Miscarriage Arrest; MA Reaped Billions for Home Visits; Dirty Work of Care Denials

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Arrested After Miscarriage in Nevada

In Winnemucca, Nevada, when the police showed up at Patience Frazier’s door, she assumed they were there for someone else, the Washington Post reported. However, they were there for her after she had a miscarriage.

Frazier was charged with manslaughter under a 1911 law, titled “taking drugs to terminate pregnancy,” that supplements Nevada’s abortion restrictions, the Post reported.

“As in Frazier’s case, women who are prosecuted are typically accused of trying to end pregnancies without the help of a medical professional — a method frequently chosen because they live far from an abortion clinic and can’t afford to get to one,” the article stated. “These prosecutions also often occur when women are thought to be relatively far along in pregnancy, near or past the point when a fetus could potentially survive outside of the womb.”

Frazier already had 2 sons when she found out she was pregnant in early 2018, the Post reported. She feared being evicted by the man she had recently moved in with. Though she scheduled an abortion in Reno, she didn’t have a way to make the 2.5-hour trip.

She admitted to ingesting large amounts of cinnamon to try to end the pregnancy, but that is not what prosecutors focused on, the Post reported.

Rather than cinnamon, which has not been linked to miscarriages, lawyers and detectives focused on Frazier’s drug use while pregnant after a toxicology lab found remnants of marijuana and methamphetamine in the remains of her miscarried fetus. Although Frazier maintained she had not used drugs in an effort to end her pregnancy, she was sentenced to between 30 months and 8 years in prison.

However, in 2021, Frazier’s conviction was set aside due to ineffective assistance of counsel, the article stated.

“Patience has been portrayed as an antichrist, but this Judge thinks she is, instead, just a mother caught hopelessly in the web of poverty with a lack of any support system,” Judge Charles McGee wrote in a 40-page decision, describing Frazier’s case as a “total miscarriage of justice.”

Medicare Advantage Made Billions from Home Visits

Last year, Medicare Advantage plans raked in about $4.2 billion in extra payments for diagnoses from home visits the companies initiated, even though they led to no treatment, the Wall Street Journal reported, citing a report from the HHS inspector general.

On average, each of these visits was worth $1,869 to the insurers — findings that are similar to those of a previous WSJ investigation published in August that showed, between 2019 and 2021, insurers made an average of $1,818 for each visit based on diagnoses for which individuals received no other treatment.

Now, for the first time, the inspector general’s office has recommended that Medicare restrict or cut off payments for diagnoses from such visits, WSJ reported.

Among the top diagnoses driving such payments is a form of rheumatoid arthritis, “which might require lab work and X-rays to diagnose, along with secondary hyperaldosteronism, a condition that can be confirmed with blood work,” the article stated.

“We’re seeing that some Medicare Advantage companies are making billions from the health risk assessment diagnoses without providing care for the conditions that they identify,” Erin Bliss, assistant inspector general for evaluation and inspections, told WSJ.

This could mean some of the diagnoses are false, or that insurers aren’t connecting patients to the care they need even though they are paid extra based on the supposed cost of treatment, Bliss further told WSJ. “Profiting off enrollees’ medical conditions without providing treatment for those conditions is wrong,” she added.

The Company Behind Insurance Denials

Insurance companies often outsource coverage decisions to a “largely hidden industry that makes money by turning down doctors’ requests for payments, known as prior authorizations,” ProPublica and the Capitol Forum reported.

The biggest player is EviCore, which is owned by insurance giant Cigna. EviCore uses an algorithm backed by artificial intelligence, “which some insiders call ‘the dial,'” that can adjust for higher denials, an investigation by the outlets found.

“Some contracts ensure the company makes more money the more it cuts health spending,” the article stated. “And it issues medical guidelines that doctors have said delay and deny care for patients.”

EviCore promises insurers a 3-to-1 return on investment, so for every $1 spent on EviCore, the insurer pays out $3 less on care, the article stated. Salespeople have pointed to a 15% increase in denials, according to the investigation, which is based on internal documents, corporate data, and dozens of interviews with former employees, doctors, industry experts, healthcare regulators, and insurance executives.

A Cigna spokesperson on behalf of EviCore told the outlets: “Simply put, EviCore uses the latest evidence-based medicine to ensure that patients receive the care they need and avoid the services they do not. … The natural product of improved care quality and reduced waste is savings for our clients, lower out-of-pocket costs for patients, and fewer healthcare premium increases for Americans.”

Large insurance companies told ProPublica and the Capitol Forum that they hired EviCore to help ensure customers received safe and necessary treatments, and hold down costs for inappropriate care.

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