A Massachusetts retiree received unexpected medical bills totaling over $17,000 for a life-sustaining treatment, despite receiving prior written approval from his insurance provider. The case involves Leading Edge Administrators, an insurer that now covers tens of thousands of home health workers in New York, raising concerns about potential risks for a vulnerable workforce.
Kevin Danahy, a 60-year-old forced into early retirement by a heart condition, depends on regular drug infusions to manage his health. After his wife's employer switched to Leading Edge Administrators, his pre-approved treatment was suddenly denied, leaving him with substantial debt and forcing him to consider skipping essential medical care.
Key Takeaways
- A patient was billed over $17,000 for a pre-approved medication called Remicade.
- The insurer, Leading Edge Administrators, provided conflicting reasons for denying coverage.
- This same insurer now provides health plans for thousands of low-wage home health aides in New York.
- The incident highlights potential coverage gaps and communication issues that could affect many others.
An Approved Treatment Leads to a Shocking Bill
Kevin Danahy manages a serious heart condition, cardiac sarcoidosis, with regular infusions of a drug called Remicade. This treatment has been effective, controlling what his doctors described as a “severe” form of the disease. Without it, his health could decline significantly.
Earlier this year, his wife’s employer changed its health insurance provider to Leading Edge Administrators, a company that often works with Anthem Blue Cross Blue Shield. Understanding the high cost of Remicade, Danahy's medical team followed standard procedure and sought pre-authorization for the treatment.
On April 1, they received an approval letter from Anthem. The letter, reviewed by New York Focus, confirmed approval for seven Remicade treatments over the next year. It explicitly stated, “This approval means that, based on the information given to us, the medication is considered medically necessary.”
Trusting the approval, Danahy proceeded with his scheduled infusion. In May, he received and paid a bill for $672, which he assumed was related to his plan's deductible. However, the situation changed dramatically in July when a new bill arrived for the same visit. This time, the amount was $11,126, with a note stating, “This medication is not covered under your medical plan.” Leading Edge had paid nothing.
A Growing Financial Burden
The financial strain mounted quickly. An August bill for a June treatment added another $5,959 to Danahy's debt, bringing the total unexpected cost to over $17,000 for two pre-approved infusions.
Conflicting Explanations From the Insurer
The reasons for the denials were inconsistent. The first large bill claimed the drug was not covered. The second bill for the June treatment cited a different issue: “Pre-certification required but not obtained.” This directly contradicted the April approval letter that Danahy and his doctor had on file.
Danahy made numerous calls to Leading Edge to understand the discrepancy. “They said, ‘Your plan doesn’t pay for specialty medication.’ I said ‘Why did you approve it then?’” Danahy recalled. He reported that the company representatives had no answer for his question.
This sequence of events is cause for concern, according to one expert. Benjamin Chartock, a health care economist at Bentley University, commented on the situation, suggesting the insurer's process was flawed.
“At the very least they ought to put more safeguards to make sure that the information that gets to their patients is accurate and timely,” Chartock said.
After weeks of persistent effort and threatening legal action, Danahy saw some progress. Leading Edge sent revised statements that reduced his liability for the two treatments to $1,451. While a significant reduction, the process to get there was stressful and time-consuming.
Wider Implications for New York Workers
Danahy's experience in Massachusetts serves as a potential warning for many in New York. In May, Leading Edge Administrators became the insurance provider for tens of thousands of home health aides participating in a state-funded program known as the Consumer Directed Personal Assistance Program (CDPAP).
Public Partnerships, LLC (PPL), the private company now running the program, selected Leading Edge to insure its workforce. These workers, who provide essential care for the elderly and disabled, are often in low-wage positions. According to reports, the two health plans offered to these aides provide limited coverage for prescription drugs, with one plan offering no coverage for most medications.
About the CDPAP Program
The Consumer Directed Personal Assistance Program (CDPAP) is a New York State Medicaid program that provides services to chronically ill or physically disabled individuals. It allows them to hire their own caregivers, including family members, to assist with daily tasks.
There are signs that changes may be coming. At a public hearing, PPL Vice President Patty Byrnes stated that the company is consulting with insurance brokers. She expressed a hope to “provide better services” for the workers by the end of the year, suggesting the current arrangement with Leading Edge could be re-evaluated.
An Uncertain Future and Difficult Choices
Just as Danahy resolved the billing issue, his family faced another setback. His wife’s employment was terminated by her employer, Stellar Health Group. The company cited performance issues as the reason for the decision.
Danahy voiced suspicion that the termination was related to the high cost of his medical care. Leading Edge plans are often self-funded, meaning the employer is directly responsible for paying medical claims. A spokesperson for Stellar Health Group denied this, stating the claim was “categorically false” and that the decision was based on business factors.
Without his wife's insurance, Danahy must now rely solely on Medicare. His current plan does not cover infusion treatments, so he is in the process of applying for one that does. The uncertainty has already impacted his health.
Worried about incurring more massive bills from Leading Edge, he skipped his scheduled infusion in August. His next treatment is in October, and his doctor has warned that further delays could allow his condition to return, with potentially serious health consequences.
The financial pressure has forced him to weigh his health against his family's stability. “I don’t want to put any burden on the family financially,” he said. “Rather than pay for my infusion, I want to be able to pay for my daughter’s wedding.”
He added, “I’m just hoping that I haven’t hurt myself.”
