In the wake of the Change Healthcare cyberattack, providers nationwide have been walking a fine line between their commitment to patient care and their financial needs.
The unprecedented network outage has crippled independent pharmacies, chain drugstores, hospitals, nursing homes and other providers that have scrambled to work around the problem while not being sure when or how much they'll be paid.
Related: CMS offers relief to providers affected by Change Healthcare outage
“It put us in a position to make a clinical decision about how the patient is going to be affected if they don't have this medication. But you're still thinking. 'If this medication goes out the door and I don't eventually get paid for it, how does that affect my business?'” said Natalie Ryan, a pharmacist and vice president of specialty pharmacy at Value Specialty Pharmacy in Duncansville, Pennsylvania.
The company dispenses drugs that can cost up to $25,000 per prescription for patients with diseases such as hepatitis C, psoriatic arthritis and rheumatoid arthritis, Ryan said. A missed dose could cause adverse effects and require patients to restart treatments.
Change Healthcare's systems have been down since the ransomware group known as BlackCat (also called ALPHV or Noberus) allegedly breached its systems Feb. 21. The division of UnitedHealth Group subsidiary Optum processes about 15 billion transactions a year and its tendrils extend throughout the healthcare sector.
When Change Healthcare was forced to take its systems offline, crucial everyday processes such as billing, claims and prior authorizations ground to a halt. UnitedHealth Group says the situation is improving but providers and health insurance companies dependent on Change Healthcare are still feeling the pain.
“It’s been a logistical nightmare,” said Greg Turner, pharmacist and co-owner of Special T Rx in Dale, Indiana. He said he had never dealt with a disruption of this magnitude during his more than three decades in the pharmacy business.
Last week, about 80 of the more than 200 prescriptions Special T Rx needed to dispense were delayed, Turner said. Drugmakers give some patients copayment coupon cards for brand name medications, and some are exclusively managed by Change Healthcare. The pharmacy provides medicines for HIV, cancer and other ailments that can cost patients $6,000 to $10,000 per month, Turner said. “Some people simply do not have the resources to afford the medication without the copay card,” he said.
This uncertainty is especially burdensome on independent pharmacies already managing tight margins that may struggle to remain open because of the Change Healthcare incident.
“I can't let a $1,000 medication out of my pharmacy and hope the coupon is going to reimburse me," said Rebecca Cormier, pharmacist and co-owner of Reed’s Pharmacy in Mamou, Louisiana. "I have to be able to see it with my own eyes first. It's causing some access to care issues.”
On Friday, Change Healthcare set up a temporary version of its Rx ePrescribing service. As of Tuesday, UnitedHealth Group estimated pharmacy claims are flowing at "near-normal levels," the company wrote in a notice on its website.
But the temporary system didn't fix the coupon problem. That may be resolved as soon as Thursday, when UnitedHealth Group expects Change Healthcare's pharmacy network to be online again for the "vast majority" of customers, UnitedHealth Group said in the notice. Once the network is reconnected, pharmacies would be able to submit claims and begin collecting reimbursements, according to the company.
'We don't want anybody to miss a dose'
Value Specialty Pharmacy, Special T Rx and Reed's Pharmacy temporarily changed claims processing vendors but are still having difficulties applying copay coupons, verifying patient coverage, determining cost-sharing and automatically sending prior authorization documentation to physicians.
Consonus Healthcare, which provides long-term care pharmacy services to St. Louis Park, Minnesota-based Lifespark Senior Living and other facilities, has filled prescriptions knowing payers could reject the claims once the pharmacy is able to process it, said Jessica Androff, president of Consonus Pharmacy.
“LTC pharmacies are highly regulated and must dispense medications on time. We dispensed prescriptions with no express obligation of payment by the pharmacy benefit managers, sending out medications unpaid to ensure continuity of care,” Androff said in a statement.
Providence Health and Services, which operates Credena Health pharmacies, is doing whatever it can to get medicines to patients, said Elie Bahou, chief pharmacy officer at the Renton, Washington-based health system.
"We don't want anybody to miss a dose. If you've got high blood pressure, you miss a dose or two, you could end up with a stroke and end up in a hospital. That's not what we want," Bahou said.
Baptist Health’s retail pharmacies began working with an alternative claims processing vendor last week, a spokesperson for the Louisville, Kentucky-based health system said in a statement. “Delays in service are expected as the pharmacies work through their backlog of claims filled during the transition,” the spokesperson said.
Cash crunch
The longer Change Healthcare's systems are down, the bigger the cash flow problem becomes.
Patients at Grants Pass Clinic in Oregon are struggling to pay claims online. The primary care practice expects a significant drop in revenue for February because of billing disruptions, CEO Christi Siedlecki said. “My focus is on preparing my physician owners for the potential financial fallout from this,” she said.
Genesis HealthCare's affiliated skilled nursing facilities face similar issues, said Johnny Patterson, vice president of government relations for the Kennett Square, Pennsylvania-based company, which has resorted to backup systems.
"This outage adds significant stressors exacerbating an already fragile situation. The aftermath of the pandemic has left the industry grappling with numerous challenges, and the additional strain we are facing is alarming," Patterson said in a statement.
UnitedHealth Group announced a temporary loan program for affected providers Friday, but the American Hospital Association slammed the initiative for its limited eligibility criteria and for terms and conditions the trade group characterized as unfair.
The AHA, the American Medical Association, and the American Health Care Association/National Center for Assisted Living separately sent letters to the Health and Human Services Department requesting accelerated and advanced Medicare payments to bolster provider finances. On Tuesday, HHS announced initiatives to address these concerns, but will only consider advance payments on a case-by-case basis.
Typically, hospitals rely on daily reimbursements from payers that use Change Healthcare as their claims processor, and providers have said manually submitting claims isn’t feasible for long.
One Florida health system hasn’t been able to submit any claims during the outage, said Mary Mayhew, president and CEO of the Florida Hospital Association. That’s tens of millions of dollars a day the health system is missing, she said without identifying the company.
“When hospitals don't get paid, that affects their ability to meet payroll for the doctors and nurses and other staff, which comprise over 60% of their budget,” Mayhew said. “I can't really overstate the gravity of this.”
