The company says it is protecting nursing home residents by curbing unnecessary hospital transfers. Whistleblowers allege cost-cutting tactics have endangered the elderly
The point of delaying and denying is so that they can collect the insurance money but never pay out. For someone in a retirement home who needs hospital services, their insurance would pay for this… But if the retirement home just simply doesn’t take them to the hospital… Then the insurance company will give the retirement home a small bonus that is significantly less than the overall hospital bill would have been.
I do not think any of us are surprised to hear which particular insurance company is being accused of doing this…
In arrangements like this, an insurer (often through Medicare Advantage) pays nursing homes a fixed monthly amount per resident, then layers on incentives tied to cost and utilization: (1) bonus payments if the facility meets targets such as lower hospital transfer rates or quality scores, (2) shared-savings payouts where the nursing home gets a portion of the medical cost savings if overall spending drops, (3) sometimes penalties or clawbacks if targets are missed, and (4) care-management support (e.g., insurer-employed clinicians embedded in the facility) that influences how care is delivered and measured — the controversy arises when these financial incentives may unintentionally discourage medically necessary hospital transfers.
Okay, so I think I follow – if the nursing home keeps patients there instead of transfering them to a hospital, the insurance company pays them more, so the nursing homes are incentivized to keep patients there, even at their detriment.
Yes. So, they are dying of a heart attack and the nursing home says, “old man, you have heartburn, go back to bed” and then they keep their bonus check.
And this is on top of all the horrible things that nursing homes do even without insurance companies giving kickbacks and bonus checks
If I live in a nursing home and I pay $1000 per month to the insurance company (via Medicare and out of pocket, etc), and they have to pay $1000 per month for my medical bills, they get no money.
So, if they make a deal with the nursing home to stop bringing me to the hospital, they won’t have to pay my medical bills and they keep the $1000.
The point of delaying and denying is so that they can collect the insurance money but never pay out. For someone in a retirement home who needs hospital services, their insurance would pay for this… But if the retirement home just simply doesn’t take them to the hospital… Then the insurance company will give the retirement home a small bonus that is significantly less than the overall hospital bill would have been.
I do not think any of us are surprised to hear which particular insurance company is being accused of doing this…
But how do they finesse the “never pay out” part? How do they avoid paying out through healthcare or rebates?
In arrangements like this, an insurer (often through Medicare Advantage) pays nursing homes a fixed monthly amount per resident, then layers on incentives tied to cost and utilization: (1) bonus payments if the facility meets targets such as lower hospital transfer rates or quality scores, (2) shared-savings payouts where the nursing home gets a portion of the medical cost savings if overall spending drops, (3) sometimes penalties or clawbacks if targets are missed, and (4) care-management support (e.g., insurer-employed clinicians embedded in the facility) that influences how care is delivered and measured — the controversy arises when these financial incentives may unintentionally discourage medically necessary hospital transfers.
Okay, so I think I follow – if the nursing home keeps patients there instead of transfering them to a hospital, the insurance company pays them more, so the nursing homes are incentivized to keep patients there, even at their detriment.
Do I have that right?
Yes. So, they are dying of a heart attack and the nursing home says, “old man, you have heartburn, go back to bed” and then they keep their bonus check.
And this is on top of all the horrible things that nursing homes do even without insurance companies giving kickbacks and bonus checks
Okay, I’m with you so far. Go on.
You seem very agreeable tonight… it’s suspicious.
Well I’m trying to understand how that translates into more revenue for the insurer.
If I live in a nursing home and I pay $1000 per month to the insurance company (via Medicare and out of pocket, etc), and they have to pay $1000 per month for my medical bills, they get no money.
So, if they make a deal with the nursing home to stop bringing me to the hospital, they won’t have to pay my medical bills and they keep the $1000.
As a reward, they will pay the nursing home $100.
$900 profit.