Pages from the United Healthcare website are displayed on a computer screen in New York on Feb. 29. Earlier in February, Change Healthcare, a massive U.S. health care technology company owned by UnitedHealth Group, announced a ransomware group claimed responsibility for a cyberattack that the company says has affected billing and care authorization portals.

Nearly three weeks after a cyberattack paralyzed the largest billing and payment clearinghouse for the U.S. health care system, some Oregon medical providers are canceling appointments and taking out loans to keep their practices afloat.

Change Healthcare, a subsidiary of the insurance juggernaut UnitedHealth Group little-known outside of the health care industry, announced Feb. 21 it was a victim of a cyberattack. The company plays a critical role in the health care system, acting as the middleman between insurance companies, health providers, clinics and pharmacies.

Resulting downtime has left providers scrambling.

Andrew Vilius, mental health nurse practitioner and owner of Lifespan Psychiatric Consulting, a private practice in Gresham specializing in mental health care for people with autism and intellectual disabilities, said roughly 65% of his patients are covered by Medicaid through CareOregon, which uses Change Healthcare as its clearinghouse and has been unable to receive electronic claims since the cyberattack.

He said he’s spent much of the past 2½ weeks trying to navigate the issue, seeking workarounds to get medical claims sent to insurers so that his clinic can get reimbursed for services. As a result of the administrative workload, he had to cancel some appointments last week.

“If I’m dealing with this, that’s time I can’t be seeing patients,” he said. Vilius said he, along with his staff of three nurse practitioners and a therapist, provide care to roughly 400 patients.

And without payments coming in, the practice is burning through cash. If billing issues persist, Vilius said he plans to borrow money against his house so that he can pay his six employees and cover other expenses.

Change Healthcare processes some 15 billion medical claims a year and handles roughly 1 in 3 patient records in the U.S., said Sean Hoar, a partner at the labor and employment law firm Constangy, Brooks, Smith & Prophete in Portland. Its issues have left health providers in Oregon and around the U.S. unable to process bills and get payments they need to operate. And until last week, providers were unable to send prescriptions to pharmacies electronically.

“When insurance eligibility and coverage cannot be determined, and payment for health care services cannot be made, the provision of healthcare services grinds to a halt,” Hoar, who also serves as his firm’s chair of cybersecurity, said in an email. “Beyond the real-time disruption in health care services, the attackers claimed to have stolen eight terabytes of data, including millions of sensitive patient records.”

Brad Larsen, a psychologist and co-founder of Portland Mental Health & Wellness, said his practice on average was receiving roughly $400,000 in reimbursements every two weeks before the Change Healthcare hack. In the two weeks since the outage, his clinic received only $35,000 in insurance payments.

Not only is his practice receiving little to no money from payers, but the small amount of payments coming in are impossible to assign to individual patients’ accounts. In other words, Larsen is unable to tell how much to bill patients after what insurance companies have covered.

“I can see a big problem if this goes on. Oregon is already having a mental health crisis,” he said. “If this continues and we can’t pay providers, it’ll only get worse.”

Larsen said his practice had to take out $300,000 in loans just so he can pay his staff of 50 therapists and nurse practitioners through the end of the month. He said if the payments don’t come in before April, he and the four other co-owners of the practice are prepared to pool all their savings to keep the doors open. After that, he said the practice will have to furlough staff if the situation doesn’t improve.

“We’re willing to do whatever we can to stay open,” he said. “Our margins are already pretty tight. Like, we never get to a point where we have a ton of cash on hand.”

Mel Davies, chief financial officer of Oregon Oncology Specialists in Salem, said its revenue has dropped 50% since Change Healthcare went dark. The independent practice provides care for more than 16,000 patients with cancer and blood disorders. Davies said employees have been working overtime the last three weeks to prevent any disruptions in patient care. They’ve had to manually verify patient insurance coverage and file paper claims.

“This is a million times worse than when COVID hit because back then we at least got federal help,” she said. “But this time there’s no guarantees, and we don’t know when things will be up and running again.”

Davies said the practice spends as much as $1 million a day on chemotherapy and other cancer treatment drugs, and to keep the drugs coming, she’s had to borrow money from a bank and ask drug manufacturers and distributors if the clinic can delay payments.

“If this goes on, we’re going to have to reduce services by a lot,” she said. “I can make payroll maybe two more times while going into debt. … If we max out using our line of credit, we’re going to have to transfer out patients.”

Davies said she was relieved when the Centers for Medicare and Medicaid announced on Saturday that it would provide some emergency funds for providers impacted by the Change Healthcare outage. Davies said she applied for aid on behalf of the clinic but does not know how much money she’ll get, or when.

Last week, UnitedHealth Group said it had restored electronic prescribing and that other parts of the system, like payment processing, would be back online by mid-March. The company said it expects electronic payments to begin functioning again by Friday and that it hopes to restore medical claims processing services Monday.

Christi Siedlecki, CEO of Grants Pass Clinic, said that the update from UnitedHealth gave her some hope but that she wished the insurance behemoth would give more details on when operations will fully resume. She said that UnitedHealth’s assurances notwithstanding, her staff still can’t use electronic prescribing and has to issue prescriptions by paper.

“Right now, our biggest impact is still the prescriptions and we’re still unable to match up bills with insurance coverage,” she said. “The inability to send prescriptions electronically really impacts elderly folks and others who don’t have the means to drive to pick up paper prescriptions.”

Siedlecki said the outage has made it impossible to get prescriptions for controlled substances to patients who live far away, and patients who haven’t been able to pick up paper prescriptions in person just haven’t been getting the medications they need.

Siedlecki said while her clinic has started to receive more payments from insurers, the amounts are less than what’s expected and billed for. Like other providers, she said she’s unable to assign the payments she’s receiving to patients that were covered, which means she’s unable to tell how much patients owe.

“This is a serious situation. … Independent practices like us were already struggling before the Change Healthcare hack,” she said. “If this doesn’t get fully fixed by the end of March, then I’m going to have some really unhappy physicians in April.”

Beyond the inability to get paid by insurers, health care providers worry of more problems ahead.

Megan Geary, a mental health provider and CEO of Cascade Counseling and Consulting in Portland, worries about patient and provider data that’s been compromised.

“I feel like this is like the teeny, tiny frozen corner of the top of the iceberg and that this is going to become the magnitude of the Titanic,” she said. “Like, this is potentially going to take down health care as we know it.”

Like other small business owners of health practices, Geary fears for the financial stability of her clinic that serves over 500 patients across the Portland metro — roughly 60% of which are covered by the Oregon Health Plan.

“The silence from insurance companies and the government for weeks was deafening,” she said. “We’ve been forced to workaround and problem solve this catastrophic situation.”

Geary wonders how and why the government allowed one company to handle so many aspects of the health care system.

“If you wanted to catastrophically paralyze our health care infrastructure and medical system, this is one way to do it,” she said. “We can’t allow for this to happen again.”

The fallout from the Change Healthcare cyberattack has brought renewed attention to the increasing consolidation in the health care industry. Change was acquired by UnitedHealth Group in 2022 for $13 billion after the federal government unsuccessfully tried to block the merger.

Meanwhile, UnitedHealth has been buying medical practices nationwide, including in Oregon. Optum, an affiliate of UnitedHealth, bought the Oregon Medical Group system in Lane County in 2020, and then Portland-based GreenField Health in 2021.

Optum also recently announced plans to buy the Corvallis Clinic, which will require approval from the Oregon Health Authority. Last Friday, Optum and the Corvallis Clinic submitted an emergency exemption request to bypass the review process, according to Erica Joy Heartquist, spokesperson for the health authority.

In the request, the parties said the “transaction is urgently necessary to maintain the solvency of The Corvallis Clinic” as its “financial condition has materially deteriorated” since the deal was proposed in early December. It’s unclear whether the request is tied to the fallout of Change Healthcare’s system outage.

Heartquist said the state agency has paused its review of the deal and is evaluating whether Optum’s proposed acquisition should be exempt from review because of the risk the clinic could fail altogether, but she offered no timeline for the decision.

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“This is a million times worse than when COVID hit because back then we at least got federal help.”

— Mel Davies, Oregon Oncology Specialists, Salem