News : VGH files lawsuit against Medicaid Providers

Concerning the lawsuit brought by Virginia Gay Hospital, they have released the following statement: Virginia Gay Hospital has brought a lawsuit against Amerihealth Caritas Iowa, Inc., United Healthcare of the Midlands, Inc. and Amerigroup Iowa, Inc. The lawsuit, initially filed in September in state court, was moved on Thursday, October 25th, to federal court because the lawsuit alleges violations of federal law. At issue are changed reimbursements that result in hospitals absorbing the cost of some emergency room care given to Medicaid patients. The Associated Press has reported that DHS officials reclassified more than 700 symptoms to non-emergency status. One of those symptoms is a form of gastric pain that is often a symptom of a heart attack and can only be accurately diagnosed with an EKG. “We believe the changes not only result in losses to hospitals,” explains Mike Riege, Virginia Gay Hospital administrator, “but we also believe it’s completely unfair to Iowa’s Medicaid population. The three managed care organizations are refusing to make appropriate payment if the patient’s diagnosis turns out not to be a medical emergency. We fear that patients with medical emergencies won’t seek care because of worry that they won’t be covered.” “What gets lost in all the political posturing and the excuses from insurance companies,” says Mike, “is who Iowa’s Medicaid program serves. About 50% of the elderly in nursing homes who have already exhausted their savings are covered by Medicaid, and this group consumes 29% of the Long Term Care Medicaid budget. Now because of cuts in reimbursements, we fear that there will be a growing number of nursing homes and other providers of services to the elderly and disabled who will be refusing Medicaid patients. Children from low-income families receive coverage, and neglecting their care is not only cruel but will result in staggering long-term costs to our society. Those who are disabled and low income receive care from Medicaid, along with others who are so severely disabled that no family would have the resources to provide the care they need. I just spoke to a provider today who said they had to tap into their retirement savings just to keep their agency going because of this.” “A civilized society cares for it’s most vulnerable people,” Mike says, “and we don’t believe small hospitals like Virginia Gay, or small communities like Vinton, will be served if we go out of business so private companies can make more money.” Virginia Gay Hospital, a critical access hospital, has filed a lawsuit against Medicaid providers Amerigroup, UnitedHealthcare and AmeriHealth Caritas claiming that they have failed to pay fully for services that were provided to Medicaid eligible patients. The lawsuit claims that these practices have cost the hospital thousands of dollars due to them for services provided by the hospital. Amerigroup and AmeriHealth Caritas are both Iowa corporations while UnitedHealthcare is from Nebraska (Referred to as MCO's, Managed Care Organizations). In January of 2016, the state of Iowa contracted with the companies to provide services, and in April of 2016, Iowa DHS transferred most of the Medicaid recipients to one of these three companies. In November of 2017, AmeriHealth withdrew and transferred it's members to UnitedHealthcare. The lawsuits indicates that there was an ICD-10 Error. Hospitals are required to use an "ICD" (International Statistical Classification of Diseases and Related Health Problems) which is a medical classification list used by the WHO (World Health Organization) as well as healthcare providers to record patient's diagnosis, symptoms, and care. The Centers for Medicare and Medicaid Services (CMS) began using the ICD-10 (a 10th revision of the ICD) rather than the ICD-9 (the 9th revision). The ICD-10, according to the lawsuit has 5 times as many codes as the ICD-9. The lawsuit states that on October 1, 2015, CMS implemented the ICD-10 at the same time Federal law required providers and insurance companies (MCO's) to use the ICD-10 for billing. The suit also claims that from October 1, 2015 - about June 15, 2017, the MCO's were not using a complete and accurate list of ICD-10 codes. So in March of 2017, the insurance companies (MCO's) began to collect alleged over payments from Virginia Gay Hospital. Each of the companies cited the non emergent policy given by DHS and IME in informational letters, sent out in 2016 and 2017. Later in 2017, in a Legislative Bulletin, DHS and IME recognized that the code list used by the MCO's, was "incomplete and inaccurate and does not include a number of codes that are used in the ER, particularly those related to behavioral health." VGH also claims that because of the failure of the companies to follow and apply the correct ICD-10 codes, they are violating the contract with the hospital by recouping patient revenue. Virginia Gay Hospital is seeking from each of these insurers, the full amount of covered services provided to each Medicaid patient according to the ICD-10 codes as well as the costs to bring this action against the companies. Because this suit alleges that the companies violated federal law, the case was moved to federal court. Virginia Gay Hospital is a privately operated, nonprofit rural hospital, which has successfully served the needs of the people of Vinton and the surrounding communities since 1923. They provide quality health care services by using innovative and growth-oriented techniques. VGH also provides acute care on an inpatient and outpatient basis, skilled nursing care, long term care and home health care. Definitions CMS (Centers for Medicare and Medicaid Services) ICD-10 (a 10th revision of the ICD), 5 times as many codes as the ICD-9 ICD-9 (the 9th revision) IME (Iowa Medicaid Enterprise) MCO (Managed Care Organizations) ---- AmeriGroup and AmeriHealth files a response.