New York Lawmakers Are Scrutinizing Home Care. We’ve Got Questions.

Much of what we’ve found out has been disconcerting. For starters, Leading Edge’s founder, the health care entrepreneur Jerry Weissman, was convicted of insurance-related felonies in the 1990s, for which he served time in federal prison. We’ve also learned that Leading Edge has regularly refused to pay its enrollees’ medical bills, once tried to cancel a patient’s insurance coverage while he was hospitalized with a coma, and has pioneered multiple ways to help employers keep money that by law is supposed to go to their workers.

In interviews with New York Focus, former Leading Edge employees described these strategies as a “shitty situation,” “very disheartening,” and a “cash cow.”

But there’s more we’d like to know.

Here are five open questions from our reporting that we hope lawmakers will ask about on Thursday:

1. Leading Edge has frequently shirked paying medical bills for care that it is supposed to cover. How will they be prevented from doing this going forward?

In June, we wrote about Robyn Hodgson, a Pennsylvania woman whose Leading Edge insurance had left her with five-figure medical debt because the company refused to cover treatments for her rare genetic condition.

After we asked Leading Edge about Hodgson’s case, the company paid her bills. But others in similar situations are not so lucky. Former employees said that patients would regularly pay bills that were supposed to be covered by insurance because they didn’t know their rights or couldn’t spend weeks fighting with Leading Edge on the phone.

PPL told us that it would not permit Leading Edge to leave eligible bills unpaid — but it didn’t say how this would be enforced or whether safeguards were written into their contract.

2. How will PPL ensure that Leading Edge handles appeals in a timely manner?

If an insurance company refuses to pay a bill, patients and doctors have a right to appeal, and the company is required to respond within a matter of weeks. Multiple former Leading Edge employees said that Leading Edge regularly flouted this rule, and that appeals would be left lingering for months or even years. Some also said that appeals from doctors were denied by default, which is not permitted under federal law.

PPL told New York Focus that they would require Leading Edge to respond to appeals in a timely manner, but again, didn’t say how this would be enforced.

3. Is Leading Edge’s insurance plan actually a scheme to keep money from workers?

Leading Edge and PPL are requiring all of their workers in the New York City area to enroll in their health insurance plan. Unfortunately, the plan is extremely bare-bones: It covers only basic preventative care, with no benefits for specialist visits, hospitalization, or surgery.

Most home care workers have better insurance already, and so won’t be helped at all by this plan. But it could make a lot of money for Leading Edge and PPL.

That’s because home care workers — who generally make about $20 an hour — fund the plan through their own paychecks. Forty cents is taken out of each worker’s hourly pay to fund the plan. That money is supposed to be used to cover medical care costs, but since the plan covers so few treatments, it will likely go mostly unspent.

A former Leading Edge employee told New York Focus that the company often used this business model, and it led to huge profits. In New York, the profit could reach up to $60 million a year — all from money taken out of workers’ paychecks, according to an estimate by New York Focus.

In a statement last month, a PPL spokesperson said that this analysis is “categorically incorrect and founded on outdated assumptions and misinformation,” and that the company and its partners are “not profiting off unspent premiums.”

The spokesperson, who wouldn’t share their name, did not agree to an interview, answer follow up questions, or provide evidence for their claims.

4. Is the “benefits card” that Leading Edge is offering another way to keep money from workers?

The health plan isn’t the only thing that workers are funding through their paychecks. Downstate workers are also required to pay 22 to 47 cents an hour towards Leading Edge’s “Flex Card,” a debit card that can be used for certain expenses like health care and transit.

The advantage of this card is that the money isn’t taxed. The disadvantage is that many workers are unaware of the card or don’t understand how to use it, as Leading Edge has previously admitted. It’s also nearly impossible for workers to benefit from the funds if they stop working in home care, meaning that whatever balance they have on the card will effectively become lost wages.

This program could generate as much as $30 million in annual profits, according to an estimate by New York Focus.

5. Are these two plans legal?