaid revenue rose to $20.5 billion, up from $18.8 in the same quarter of 2023.

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Molina on April 24 reported nearly $7.5 billion in Medicaid revenue in the first quarter of 2024, up from $6.3 billion in the same quarter a year earlier.

On April 26, Centene reported that its Medicaid enrollment fell 18.5% to 13.3 million in the first quarter of 2024 compared with the same period a year ago. The company's Medicaid revenue dipped 3% to $22.2 billion.

Unlike UnitedHealthcare, whose Medicaid enrollment fell to 7.7 million in March 2024 from 8.4 million a year prior, Molina's Medicaid enrollment rose in the first quarter of 2024 to 5.1 million from 4.8 million in March 2023. Molina's enrollment jump last year was partly a result of its having bought a Medicaid plan in Wisconsin and gained a new Medicaid contract in Iowa, the company said in its earnings news release.

Molina added 1 million members because states were prohibited from terminating Medicaid coverage during the pandemic. The company has lost 550,000 of those people during the unwinding and expects to lose an additional 50,000 by June.

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About 90% of Molina Medicaid members have gone through the redetermination , Zubretsky said.

The corporate giants also offset the enrollment losses by getting more Medicaid money from states, which they use to pass on higher payments to certain facilities or providers, Schneider said. By holding the money temporarily, the companies can count these “directed payments” as revenue.

Medicaid health plans were big winners during the pandemic after the federal government prohibited states from dropping people from the program, leading to a surge in enrollment to about 93 million Americans.

States made efforts to limit health plans' profits by clawing back some payments above certain thresholds, said Elizabeth Hinton, an associate director at KFF.

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But once the prohibition on dropping Medicaid enrollees was lifted last spring, the plans faced uncertainty. It was unclear how many people would lose coverage or when it would happen. Since the unwinding began, more than 20 million people have been dropped from the rolls.

Medicaid enrollees' health care costs were lower during the pandemic, and some states decided to exclude pandemic-era cost data as they considered how to set payment rates for 2024. That provided yet another win for the Medicaid health plans.

Most states are expected to complete their Medicaid unwinding processes this year.

——————————
By: Phil Galewitz, KFF Health News
Title: Millions Were Booted From Medicaid. The Insurers That It Gained Medicaid Revenue Anyway.
Sourced From: kffhealthnews.org/news/article/medicaid-unwinding-insurer-revenue/
Published Date: Fri, 26 Apr 2024 13:55:00 +0000

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California Is Investing $500M in Therapy Apps for Youth. Advocates Fear It Won’t Pay Off.

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Molly Castle Work
Fri, 26 Apr 2024 09:00:00 +0000

With little pomp, California launched two apps at the start of the year offering behavioral health services to youths to them cope with everything from living with anxiety to body acceptance.

Through their phones, young people and some caregivers can meet BrightLife Kids and Soluna coaches, some who specialize in peer support or substance use disorders, for roughly 30-minute virtual counseling sessions that are best suited to those with more mild needs, typically those without a clinical diagnosis. The apps also feature self-directed activities, such as white noise sessions, guided breathing, and videos of ocean waves to help users relax.

“We believe they're going to have not just great impact, but wide impact across California, especially in places where maybe it's not so easy to find an in-person behavioral health visit or the kind of coaching and supports that and young people need,” said Gov. Gavin Newsom's health secretary, Mark Ghaly, during the Jan. 16 announcement.

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The apps represent one of the Democratic governor's major forays into health technology and come with four-year contracts valued at $498 million. California is believed to be the first to offer a mental health app with free coaching to all young , according to the Department of Health Care Services, which operates the program.

However, the rollout has been slow. So slow that one of the companies has missed a deadline to make its app available on Android phones. Only about 15,000 of the state's 12.6 million children and young adults have signed up for the apps, and school counselors say they've never heard of them.

Advocates for youth question the wisdom of investing taxpayer dollars in two private companies. Social workers are concerned the companies' coaches won't properly identify youths who need referrals for clinical care. And the spending is drawing lawmaker scrutiny amid a state deficit pegged at as much as $73 billion.

An App for That

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Newsom's administration says the apps fill a need for young Californians and their families to access professional telehealth for free, in multiple languages, and outside of standard 9-to-5 hours. It's part of Newsom's sweeping $4.7 billion master plan for kids' mental health, which was introduced in 2022 to increase access to mental health and substance use support services. In addition to launching virtual tools such as the teletherapy apps, the initiative is working to expand workforce capacity, especially in underserved .

“The reality is that we are rarely 6 feet away from our devices,” said Sohil Sud, director of Newsom's Children and Youth Behavioral Health Initiative. “The question is how we can leverage technology as a resource for all California youth and families, not in place of, but in addition to, other behavioral health services that are being developed and expanded.”

The virtual platforms come amid rising depression and suicide rates among youth and a shortage of mental health providers. Nearly half of California youths from the ages of 12 to 17 report recently struggled with mental health issues, with nearly a third experiencing serious psychological distress, according to a 2021 study by the UCLA Center for Health Policy Research. These rates are even higher for multiracial youths and those from low-income families.

But those supporting youth mental health at the local level question whether the apps will move the needle on climbing depression and suicide rates.

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“It's fair to applaud the state of California for aggressively seeking new tools,” said Alex Briscoe of California Children's Trust, a statewide initiative that, along with more than 100 local partners, works to improve the social and emotional health of children. “We just don't see it as fundamental. And we don't believe the youth mental health crisis will be solved by technology projects built by a professional class who don't share the lived experience of marginalized communities.”

The apps, BrightLife Kids and Soluna, are operated by two companies: Brightline, a 5-year-old venture capital-backed startup; and Kooth, a London-based publicly traded company that has experience in the U.K. and has also signed on some schools in Kentucky and Pennsylvania and a health plan in Illinois. In the first five months of Kooth's Pennsylvania pilot, 6% of who had access to the app signed up.

Brightline and Kooth represent a growing number of health tech firms seeking to profit in this space. They beat out dozens of other bidders including international consulting companies and other youth telehealth platforms that had already snapped up contracts in California.

Although the service is intended to be free with no insurance requirement, Brightline's app, BrightLife Kids, is folded into and only accessible through the company's main app, which asks for insurance information and directs users to paid licensed counseling options alongside the free coaching. After KFF Health questioned why the free coaching was advertised below paid options, Brightline reordered the page so that, even if a child has high-acuity needs, free coaching shows up first.

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The apps take an expansive view of behavioral health, making the tools available to all California youth under age 26 as well as caregivers of babies, toddlers, and children 12 and under. When KFF Health News asked to speak with an app user, Brightline connected a reporter with a mother whose 3-year-old daughter was learning to sleep on her own.

‘It's Like Crickets'

Despite being months into the launch and having millions in marketing funds, the companies don't have a definitive rollout timeline. Brightline said it hopes to have deployed teams across the state to present the tools in person by midyear. Kooth said developing a strategy to hit every school would be “the main focus for this calendar year.”

“It's a big state — 58 counties,” Bob McCullough of Kooth said. “It'll take us a while to get to all of them.”

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Brightline's contract states that the company was required to launch downloadable apps for iOS and Android phones by January, but so far BrightLife Kids is available only on Apple phones. Brightline said it's aiming to launch the Android version over the summer.

“Nobody's really done anything like this at this magnitude, I think, in the U.S. before,” said Naomi Allen, a co-founder and the CEO of Brightline. “We're very much in the early innings. We're already learning a lot.”

The contracts, obtained by KFF Health News through a records request, show the companies operating the two apps could earn as much as $498 million through the contract term, which ends in June 2027, months after Newsom is set to leave office. And the state is spending hundreds of millions more on Newsom's virtual behavioral health strategy. The state said it aims to make the apps available long-term, depending on usage.

The state said 15,000 people signed up in the first three months. When KFF Health News asked how many of those users actively engaged with the app, it declined to say, noting that data would be released this summer.

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KFF Health News reached out to nearly a dozen California mental health professionals and youths. None of them were aware of the apps.

“I'm not hearing anything,” said Loretta Whitson, executive director of the California Association of School Counselors. “It's like crickets.”

Whitson said she doesn't think the apps are on “anyone's” radar in schools, and she doesn't know of any schools that are actively advertising them. Brightline will be presenting its tool to the counselor association in May, but Whitson said the company didn't reach out to plan the meeting; she did.

Concern Over Referrals

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Whitson isn't comfortable promoting the apps just yet. Although both companies said they have a clinical team on staff to assist, Whitson said she's concerned that the coaches, who aren't all licensed therapists, won't have the to detect when users need more help and refer them to clinical care.

This sentiment was echoed by other school-based social workers, who also noted the apps' duplicative nature — in some counties, like Los Angeles, youths can access free virtual counseling sessions through Hazel Health, a for-profit company. Nonprofits, too, have entered this space. For example, Teen Line, a peer-to-peer hotline operated by Southern California-based Didi Hirsch Mental Health Services, is free nationwide.

While the state is also funneling money to the schools as part of Newsom's master plan, students and school-based mental health professionals voiced confusion at the large app investment when, in many school districts, few in-person counseling roles exist, and in some cases are dwindling.

Kelly Merchant, a student at College of the Desert in Palm Desert, noted that it can be hard to access in-person therapy at her school. She believes the community college, which has about 15,000 students, has only one full-time counselor and one part-time bilingual counselor. She and several students interviewed by KFF Health News said they appreciated having engaging content on their phone and the ability to speak to a coach, but all said they'd prefer in-person therapy.

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“There are a lot of people who are seeking therapy, and people close to me that I know. But their insurances are taking forever, and they're on the waitlist,” Merchant said. “And, like, you're seeing all these people struggle.”

Fiscal conservatives question whether the money could be spent more effectively, like to bolster county efforts and existing youth behavioral health programs.

Republican state Sen. Roger Niello, vice chair of the Senate Budget and Fiscal Review Committee, noted that California is forecasted to face deficits for the next three years, and taxpayer watchdogs worry the apps might cost even more in the long run.

“What starts as a small financial commitment can become uncontrollable expenses down the road,” said Susan Shelley of the Howard Jarvis Taxpayers Association.

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

——————————
By: Molly Castle Work
Title: California Is Investing $500M in Therapy Apps for Youth. Advocates Fear It Won't Pay Off.
Sourced From: kffhealthnews.org/news/article/california-youth-teletherapy-apps-rollout-slow/
Published Date: Fri, 26 Apr 2024 09:00:00 +0000

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KFF Health News’ ‘What the Health?’: Abortion — Again — At the Supreme Court

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Wed, 24 Apr 2024 20:30:00 +0000

The Host

Julie Rovner
KFF Health


@jrovner


Read Julie's stories.

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Julie Rovner is chief Washington correspondent and host of KFF Health News' weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care and Policy A to Z,” now in its third edition.

Some justices suggested the Supreme Court had said its piece on when it overturned in 2022. This term, however, the court has agreed to review another abortion case. At issue is whether a federal law requiring emergency care in hospitals overrides Idaho's near-total abortion ban. A decision is expected by summer.

Meanwhile, the Centers for Medicare & Medicaid finalized the first-ever minimum staffing requirements for nursing homes participating in the programs. But the industry argues that there are not enough workers to hire to meet the standards.

This week's panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins University's nursing and public health schools and Politico Magazine, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

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Panelists

Joanne Kenen
Johns Hopkins University and Politico


@JoanneKenen


Read Joanne's articles.

Tami Luhby
CNN

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@Luhby


Read Tami's stories.

Alice Miranda Ollstein
Politico


@AliceOllstein

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Read Alice's stories.

Among the takeaways from this week's episode:

  • This week's Supreme Court hearing on emergency abortion care in Idaho was the first challenge to a state's abortion ban since the overturn of the constitutional right to an abortion. Unlike previous abortion cases, this one focused on the everyday impacts of bans on abortion care — cases in which pregnant patients experienced medical emergencies.
  • Establishment medical groups and doctors themselves are getting more vocal and active as states set laws on abortion access. In a departure from earlier political moments, some major medical groups are campaigning on state ballot measures.
  • Medicaid this week finalized new rules intended to more closely regulate managed-care plans that enroll Medicaid patients. The rules are intended to ensure, among other things, that patients have prompt access to needed primary care doctors and specialists.
  • Also this week, the Federal Trade Commission voted to ban most “noncompete” clauses in employment contracts. Such language has become common in health care and prevents not just doctors but other health workers from changing — often forcing those workers to move or commute to a position. Business interests are already suing to block the new rules, claiming they would be too expensive and risk the loss of proprietary information to competitors.
  • The fallout from the cyberattack of Change continues, as yet another group is demanding ransom from UnitedHealth Group, Change's owner. UnitedHealth said in a statement this week that the of “a substantial portion of America” may be involved in the breach.

Plus for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: NBC News' “Women Are Less Likely To Die When Treated by Female Doctors, Study Suggests,” by Liz Szabo.  

Alice Miranda Ollstein: States Newsroom's “Loss of Federal Protection in Idaho Spurs Pregnant Patients To Plan for Emergency Air Transport,” by Kelcie Moseley-Morris.  

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Tami Luhby: The Associated Press' “Mississippi Lawmakers Haggle Over Possible Medicaid Expansion as Their Legislative Session Nears End,” by Emily Wagster Pettus.  

Joanne Kenen: States Newsroom's “Missouri Prison Agency To Pay $60K for Sunshine Law Violations Over Inmate Death Records,” by Rudi Keller.  

Also mentioned on this week's podcast:

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

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To hear all our podcasts, click here.

And subscribe to KFF Health News' “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

——————————
Title: KFF Health News' ‘What the Health?': Abortion — Again — At the Supreme Court
Sourced From: kffhealthnews.org/news/podcast/what-the-health-344-abortion-supreme-court-april-25-2024/
Published Date: Wed, 24 Apr 2024 20:30:00 +0000

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