Latest news with #UnitedHealthcare
Fox News
19 minutes ago
- Politics
- Fox News
America's Iran dilemma, why left's 'No Kings' protests are a Trojan horse and more
Print Close By Fox News Staff Published June 20, 2025 Welcome to the Fox News Opinion Newsletter. JESSE WATTERS – Fox News host discusses how President Donald Trump is weighing his options regarding Iran… Continue watching… HUGH HEWITT – There is a lot of news, but only one 'story' history will focus on… Continue reading… DON'T BE FOOLED – 'No Kings' rallies are a Trojan Horse for radical, violent Leftists… Continue reading… REP. RO KHANNA – A commonsense, bipartisan plan for immigration… Continue reading… MIKE POMPEO – Fox News contributor and former Secretary of State Mike Pompeo suggests 'the world will be safer' after Israel targeted Iranian nukes… Continue watching… WORDS MATTER – The Left's dehumanization of Trump is pushing people over the edge – with disastrous consequences… Continue reading… SEEN AND UNSEEN – Fox News contributor Raymond Arroyo calls out the 'ultimate threat to democracy' in Los Angeles and dissects a musical glorifying accused United Healthcare CEO killer Luigi Mangione on 'The Ingraham Angle.' Continue watching… ART OF THE DEAL – Trump's Middle East moves actually follow a brilliant master plan… Continue reading… STEVE MOORE – The good, the bad and the ugly in the Senate's 'big beautiful' tax bill… Continue reading… AMERICA'S IRAN DILEMMA – How to strike Fordow without losing sight of China threat… Continue reading… CARTOON OF THE DAY – Check out all of our political cartoons… Print Close URL
Boston Globe
22 minutes ago
- Health
- Boston Globe
Even with job-based health coverage, experts suggest signing up for Medicare
More than a year after her riding accident, Diamond was back at the emergency room after she tripped on a step while entering a New York restaurant. Her face covered in blood, Diamond was examined by staff, who did multiple CT scans. The bill for that care: $12,000. Advertisement This time, though, the insurance coverage wasn't routine. Nearly all her claims were denied. Diamond was caught in a fairly common coverage snag: People who have group health insurance when they become eligible for Medicare sometimes find themselves on the hook for their medical bills because their group plan stops paying. Diamond contacted several people at UnitedHealthcare before she found out why the insurer refused to pay her claims. When Diamond turned 65 in 2022, Medicare — unbeknownst to her — became the 'primary payer' for her claims, meaning the federal health program for older or disabled people was supposed to take the lead in covering her medical bills, before other insurers paid anything. (As secondary payer, Diamond's employer policy picked up 20% of what Medicare would have paid.) Advertisement Had she signed up for the government insurance plan when she turned 65, Diamond could have avoided a financially perilous situation that left her unexpectedly responsible for the medical costs she incurred during that time. She began to understand what had happened as she made inquiries about the denied claims. Diamond said she was told that UnitedHealthcare audited her claims last year and determined it had been improperly paying for her care, perhaps because her pricey medical claims after her fall from the horse raised a red flag. The insurer not only stopped paying current claims but also moved to claw back tens of thousands of dollars it had paid to providers in the two years since she turned 65. Some of those providers are now seeking payment from her. 'It's horrifying,' she said. 'For about two months I was devastated. I thought, 'Where am I going to get the money to pay all these people? There goes my retirement.'' The mistake has already cost her $25,000 and may cost her much more if providers continue to bill her for amounts that UnitedHealthcare has clawed back for care she received before signing up for Medicare in February. A UnitedHealthcare spokesperson declined to provide an on-the-record statement, citing safety concerns. Patient advocates say they frequently hear from people who, like Diamond, thought they didn't need to sign up for Medicare upon turning 65 because they had group health coverage. That assumption is generally correct if they or their spouse is working at a company with at least 20 employees. In that case, employer coverage is considered primary and they can delay signing up for Medicare as long as they or their spouse continues to be employed there. Advertisement But if someone has employer coverage through a company with fewer than 20 workers, Medicare Similarly, if someone is older than 65 and has retiree health coverage or has left their job and opted to continue their employer coverage under the Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, Medicare pays first. The issue can also arise for people who are younger than 65 if they are eligible for Medicare because of a disability. In those instances, Medicare pays first if they or their family member works at a company with fewer than 100 employees. If people in these groups don't sign up for Medicare when they become eligible, they can find themselves responsible for all their medical bills for years. (They may also owe a penalty for late enrollment in the Medicare program.) 'It's very alarming and there's no current fix to the situation,' said Fred Riccardi, president of the New York-based Medicare Rights Center, a national patient advocacy organization. The Centers for Medicare & Medicaid Services did not respond to a request for comment. 'What I see constantly now is that insurers go back and they claw back the money from the doctor and the doctor then claws the money back from the patient,' he said. Advertisement Costly claims may trigger an insurer to examine someone's coverage. Those big claims 'seem to get on the insurer's radar,' said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center. UnitedHealthcare has recouped over $50,000 in medical bills from some of the providers who treated Diamond in New York after her riding accident. She's paid them about $25,000 so far. Some have agreed to let her pay the amount Medicare would have paid. But there may be more bills to come. Under New York law, health plans have two years after claims are paid to claw back payments from providers, and providers have three years to sue patients for medical debt. So, while there is still time for Diamond to be billed, the clock will eventually run out. Diamond plans to sue the broker who manages her company's health plan and other benefits for negligence. 'The Medicare secondary payment rules basically say that if you didn't sign up because you didn't know Medicare was supposed to be primary, that's on you,' said Melanie Lambert, senior Medicare advocate at the Center for Medicare Advocacy in Connecticut. Lambert said she has seen the issue 'many, many times.' In some instances, if a beneficiary can demonstrate they were misled by an employer or a federal employee, they may qualify for relief or a special enrollment period, she said. In a Advertisement The Department of Labor didn't respond to a request for comment. In earlier times, people started collecting Social Security benefits then automatically got Medicare when they turned 65. Now, enrolling in Medicare is more complicated for many people, said Tricia Neuman, a senior vice president and the executive director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News. 'As more people are delaying going on Social Security and delaying going on Medicare, there's more opportunities for people to make mistakes, and those mistakes are costly,' Neuman said. Coverage experts say there are no clear requirements for insurers, employers, or the federal government to notify people about how the payment rules governing coordination of benefits between health plans may change when they become eligible for Medicare. The information appears in a chart in the government's 'Medicare & You' handbook, if someone knows to look for it. But it is not easy to find. A straightforward fix could solve many of the problems people face in this area, Scherzer said. Since every health plan knows its enrollees' ages, why not require them to notify people approaching 65 of possible benefit coordination issues with Medicare? 'It's so simple and such a no-brainer.' This story was published in partnership with .
CNBC
2 hours ago
- Health
- CNBC
Taking on Goliath: Brain surgeon's clash with UnitedHealthcare shows insurer's hardball tactics
Dr. Catherine Mazzola, a pediatric neurosurgeon, runs a practice in New Jersey that treats low-income children on Medicaid. Since 2008, she has cared for boys and girls with cerebral palsy, spina bifida and other neurological disorders. But now, her practice is in serious jeopardy, she says, because of recent moves by the insurance and health care giant UnitedHealth Group. The story begins in February 2024, when a unit of UnitedHealth experienced a massive hack. The unit, Change Healthcare, shuttered its systems and halted all reimbursements owed to hospitals and doctors like Mazzola. To help providers stay afloat, Optum, another UnitedHealth subsidiary that includes a bank, began offering "temporary," no-interest loans. Mazzola's practice was among those tapping into the program — it received $535,000, documents show. The practice began repaying the loans, but in January Optum demanded that it repay the money in full and within five business days. "Our practice is doing the BEST we can," Mazzola wrote in an email to Optum on Jan. 20. "Please ask the loan collection people to STOP. We are already in repayment at the maximum possible amount monthly." The situation soon got worse. In mid-February, she stopped receiving reimbursements from UnitedHealthcare. By April, her practice was out $78,000, her accountant's records show, and was struggling to make payroll. Mazzola dug into the UnitedHealthcare claims and was shocked to find the insurer had drawn up reimbursement checks payable to her practice and then deposited those checks into its own bank account, records shared with NBC News show. "They are trying to bankrupt our practice," Mazzola said. "Now, we're going to do brain surgery and instead of paying us, they're going to take the money themselves." Bryan Fisher, a spokesman for UnitedHealth Group, the conglomerate that owns the insurer, declined to comment on its actions related to Mazzola's practice, New Jersey Pediatric Neuroscience Institute. Her case sheds light on something few patients know about: the behind-the-scenes battles doctors say they must wage with insurers over reimbursements and the increasingly aggressive tactics taken by huge payers like UnitedHealthcare. Her experience also gives credence, antitrust experts say, to concerns that UnitedHealth Group's acquisitions of an array of health care operations in recent years have given it too much power over patients and the doctors treating them. "You've got physicians looking out for hundreds and thousands of families, and you've got this big corporate entity exerting as much financial power as it can, just because it can," said Josh Bengal, staff counsel at the Medical Society of New Jersey. "It's upsetting." The hack in February 2024 affected 190 million patients, making it the largest ever involving medical data. UnitedHealth Group ultimately paid a $22 million ransom to the cybercriminals. After the pause in reimbursements, many providers took out loans through Optum — over $9 billion was borrowed, according to company filings. Repayment terms on the loans were vague, with Mazzola's contract noting only that her practice would have to repay the loan within 30 business days of receiving notice from UnitedHealth Group. But Mazzola and other doctors said they were assured by the congressional testimony of Andrew Witty, UnitedHealth Group's former chief executive, who said in May 2024 that the company would seek repayment only when borrowers' businesses were back to normal. Even though Change Healthcare said it restarted claims processing about a month after the breach, doctors who spoke with NBC News said their operations continued to struggle long after, with some saying they are out millions as a result. Others were forced to close after being crippled by the loss of income. When Optum began demanding repayment of loans in January, it gave borrowers five business days, according to letters reviewed by NBC News. Those who didn't meet the demands could have their UnitedHealthcare reimbursements withheld as repayment, the letters say. Mazzola's practice had promised to submit $10,000 a month until her $535,000 loan was repaid. It was all she could afford, she told Optum in emails reviewed by NBC News. Mazzola said an Optum executive told her by phone that her repayments weren't enough. And in mid-February, UnitedHealthcare began intercepting reimbursements owed to Mazzola's practice "to repay amounts owed under your agreement with Change Healthcare Operations LLC," documents show. Upon further investigation, Mazzola learned the puzzling way UnitedHealthcare diverted the money — drawing up checks payable to Mazzola's practice and then depositing them into a UnitedHealthcare bank account, the documents show. "How can United Healthcare claw back money that we are due for surgeries and office visits?" Mazzola wrote to an Optum executive she had been dealing with. She received no response, but in April the company stopped seizing reimbursements from her practice after she complained to the American Medical Association. It waded into the fight on April 11, when Dr. James Madara, the AMA's chief executive, wrote to Roger Connor, the chief executive of Optum Insight, asking that the company stop its payment demands. "Physician practices are still suffering severe financial distress as a result of the cyberattack nearly 14 months after the breach was first discovered," Madara wrote. "We want Optum to honor its commitment to wait to recover repayment for any loans until the physician determines that it is the appropriate time, because the physicians have relied on Optum's statements." In a statement, Optum said it is working with providers "to identify flexible repayment plans based on the individual circumstances of providers and their practices." "We have also worked with UnitedHealthcare to ensure the claims it receives are reviewed in light of the challenges providers experienced, including waiving timely filing requirements for the plans under its control," it added. Multiple lawyers interviewed by NBC News reviewed the loan agreement Mazzola's practice signed and characterized it as a contract of adhesion — in which one party calls the shots and the other has little choice but to agree. The financial ruin Mazzola and other doctors faced because of the hack, an event caused by inadequate security at Change Healthcare, made the loans even more one-sided, some lawyers said. As a result, doctors may have legal recourse after the aggressive actions UnitedHealth Group took to extract loan repayments. The central question surrounding UnitedHealth Group's reimbursement actions is "whether they abused their use of this remedy by insisting on repayment before it was appropriate for them to do so given the damages that they caused," Daniel Schwarcz, a professor at the University of Minnesota law school, said in an email. Amid its clashes with doctors, UnitedHealth Group announced earnings of $9 billion from operations in the first quarter of 2025, a 15% jump from the same period last year. Revenue for the three months was $110 billion. Even after Change Healthcare restarted claims processing, doctors who spoke with NBC News said they were never reimbursed for many claims because the disruption meant they couldn't submit them within insurers' required time periods. The doctors also said their costs increased after the hack because they had to pay staff members to chase reimbursements. Mazzola, who estimates that her practice lost $1 million because of the hack, has asked Optum to reimburse her for costs her practice incurred as a result of the breach. But the terms Optum offered would have barred her from being able to sue it because of the hack. So she declined to accept it. "I really believed that Optum, who was orchestrating these loans, would give physicians and physician groups a reasonable amount of time to repay the loans with the understanding that this financial crisis almost bankrupted us," Mazzola said. "I mean literally, you're talking about $0 in your bank account, and you have 70 employees to pay." Doctors say they weren't the only ones hurt by the hack. Patients, too, were harmed when providers didn't have the reimbursement revenue needed to buy medicine, for example. "There were a lot of delays of patient care as a result of it," said Dr. Pruvi Parikh, an allergist and immunologist in New York City who is medical director of a practice with six locations in New York and 15 in New Jersey. Parikh's group borrowed $400,000 from Optum to survive the hack. By the end of 2024, it had repaid all but $102,000 of it, documents show. On Jan. 7, Optum threatened to withhold reimbursements to Parikh's practice if the rest of the loan wasn't repaid in days, an email shows. "Coming up with that amount of money in five business days is not possible for the majority of private practices," Parikh said in an interview. "Not only did they not give us time to get back on our feet, they were like, 'Pay it now.'" While the practice met Optum's demand, she estimated it is out $2 million because of the hack. In a statement, Change Healthcare said it started clawing back funding it had provided "more than one year post the event and with services restored." The company said it is reaching out to those "that have not been responsive to previous calls or email requests for more information." The main reason doctors like Parikh and Mazzola are in this crucible, antitrust experts and physicians say, is that UnitedHealth Group operates so many cogs in the nation's health care machinery. By acquiring an array of health care operations in recent years—including physician practices and pharmacy benefits management, technology, claims processing and financial services — UnitedHealth Group can exert market muscle over weaker participants like doctors and patients. Federal antitrust lawyers concerned about possible monopolistic activities have sued health care companies in recent years. In 2022, two years before the Change Healthcare hack, the Justice Department and the states of New York and Minnesota sued to stop UnitedHealth Group's acquisition of the claims processor, saying it would reduce competition in health care insurance markets. Because Change Healthcare dominates the claims clearinghouse business, the government argued, its purchase by UnitedHealth Group would give the conglomerate information about how rivals' insurance plans work, a competitive advantage. UnitedHealth disagreed, saying it had strong "firewalls" between units that would prevent sensitive data from being shared throughout the company. Optum, the subsidiary that now houses Change Healthcare, would protect external customers' data from being shared with UnitedHealthcare or its affiliates if the deal went through, the company said. That argument seemed to persuade the federal judge hearing the case in Washington, D.C., a Trump appointee. In his October 2022 decision greenlighting the $13 billion Change acquisition, U.S. District Judge Carl J. Nichols cited the company's data-sharing firewalls as weighing "strongly against the government's position." Now, doctors say UnitedHealthcare's diverting reimbursements to repay Optum loans shows the kind of data-sharing the government was concerned about. Hayden Rooke-Ley is senior fellow for health care at the American Economic Liberties Project, a nonprofit, nonpartisan organization that works to curb monopolies. He said UnitedHealth Group's seizure of doctors' reimbursements is an example of what happens when a company coordinates among its different subsidiaries for its own purposes. "These are the sorts of conflicts of interest we worry about when an insurance company also owns the payment pipes and a bank," Rooke-Ley said in an interview. Asked to respond to the criticism, Fisher of UnitedHealth Group declined. When it added Change Healthcare to its operations in late 2022, Optum said the combined companies would "benefit the entire health system, resulting in lower costs and a better experience for all stakeholders." Parikh, the New York City allergist and immunologist, begs to differ. "It was a complete disaster, and to this day it's not corrected," she said of the hack. "But there hasn't been any accountability to this goliath Optum."
Daily Mail
2 hours ago
- Politics
- Daily Mail
EXCLUSIVE John Fetterman slams 'twisted martyr' Luigi Mangione after he brags about his $1M legal fund
Outspoken Senator John Fetterman has blasted accused CEO killer Luigi Mangione and his legion of supporters who have now handed their 'folk hero assassin' an astonishing $1million for his defense. Mangione revealed the staggering amount in a self-reflective list of 27 things he's 'grateful for' to mark his birthday of the same number inside the notorious Metropolitan Detention Center in Brooklyn, New York. Fetterman, a long-standing critic of the Mangione support cult, told exclusively in a reaction to the figure: 'Spoiler… to those who exalt, donate and defend their twist martyr, that cowardly a**hole will die in prison.' Mangione was arrested in Fetterman's home state Pennsylvania after five days on the run following the shooting death of healthcare boss Brian Thompson on a Manhattan street. The senator is one of many who believe Mangione's list was widely circulated to his army of devotees – who view him as a romanticized folk hero for his alleged slaying of the UnitedHealthcare CEO on December 4, 2024 – as a way to garner sympathy as the legal clock ticks. Millionaire Mangione references his large bounty in item 13 on his list of the '27 things I am grateful for'. It reads: 'The some 30,000 individuals around the globe who have come together to donate over $1,000,000 to my legal fund, enabling me to retain a world class defense team across three concurrent prosecutions.' Mangione allegedly shot Thompson in the back on a Manhattan sidewalk as he arrived for an investors meeting. The now 27-year-old was arrested at a McDonald's in Altoona, Pennsylvania, after an anonymous 911 call describing a 'suspicious man' resembling the suspect. According to a manifesto on him when seized, he was critical of the state of healthcare in the United States. The alleged killer, who was born into a wealthy and prominent family in Baltimore, Maryland, painted a rough canvas of his daily 'birdcage' incarceration in the 27-point list which also appears to revel in his 'celebrity' status. He mailed it out from the jail on June 6. Mangione, who is pleading not guilty to federal and state murder charges, gushes surprising praise toward staff at the jail, currently also housing rap mogul Sean 'Diddy' Combs during his sex-trafficking trial. He also gets political, dubbing America as 'sick' and praising both conservatives and liberals alike while calling free speech 'the basis of our way of life'. Mangione additionally reveals his supporters are deluging him with their own stories of everyday travails and adversity in an effort to boost him as he awaits a December 5 hearing to set his federal trial date. It appears money for goodies inside is not a problem, with him revealing he's being bombarded with top-ups for his commissary account to buy essentials and treats – and disclosing what he likes to eat. But Mangione's first thoughts are reserved for those closest to him. Leading his list of gratitude is a heartfelt nod to his inner circle: 'My friends, for being there when I needed it most,' he writes in thought number one. He is grateful for his family, yet curtly, and confusingly, considering his appeals for sympathy – informing his followers 'my personal life is none of your business!' And he praises 'the many talented and generous individuals who – if not for my current predicament – I would never have crossed paths with'. The accused assassin, who has a cushy job in jail cleaning showers, claims he suffers Groundhog Day symptoms as a result of others' kindness. Reasons to be grateful number four says: 'Letters. I spend each day between the same four walls of my unit, where I receive both holiday cards sent in December and birthday cards sent between March and May, creating a bizarre and disorienting Groundhog Day scenario where every day is both Christmas and my May 6th birthday. 'Nonetheless, I am incredibly grateful. The monotony of my physical environment is offset by the variety and richness of the lives I experience through letters: multi-page life stories, retellings of workplace conversations, stream of consciousness journal entries. 'Admissions of greatest fears, eager recaps of recent triumphs, mothers reliving senseless tragedies. Soulful creations, generous offers, advice.' Aside from his defense fund, he is also receiving money to make life easier inside the federal lock-up. Item 17 reads: 'Everyone who has donated to my commissary account, whose contributions have funded a tablet, songs, stamps, hygiene items, bbq sauce, Goya sazon, peanut butter and lot of tuna packets.' His tastes inside also extend to 'Chicken Thursdays and Sweet Baby Ray's bbq sauce'. Aside from food, the University of Pennsylvania alumni admitted he cannot wade through all the 'countless books I've been sent' but he's 'distributed these books to my grateful inmates'. 'While I've never read the vast majority of them, I've loved facilitating this collective practice in tsundoko', he continues, referring to a Japanese word meaning acquiring books but letting them pile up without reading them. Reason number 17 was a direct shout out to his fans whose donations to his prison commissary account allowed him to purchase Barbeque sauce, Sazon seasoning packets and even a tablet He also gives a fascinating insight into his own taste in literature. In a nod to the shadow of the charges facing him, he gives a thumbs up to two dystopian works involving rebellion against the system. 'My favorites include Ayn Rand's Anthem, Patrick Bet-David's Your Next Five Moves and Ray Bradbury's Fahrenheit 451,' he writes. Anthem is a dystopian fiction novella published in 1938 with the plot taking place at an unspecified future date when mankind is entering an age where individuality is eliminated. In it, a young man known as Equality 7-2521 rebels by doing secret scientific research. Fahrenheit 451 is another dark work, this time depicting an America where books are outlawed. It follows a man who rebels against his role as a fireman who burns books, quits his job and commits to preserving literature. Meanwhile, Your Next Five Moves: Master the Art of Business Strategy is a complete shift of gears, charting strategies for life and business – stating that the first move is understanding your own strengths and weaknesses. Mangione is grateful for 'being born in America', yet he adds: 'She is haunted by her past, she is sick, she is plagued by inner turmoil – such is her nature as a nation of individuals. 'She is young, in midst of an adolescent identity crisis. But despite her flaws, her frame is robust and her potential unmatched.' Mangione's gratitude further includes 'free speech, the basis of our way of life'. He adds: 'When you tear out a man's tongue, you are not proving him a liar, you're only telling the world that you fear what he might say' – George.' The quote is from A Clash of Kings, a fantasy novel by George RR Martin. Politically, Mangione strikes a seemingly even-handed tone. In items 23 and 24, he writes: 'The conservatives, who fiercely conserve the aspects of our society that make us great.' 'The liberals, who liberate us from the outdated aspects of our society that prevent us from being greater.' Meanwhile, he heaps praise on one man who has been helping him negotiate jail life. 'My cellmate J, who – despite spending half of every day inside a shared birdcage and being sentenced to a decade away from his six kids who he loved – tolerates the clutter of all my papers, shares his unique wisdom and doesn't hesitate to humble me when I need it.' Of the jail itself, he writes in thought number 10: 'The MDC staff and CO's (corrections officers), who are nothing like what The Shawshank Redemption or The Stanford Prison Experiment had me to believe. 'While the occasional minor dissent arises, I've found that they are people too and largely there to help.' Mangione's job cleaning showers was revealed by short-term cellmate Michael Daddea, who spent two weeks at MDC. In a now deleted video on X, he said he found Mangione welcoming, saying: 'Luigi is standing there and he's like, 'Hey, how's it going?' Like, super nice. Introduced himself to me first thing,' he said. Daddea, accused of 3D-printing at least 25 untraceable 'ghost guns' similar to the weapon allegedly used to kill Thompson, added Mangione was a 'collie'. 'So, a collie could be like a unit boss that tells you what cell you're going to. Luigi just happened to be a collie that cleans the showers,' he said. Daddea was arrested at his parents' house at Weeki Wachee, about 60 miles north of Tampa, Florida, and transferred to New York before being released on $250,000 bail. He was reluctant to talk further about Mangione when spoke with him at the single-family rural home. He said his attorney had advised him to take down the X posting about the alleged killer – and he told us he was fighting the accusations against him.
Miami Herald
6 hours ago
- Health
- Miami Herald
Have job-based health coverage at 65? You may still want to sign up for Medicare
When Alyne Diamond fell off a horse in August 2023 and broke her back, her employer-based health plan through UnitedHealthcare covered her emergency care in Aspen, Colorado. It also covered related pain management and physical therapy after she returned home to New York City. The bills totaled more than $100,000. The real estate lawyer, now 67, was eligible for Medicare at the time but hadn't enrolled. Since she was still working, she thought her employer health insurance plan would cover her. That misunderstanding has had financial repercussions that she continues to deal with today. More than a year after her riding accident, Diamond was back at the emergency room after she tripped on a step while entering a New York restaurant. Her face covered in blood, Diamond was examined by staff, who did multiple CT scans. The bill for that care: $12,000. This time, though, the insurance coverage wasn't routine. Nearly all her claims were denied. Diamond was caught in a fairly common coverage snag: People who have group health insurance when they become eligible for Medicare sometimes find themselves on the hook for their medical bills because their group plan stops paying. Diamond contacted several people at UnitedHealthcare before she found out why the insurer refused to pay her claims. When Diamond turned 65 in 2022, Medicare — unbeknownst to her — became the 'primary payer' for her claims, meaning the federal health program for older or disabled people was supposed to take the lead in covering her medical bills, before other insurers paid anything. (As secondary payer, Diamond's employer policy picked up 20% of what Medicare would have paid.) Had she signed up for the government insurance plan when she turned 65, Diamond could have avoided a financially perilous situation that left her unexpectedly responsible for the medical costs she incurred during that time. She began to understand what had happened as she made inquiries about the denied claims. Diamond said she was told that UnitedHealthcare audited her claims last year and determined it had been improperly paying for her care, perhaps because her pricey medical claims after her fall from the horse raised a red flag. The insurer not only stopped paying current claims but also moved to claw back tens of thousands of dollars it had paid to providers in the two years since she turned 65. Some of those providers are now seeking payment from her. 'It's horrifying,' she said. 'For about two months I was devastated. I thought, 'Where am I going to get the money to pay all these people? There goes my retirement.'' The mistake has already cost her $25,000 and may cost her much more if providers continue to bill her for amounts that UnitedHealthcare has clawed back for care she received before signing up for Medicare in February. A UnitedHealthcare spokesperson declined to provide an on-the-record statement, citing safety concerns. Patient advocates say they frequently hear from people who, like Diamond, thought they didn't need to sign up for Medicare upon turning 65 because they had group health coverage. That assumption is generally correct if they or their spouse is working at a company with at least 20 employees. In that case, employer coverage is considered primary and they can delay signing up for Medicare as long as they or their spouse continues to be employed there. But if someone has employer coverage through a company with fewer than 20 workers, Medicare generally becomes the primary payer when they turn 65. The real estate law firm at which Diamond is a partner has a handful of employees. Similarly, if someone is older than 65 and has retiree health coverage or has left their job and opted to continue their employer coverage under the Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, Medicare pays first. The issue can also arise for people who are younger than 65 if they are eligible for Medicare because of a disability. In those instances, Medicare pays first if they or their family member works at a company with fewer than 100 employees. If people in these groups don't sign up for Medicare when they become eligible, they can find themselves responsible for all their medical bills for years. (They may also owe a penalty for late enrollment in the Medicare program.) 'It's very alarming and there's no current fix to the situation,' said Fred Riccardi, president of the New York-based Medicare Rights Center, a national patient advocacy organization. The Centers for Medicare & Medicaid Services did not respond to a request for comment. Mark Scherzer, a lawyer in Germantown, New York, who helps people with insurance problems, and who advised Diamond, said he gets calls a couple of times a month from people who face this issue. 'What I see constantly now is that insurers go back and they claw back the money from the doctor and the doctor then claws the money back from the patient,' he said. Costly claims may trigger an insurer to examine someone's coverage. Those big claims 'seem to get on the insurer's radar,' said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center. UnitedHealthcare has recouped over $50,000 in medical bills from some of the providers who treated Diamond in New York after her riding accident. She's paid them about $25,000 so far. Some have agreed to let her pay the amount Medicare would have paid. But there may be more bills to come. Under New York law, health plans have two years after claims are paid to claw back payments from providers, and providers have three years to sue patients for medical debt. So, while there is still time for Diamond to be billed, the clock will eventually run out. Diamond plans to sue the broker who manages her company's health plan and other benefits for negligence. 'The Medicare secondary payment rules basically say that if you didn't sign up because you didn't know Medicare was supposed to be primary, that's on you,' said Melanie Lambert, senior Medicare advocate at the Center for Medicare Advocacy in Connecticut. Lambert said she has seen the issue 'many, many times.' In some instances, if a beneficiary can demonstrate they were misled by an employer or a federal employee, they may qualify for relief or a special enrollment period, she said. In a 2023 letter to the acting secretary of the Department of Labor, the National Association of Insurance Commissioners advocated applying a 'commonsense rule to COBRA plans, individual health insurance, and other coverage sources: those entitled to Medicare Part B but not enrolled in it should not lose benefits they pay for from a non-Medicare coverage source.' The Department of Labor didn't respond to a request for comment. In earlier times, people started collecting Social Security benefits then automatically got Medicare when they turned 65. Now, enrolling in Medicare is more complicated for many people, said Tricia Neuman, a senior vice president and the executive director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News. 'As more people are delaying going on Social Security and delaying going on Medicare, there's more opportunities for people to make mistakes, and those mistakes are costly,' Neuman said. Coverage experts say there are no clear requirements for insurers, employers, or the federal government to notify people about how the payment rules governing coordination of benefits between health plans may change when they become eligible for Medicare. The information appears in a chart in the government's 'Medicare & You' handbook, if someone knows to look for it. But it is not easy to find. A straightforward fix could solve many of the problems people face in this area, Scherzer said. Since every health plan knows its enrollees' ages, why not require them to notify people approaching 65 of possible benefit coordination issues with Medicare? 'It's so simple and such a no-brainer.' 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.
