JustCare

Category: Medicaid

  • States address prior authorization denials, while Congress fears to tread

    States address prior authorization denials, while Congress fears to tread

    People across the country are facing increasing numbers of treatment denials from insurers, even after their insurers have approved these treatments for extended periods. Shalina Chatlani reports for Medical Express on how some states are addressing these prior authorization denials that are undermining patients’ continuity of care and causing them serious hardship. Meanwhile, Congress has been unwilling to act in meaningful ways.

    One patient suffering from chronic pain had been getting monthly infusions for pain relief. Then, Medicaid refused to cover these infusions. After many months, the corporate insurer administering Medicaid benefits decided to overrule the patient’s treating physician and deem the treatment medically unnecessary.

    Prior authorization denials keep health care spending down. They also enrich the insurers that contract to deliver Medicare and Medicaid services as well as coverage for working people. They are generally paid a fix rate upfront. What they don’t spend, they are largely able to keep for themselves, so they have an incentive to deny care or delay care. It helps to maximize their profits.

    Insurers leave patients without needed treatments, often to the detriment of their health and sometimes their lives. States have been stepping in to reduce the number of prior authorization delays and denials. Nine states have laws in place now to protect patients.

    New Jersey addresses insurer delays of care by requiring insurers to make determinations as to whether care is covered within 72 hours of a request. In Texas, doctors whose requests to provide care are approved 90 percent of the time receive a “gold card” that eliminates their need to seek prior authorization. But, to date, only three percent of doctors in Texas have gold cards.

    Washington has a law that ensures insurers make swift prior authorization determinations. Michigan ensures that insurers use only prior authorization processes that are peer-reviewed and approved. Arizona is considering a law that would require insurers to honor their own, or another insurer’s prior authorization determination if someone switched insurers, within 90 days of the determination. But, it would not apply to Medicaid patients.

    What’s insane is that our federal government effectively trusts insurers to implement prior authorization rules that are evidence-based and appropriate, with little oversight to ensure that is the case, even though mountains of evidence indicate that it is not. Moreover, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare and Medicaid, has little ability to hold insurers accountable when they violate prior authorization regulations.

    A new CMS rule is intended to speed up insurer prior authorization decisions for medical services. It goes into effect in 2026. But, it has no meaningful enforcement mechanism. As well, inexplicably, it does not apply to insurer determinations as to whether a drug is covered.

    State laws, for the most part, only apply to private health insurance that is state-regulated. Consequently, people in ERISA plans, who work for companies that self-fund their health insurance, are not protected by state laws. These laws also generally do not protect people with Medicaid.

    One recent study found that one in five people with cancer are denied care their treating physicians recommend. The American Medical Association found that patients often experience “serious adverse event(s)” as a result of prior authorization processes.

    Even when states are able to detect violations by insurers and hold them accountable, the penalties generally are so small as not to be a deterrent for the large insurers. One expert suggested holding insurance company medical directors accountable for wrongful prior authorization determinations; medical directors could be sued for malpractice. Oklahoma is considering a law that would do that.

    Here’s more from Just Care:

  • Medicare Advantage: Expect lots of care denials

    Medicare Advantage: Expect lots of care denials

    If you’re in a Medicare Advantage plan or any other corporate health insurance plan and need costly care, you can expect a denial from your insurer about once every seven times you seek treatment, reports Jeff Lagasse for HealthcareFinanceNews. A new national survey by Premier found that insurers deny almost 15 percent of claims for reimbursement, including claims for care that the insurers had authorized. And, insurers offering Medicare Advantage plans require prior authorization about 25 percent of the time.

    Insurers sometimes do not pay hospitals, health systems and nursing homes, even after they have okayed delivery of care. To be clear, insurers can deny payment with impunity, allowing them to hold onto assets. They challenge providers to appeal their decisions, a tactic that serves insurers’ bottom lines well.

    Insurers end up paying more than half of the claims that they deny initially. However, they only do so if providers are willing and able to go through a time-consuming and costly appeal process. For the providers, it is usually worth appealing since insurer denials are generally for costly charges.

    Health care providers spend nearly $20 billion each year appealing insurance corporation denials. That breaks down to $43.84 per claim on about three billion claims. Providers incur additional costs from the need for more clinical work–$13.29 for an inpatient stay and $51.20 for inpatient surgery, according to  American Medical Association estimates.

    Even when providers prevail on appeal, they generally can wait as long as six months after treating patients to get paid. Not surprisingly, many hospitals are hurting. In stark contrast, UnitedHealth and Cigna have around 25 percent more cash on hand today than they did five years ago.

    People with corporate health insurance not yet eligible for Medicare might not get the care they need for fear of having to pay out of pocket for it. About half say that they couldn’t pay a $1,000 hospital bill in 30 days time, according to a Commonwealth Fund report. Forty-six percent say they skip or delay needed care because they can’t afford to pay for it.

    People with Medicare should never be responsible for bills Medicare or their Medicare Advantage plans don’t pay. But, their doctors and hospitals might not provide them needed care, concerned that they won’t be paid for it.

    Premier’s survey found that people in Medicare Advantage plans needing skilled nursing facility care are especially likely to face denials. Insurers deny about one in five provider requests for discharge from a hospital to a skilled nursing facility.

    CMS needs to collect data on MA insurer payment delays and denials. Inappropriate delays and denials violate insurers’ contractual obligations.

    Here’s more from Just Care:

  • Corporate health insurers generate sizeable profits covering people with Medicare and Medicaid. Why?

    Corporate health insurers generate sizeable profits covering people with Medicare and Medicaid. Why?

    Corporate health insurers are generating sizeable profits covering care for people with Medicare and Medicaid, sometimes called “dual-eligibles,” reports Caitlin Owens for Axios. The question is why these for-profit insurers are able to earn billions in profits from the dual-eligible population who generally need a lot of health care? Are the insurers withholding needed care inappropriately in order to pocket the money they don’t spend and maximize profits?

    What’s noteworthy is that the largest corporate health insurers have moved big time into the Medicare and Medicaid health care markets. They clearly see big dollar signs in the Medicare and Medicaid markets. In fact, their profits for people with Medicare are projected to be two-thirds more than their profits for working people.

    Of the 65 million Americans with Medicare about 13 million have both Medicare and Medicaid. Nearly four million of them are enrolled in corporate health plans that are supposed to cater to their special needs, called Medicare Advantage Special Needs Plans. All told, around seven million of them are enrolled in either a special needs Medicare Advantage plan or simply a Medicare Advantage plan that covers a broader array of people.

    More than 11 million dual-eligible individuals have incomes under $20,000 a year. More than five million of them have long-term disabilities and are under 65. More than three milion of them have at least five chronic conditions.

    McKinsey recently issued a report estimating that corporate insurers will see their profits grow treating dual-eligibles, increasing more than 70 percent to $12 million over the five year period ending in 2027. Why? The government pays more to treat dual-eligibles because they have costlier health care needs. But, insurers are clearly not spending proportionally more on this population.

    Profit margins are particularly high for insurers covering dual-eligibles, according to MedPAC, and that’s especially true if the insurers attract dual-eligible enrollees who don’t receive a lot of care.

    Here’s more from Just Care:

  • CMS should not be hiding Medicare and Medicaid data

    CMS should not be hiding Medicare and Medicaid data

    Researchers are up in arms against a plan to restrict access to Medicare and Medicaid data by the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare and Medicaid. The CMS plan will make it harder for researchers to access and analyze Medicare and Medicaid data as they please. This data is critical for understanding what’s working and not working in our health care system for different populations and in different geographic areas, explains Ge Bai, a professor of accounting and health policy at Johns Hopkins in Forbes.

    Medicare and Medicaid data reflects health care usage by 4o percent of insured Americans, allowing researchers to report on how well our health care system is working for different populations. But, CMS just announced that it’s ending the ability of institutions to use Medicare and Medicaid data freely, easily and inexpensively. Rather, it will charge more for this data and impose many more restrictions on its use. CMS plans to begin this new policy in 10 weeks.

    As it is, CMS is not collecting key Medicare Advantage data that would help researchers better understand the care people are receiving in their Medicare Advantage plans.

    Bai outlines three serious implications of this new CMS plan.

    1. It will be harder for researchers to study Medicare and Medicaid, so less research will occur. This will limit government accountability and shield CMS from public scrutiny. We need external oversight to ensure CMS ensures Medicare and Medicaid are working as well as possible. External analysis of data will always add a new array of insights and solutions for improving Medicare and Medicaid and the health of older adults and people with disabilities and low incomes.
    2. It will end a lot of research by independent entities. Already today it is too expensive for smaller entities to access CMS data. The administration will control the narrative about the data.
    3. Cronies will benefit from requiring the purchase of data at a high price from CMS.

    CMS claims that it is concerned about data breaches but has not indicated that researchers’ use of the data has led to breaches. Moreover, CMS could easily do more to minimize the likelihood of breaches without restricting access to data and harming the public good.

    CMS is undermining data transparency in its own agency at the same time that it is requiring more transparency from hospitals and other health care stakeholders. How does this promote competition?

    CMS claims to own the Medicare and Medicaid data, but in truth the public owns it. CMS is charged with collecting data. But, the public cannot assess CMS’ work without access to the data. Of course, it can be deidentified.

    For the good of Medicare and Medicaid and the people who benefit from it, CMS should make all its data easily available to researchers at a fair price.

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  • Mental health treatment remains challenging to come by, even with insurance

    Mental health treatment remains challenging to come by, even with insurance

    Notwithstanding federal law requiring “mental health parity”–insurance coverage for mental conditions–mental health treatment remains hard to come by in the US. Even with health insurance, the majority of Americans in need of treatment for a mental health condition could not get it in 2021. If you have Medicare, few health care providers are willing to treat you because Medicare’s rates are so low, and the data suggest that Medicare Advantage plans do a poor job of including mental health providers in their networks.

    About one in five people in the US have a mental health condition. But, only a small minority of them are able to get treatment for their conditions. Fewer than one in seven people with Medicare–15 percent–receive treatment for mental health conditions.

    A story on NPR, based on a new Milliman report, explains that about two in three Americans with health insurance could not receive treatment for their mental health conditions. Of the people experiencing mental health crises who required emergency treatment or hospitalization, only one in three got follow-up treatment within 30 days of leaving the hospital.

    Inseparable, an advocacy group focussed on the treatment of mental health conditions, commissioned the Milliman report. Its founder, Bill Smith, wanted to see the data underlying the endless stories his group was hearing about insurance companies refusing to cover mental health care.

    What keeps people from getting treatment for mental health conditions? In addition to a health insurance industry that does not want to cover the care, there’s a shortage of workers, poor provider reimbursement rates, and government failure to ensure compliance by insurance companies to cover mental health care as required under federal law.

    Milliman’s findings show that almost one in four people with insurance, including Medicaid, Medicare and commercial insurance, had a minimum of one mental health condition in 2021. People with Medicaid had the highest likelihood of receiving mental health care.

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  • President Biden drafts a package of health care reforms for his second term

    President Biden drafts a package of health care reforms for his second term

    President Joe Biden is assembling a package of health care reform proposals for his second term, including a proposal to bring down the price of prescription drugs, reports CNN. It’s a smart move given that health care affordability is the second most important issue for Americans, after inflation.

    At the same time as President Biden looks to enhance people’s health care benefits, former President Donald Trump is calling to repeal the Affordable Care Act (ACA). President Biden wants to keep federal subsidies for people receiving care through the ACA and do more to reduce drug prices for people with Medicare and all other Americans. Biden’s goals are modest given the state of health care in the US and we need to push him to call for affordable health care for all, but his goals are far better than Trump’s.

    The ACA not only gives 10 million more Americans health insurance through the state health insurance exchanges, it expanded Medicaid to cover more Americans. People with incomes up to 135 percent of the federal poverty level are Medicaid-eligible. President Biden is looking into ways to ensure that the three and a half million people in the 10 states that opted against expanding Medicaid have Medicaid coverage.

    President Biden is again calling for a public health insurance option. In theory, such an option could remove the private insurer middlemen and all the waste and increased costs they bring. But, it’s not at all clear, based on Medicare Advantage and traditional Medicare (the public option) that a public health insurance option would bring down costs. The devil is in the design.

    Right now, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, is focused on bringing down the price of ten drugs that cost the Medicare program the most, as required by the Inflation Reduction Act. That’s both the camel’s nose under the tent for lower drug prices and small potatoes. The swiftest and easiest way to bring down drug prices is to allow people to import drugs from abroad and require insurers to cover those far less costly drugs.

    The Inflation Reduction Act also penalizes drug companies for raising drug prices more than the rate of inflation. This measure should keep drug prices from going up at obscene rates. But, it is also small potatoes, given how high drug prices are in the US–often four times higher than in France.

    Here’s more from Just Care:

  • Cigna sued in California for denying coverage 300,000 times in two months

    Cigna sued in California for denying coverage 300,000 times in two months

    Corporate health insurers’ use of AI to deny coverage is too often killing and disabling people. People in Medicare Advantage, people in State health insurance exchanges and people with job-based coverage are all at risk.  Now, Axios reports that a class of people are suing Cigna for using computer software to “deny payments in batches of hundreds or thousands at a time.” Why not? It maximizes Cigna’s profits, and Cigna has so far been able to get away with it.

    Mounting evidence shows that corporate insurers offering Medicare Advantage plans too often deny costly and critical care, including nursing home stays, rehab, home care and hospital care. This is care they are paid to cover and that traditional Medicare covers.

    The Clarkson law firm filed the lawsuit in California claiming that Cigna is violating state law. Cigna is supposed to thoroughly and fairly review insurance claims under California law. Computer algorithms is clearly at odds with that requirement. It’s hard to believe that a judge could find that a speedy computer review of a claim could be fair and thorough. But, these days, anything’s possible.

    The lawsuit claims that Cigna’s AI system denied 300,000 requests for authorization over two months in 2022. The system spent an average of 1.2 seconds on each claim. Thorough? Fair? One Cigna medical director, Cheryl Dopke, denied 60,000 claims in one month. Thorough? Fair? Hardly. California law requires individual review. And four out of five claims that were reviewed were overturned on appeal.

    Use of AI is the latest way health insurance corporations can inexpensively and swiftly turn a huge profit. Who’s designing the computer software algorithms? What’s their goal? As many denials as possible is what’s in Cigna’s economic interest. You have to wonder what questions Cigna asks about the algorithms before buying the software.

    Even some Republicans in Congress appear concerned, including House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.). She wrote Cigna for an explanation. Members of Congress appear to appreciate that people in Medicare Advantage and Medicaid are at risk of wrongful denials. But, what is she and her fellow members of Congress willing to do about it?

    Here’s more from Just Care:

  • Office of Inspector General finds insurers inappropriately deny care to people with Medicaid

    Office of Inspector General finds insurers inappropriately deny care to people with Medicaid

    Healthcare Finance reports on new Office of Inspector General findings regarding high prior authorization denial rates in Medicaid managed care as well as a high likelihood that some people with Medicaid are not getting the care they need. The OIG urges the Centers for Medicare and Medicaid Services (CMS) to do more to ensure that the insurance companies offering managed care to people with Medicaid are honoring their obligations to cover needed care, rather than putting profits first by denying care inappropriately.

    The Office of the Inspector General is concerned that people with Medicaid are not getting needed care that corporate insurers should be covering. Moreover, there is little oversight of these corporate insurers. The Centers for Medicare and Medicaid Services and state insurance departments only conduct limited oversight of the insurance companies’ denials. And, people with Medicaid have restricted access to reviews of their denials. Even in Medicare Advantage, CMS oversight is extremely limited; CMS allows health insurers to deny care wrongly with near impunity.

    Medicaid insurance companies denied about 12 percent of prior authorization requests or about one in eight of them on average. But, ten percent of the managed care plans that the OIG reviewed denied one in four or more requests for prior authorization. People with Medicaid should know which plans have these high denial rates so they can avoid enrolling in them.

    The OIG fears that oversight bodies are not on top of many inappropriate denials of care. So, inappropriate denials continue because they are not addressed.

    In addition, the Medicaid appeals process in most states does not offer people the opportunity for an independent review of denials. So, the appeals process is not a check on most insurance companies offering Medicaid. People do have the right to fair hearings in their state, but the process can be challenging for people with Medicaid. Appealing to the Medicaid health plan directly is also not common.

    The OIG claims that the system is better for people in Medicare plans operated by insurance companies. That may be true, but the differences do not lead to particularly good outcomes for people with Medicare in these corporate managed care plans. The Centers for Medicare and Medicaid Services does little to hold Medicare Advantage plans accountable for their bad acts, even if these plans must report data on denials and appeals.

    If CMS reviews the appropriateness of Medicare Advantage prior authorization denials each year, it should report its findings. People should not be forced to choose a Medicare Advantage plan without knowing the risks that they will be denied care inappropriately if they enroll.

    Prior authorizations can be harmful to people’s health, often delaying critical care needlessly. More than nine in ten physicians report these delays. And one in three physicians say that prior authorization leads to serious harm to patients they care for. Nine percent of them say prior authorization leads to “permanent bodily damage, disability or death.”

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  • Homelessness among older adults is on the rise

    Homelessness among older adults is on the rise

    Christopher Rowland reports for The Washington Post on rising homelessness among older adults. Increasingly middle class older adults are facing food and housing insecurity.

    As many as 250,000 older adults were homeless in part of 2019, according to one federal study. While they are a small portion of the baby boomers, their ranks are growing. Local communities are scrambling to address this crisis, through shelters designed specifically for older adults and specially trained staff. In California, one company is setting up an assisted living facility for older adults who are homeless.

    Some experts say that older adults are the “fast-growing group” of homeless people. Cities do not begin to have the resources to meet their needs and ensure their health and well-being. One organization in Arizona said that its client population of older adults grew more than 4o percent in 2022 to 1,717.

    The exact number of homeless older adults is hard to establish. But, estimates are that people who are older than 55 represent about one in six homeless people. In 2019, there were about 1.45 million homeless people. By 2030, projections are that the number of homeless older adults will more than double. 

    How did this happen? The cost of housing has risen dramatically across the US. Often, when a spouse or parent dies, it becomes impossible for the lone older adult to keep paying the bills.

    Nursing homes and other housing for older adults often cannot meet the needs of older adults who are homeless. They often suffer from mental illness and substance abuse; and they often have multiple chronic conditions.

    Today, hospitals treat homeless patients with serious illnesses and then discharge them back to shelters, where their health is often at risk because the shelters do not have the staff to provide them with the care they need. Often, these older adults relapse and need to be readmitted to hospital. Dehydration, heat stroke and burns are common ailments for homeless older adults when the temperature rises. Subsidized housing for homeless older adults is generally not available or only available after a long wait.

    Low-income older adults cannot always rely on Medicaid. Medicaid, which covers care for people with low incomes, does not pay for nursing home care or assisted living when you can care for yourself. Some homeless older adults can care for themselves and don’t meet the eligibility criteria. Nursing homes might determine they are not sufficiently infirm. And, if they are taken in, they can still be evicted.

    Some shelters have units called “respite” centers. Some local hospitals help support these centers located in shelters. The hospitals can then discharge these older adults to the respite centers where they can rest post-hospitalization. But, even respite centers can fail older adults because they might not have the resources to care for them appropriately.

    Here’s more from Just Care:

  • Fraudsters banned from the Medicare program circumvent the ban

    Fraudsters banned from the Medicare program circumvent the ban

    How does the federal government stop repeated Medicare fraud and abuse you might ask? Too often it does not. Sarah Jane Tribble reports for Kaiser Health News on Congressman Lloyd Doggett’s attempt to address this issue in Traditional Medicare.

    After a Kaiser Health News investigation exposed how the Medicare and Medicaid systems were broken and not able to prevent repeat health fraud, Congressman Doggett introduced a bill to keep the fraudsters from continuing to bill Medicare.

    The problem: The federal government has the authority to ban Medicare providers from the program for fraudulent or illegal behavior. But, these providers can circumvent the ban very easily in many cases. Why? The government relies on these fraudsters to be honest when reporting their criminal histories whenever they apply to offer Medicare or Medicaid services.

    The government does not confiscate the national provider identifiers of fraudsters. The Centers for Medicare and Medicaid Services, which oversees Medicare and Medicaid, cannot take away people’s national provider identifiers, even when the government has banned them from these programs. The federal government has no authority to ban these providers from delivering services outside of Medicare and Medicaid, and the providers use these identifiers for those services as well.