More COVID-19 Fallout: Social Isolation Associated with Poor Health and Emotional Distress

Commonwealth Fund

As a result of social distancing and other interventions, the COVID-19 pandemic has cut many people off from their emotional and social support systems. For older adults, this may have exacerbated feelings of isolation; the percentage of those who reported feeling isolated jumped from 27 percent in 2018 to 56 percent after the start of the pandemic. This is particularly concerning for older adults with high health care needs — that is, people with multiple chronic conditions or functional limitations who require assistance with daily activities. Feelings of isolation not only create emotional distress but also have the potential to further exacerbate their already complicated health problems and even contribute to early mortality. Social distancing was an effective approach to slowing COVID-19 transmission — especially among a population at increased risk of infection — but any resulting feelings of isolation may have contributed to new health and social risks for this medically vulnerable group.

To explore how isolation affects high-need older adults and examine their experiences during the pandemic, we analyzed data from the Commonwealth Fund 2021 International Health Policy Survey of Older Adults. We found, consistent with previous research, that high-need adults are significantly more likely to report social isolation; more than one of 10 (12%) high-need older adults reported often feeling isolated from others, compared to 5 percent of older adults without high needs.

In line with previous research, isolation appears to be associated with poorer health. High-need older adults who reported feeling isolated were more likely than those not feeling isolated to report they were in fair or poor health (rather than good or excellent health); these adults were also more likely to report going to the emergency room for care that could have been provided by their regular clinician.

Among high-need adults who feel isolated, nearly two-thirds reported having a mental health diagnosis or feeling emotionally distressed in the past year; this is a significantly higher rate than high-need adults who do not feel isolated. Experts report that the relationship between mental well-being and feelings of isolation are bidirectional, with isolation worsening an individual’s mental health conditions, and mental health conditions exacerbating feelings of isolation. It is possible the COVID-19 pandemic had a multifaceted impact on the mental well-being of older adults.

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National Women’s Health Week Resources from the NIH

It’s National Women’s Health Week—a time for women to focus on making good choices to promote their physical and mental health.  

We have resources that can help. Visit our website for information on:

• Stress
• Yoga
• Relaxation techniques
• Menopause symptoms
• Other topics in our A to Z index

Read more at https://www.nccih.nih.gov/health/womens-health-and-complementary-approaches?nav=govd

Hospice CAP Liability and Claims Denials

The Health Group 

As hospices become subjected to claims denials, whether such denials are the result of a UPIC or not, the hospice may be entitled to a refund of previously paid CAP liabilities.  We reported on this in 2021; however, The Health Group, LLC ("THG") recently has identified several hospices that are entitled to a CAP liability refund.

When a claim is retroactively denied for a completed CAP Year, the denied claims impact Medicare payments and beneficiary counts used in the determination of the aggregate payment limitation (“CAP”).

If your hospice has incurred a CAP liability in completed CAP Years, but has experienced claim denials for whatever reason, you should be tracking the CAP liability monthly for purposes of identifying the status of that CAP liability.  This monthly tracking allows you to monitor the increasing CAP liability, but also allows you to identify the impact of claim denials, if any, on that liability.

If you identify an overpayment, notify the Medicare Administrative Contractor (“MAC”) immediately of the overpayments, including calculations, and request a refund of the overpayment.  Remember, if you have overpaid a CAP liability because of denied claims, then Medicare has recovered from you twice; once when the claim was denied and again when the CAP overpayment was demanded for repayment.

CMS is aware of the potential of a double recovery of amounts from hospices.  On April 19, 2021, the following was added to the Medicare Program Integrity Manual, Chapter 4: 4.17 – UPIC Hospice Cap Liability Process – Coordination with the MAC (Rev. 10711; Issued: 04-01-21; Effective: 04-19-21; Implementation: 04-19-21). . .

See https://www.cms.gov/files/document/r10711pi.pdf  for the changes.

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Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds

New York Times

Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.

Enrollment in Advantage plans has more than doubled over the last decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.

The new report, from the inspector general’s office of the Health and Human Services Department, looked into whether some of the services that were rejected would probably have been approved if the beneficiaries had been enrolled in traditional Medicare.

Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.

The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.

In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.

Based on its finding that about 13 percent of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.

Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.

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