JustCare

Tag: Prior authorization

  • Medicare Advantage and other HMOs compromise continuity of care

    Medicare Advantage and other HMOs compromise continuity of care

    If you’re in a Medicare Advantage plan or any health insurance plan that requires you to use in-network health care providers and you have not thought about the fact that you can’t count on your health plan covering those physicians and hospitals over time, you should. In fact, right now, hospitals and physicians are dropping like flies from a large number of health plans. Melanie Evans reports for the Wall Street Journal about the ugly situations patients in these health plans are facing.

    One reason to stay away from Medicare Advantage plans–which cover your care from in-network providers only or which cover only some of the cost of your care from out-of-network providers–is that you might end up having to switch physicians mid-course of treatment. That seems to be happening to tens of thousands of people in Medicare Advantage plans and other health plans in the last couple of years. The corporate health insurers offering Medicare Advantage plans too often are denying payments to hospital systems and forcing physicians to go through multiple hoops to get care approved, at enormous cost to them. So, the hospitals and physicians are fighting back, refusing to contract with the insurers.

    Lots of patients are hearing from their local hospitals and physicians that their insurance will no longer cover their care from these providers. Hospitals want more money and less headache. They say that insurer prior authorization rules are endangering the health and well-being of their patients.

    Patients, in turn, are left in a serious quandary. Stay with their longtime physicians and hospitals and be liable for the full cost of their care, often thousands or tens of thousands of dollars. Or, switch to new hospitals and physicians, which can compromise their health. Moreover, switching care providers is almost always a total headache and challenging in and of itself.

    A lot of the problem stems from the fact that unlike other wealthy nations, the US does not set provider rates, we leave it to the health insurers to negotiate them. It’s a recipe for insanity. If providers have a lot of power, the rates can be excessive. If the insurers have all the power, the rates can be so low as to threaten the quality of care.

    For example, in Medicare Advantage, insurers can spend less if they don’t contract with cancer centers of excellence. But, the latest research suggests that means patients are likely to get poor quality cancer care and face higher mortality rates.

    What’s worse is that our health care system allows insurers offering Medicare Advantage plans and all other health plans the discretion to decide when care is covered. If they’re facing pressure from Wall Street to return greater profits, the insurers can stint on care. The less care they cover, the more money they get to keep and the more they profit.

    In January, UnitedHealth ended some in-network coverage from Mount Sinai in New York City. On March 1, UnitedHealth terminated contracts with other Mount Sinai hospitals. As of March 22, it will end coverage for physicians in the Mount Sinai system. UnitedHealth hasn’t been paying Mount Sinai providers as much as providers at other hospital systems.

    What can you do if your health care providers leave your insurers’ networks? You have some protection against surprise medical bills. And, your insurer is obligated to have adequate networks, so your insurer might continue to cover your care in order to meet network adequacy requirements. But, this is no way to run a healthcare system if you care at all about patients’ health and well-being.

    Here’s more from Just Care:

  • Biden administration finalizes Medicare Advantage prior authorization rule

    Biden administration finalizes Medicare Advantage prior authorization rule

    Last week, the Biden administration finalized a prior authorization rule that, among other things, will require insurers offering Medicare Advantage plans to use an electronic prior authorization process, approve requests more speedily, and report on their prior authorization denials. But, the rule does not take effect for three years and still leaves people with urgent health care needs at risk of not getting timely care and suffering serious harm in Medicare Advantage.

    (If you’re enrolled in Medicare Advantage, you should take advantage of the Medicare Advantage Open Enrollment Period, which end at the end of March, and study your Medicare options. Traditional Medicare has no prior authorization requirements, and you are covered for care anywhere in the US. Traditional Medicare also has no out-of-pocket cap, so it’s good to get supplemental coverage if you don’t have Medicaid. Supplemental plans K and L are lower cost.)

    The Centers for Medicare and Medicaid Services’ (“CMS”) final prior authorization rule does not dictate when or how often insurers can use prior authorization, nor does it require insurers to disclose this information. And, it still allows insurers to take a week to make a determination on a standard  prior authorization request and 72 hours on an urgent request. When people urgently need care, a 72-hour wait could literally kill them.

    Moreover, the new prior authorization rule doesn’t apply to prescription drug coverage. Right now, some Medicare Advantage plans require people with diabetes to go through a prior authorization process each time they need a continuous glucose monitor, even though it is standard treatment.

    Given that many insurers impose prior authorization rules that are not evidence-based and that can lead to serious harm to the most vulnerable patients, CMS should be establishing a standard set of prior authorization rules that Medicare Advantage plans can use. Standardizing prior authorization also would be a step towards helping people understand their Medicare options; people should know how often the MA plans will force them to go through prior authorization hoops when choosing between Traditional Medicare and Medicare Advantage as well as when choosing among Medicare Advantage plans.

    Today, people choose Medicare Advantage plans with blindfolds on. The government does not allow them to meaningfully distinguish among plans, let alone protect them from plans that are bad actors. Denial rates in some MA plans are more than 25 percent, but no one knows which deny care inappropriately at high rates and which allow enrollees to get the care they need.

    In sum, people can’t  know whether a particular Medicare Advantage plan will make them go through mega hoops before they can receive urgently needed care or whether it will inappropriately deny critically needed care. Even with these prior authorization final rules in effect, they can’t know. That’s not meaningful choice, that’s Russian Roulette.

    Here’s more from Just Care:

  • Why won’t the government protect people from prior authorization hell?

    Why won’t the government protect people from prior authorization hell?

    Lauren Sausser reports for KFF Health News on the failure of the Centers for Medicare and Medicaid Services to protect people enrolled in Medicare Advantage plans from prior authorization rules that lead to inappropriate denials and delays of care and endanger their health and well-being. For those of you who don’t quite understand “prior authorization,” it is a process that allows health insurers to second-guess treating physicians, delay or deny coverage for your care before you receive it, and it is pure hell if you need care quickly. Because insurers profit more the more prior authorization they require, they use it without justification.

    Like patients, doctors do not like prior authorization rules. These rules allow the insurers to overrule them, even when the insurers know little about patient needs. Prior authorization rules often require doctors to submit additional paperwork and evidence of the need for care, making it costly and resource intensive for the doctor to deliver the care that is needed.

    Back in 2021, Medicare data reveal 1.5 prior authorization requests for each Medicare Advantage enrollee. When you consider that about half the Medicare population uses few or no services and 10 percent are responsible for 70 percent of services, we’re talking a lot of prior authorization hurdles to surmount for the people who most need care.

    Congress can’t seem to get its act together to pass helpful legislation on prior authorization. At the very least, prior authorization rules should be public and evidence-based. Truly they should be consistent across all Medicare Advantage plans. Otherwise, how can people distinguish among the MA plans that require prior authorization and those that do not?

    Right now, CMS is considering a proposed prior authorization rule that could help streamline and expedite the prior authorization process for people in Medicare Advantage, Medicaid or a state health insurance exchange. It would automate prior authorization, require insurers to make prior authorization decisions more quickly and explain the reason for their denials.

    But, CMS has yet to act on its proposed rule even though the comment period ended last fall. Moreover, its proposed rule really does not go far enough. The American Medical Association agrees, as does the AHA. Congress is going to need to step in.

    The insurance industry hides behind a lame rationale for prior authorization–ensuring enrollees get the care they need when they need it. In fact, prior authorization prevents just that. If the rationale for insurance provider networks is to ensure good care, insurers should not be second-guessing network providers.

    Of course, prior authorization takes its biggest toll on the most vulnerable people with Medicare, who struggle to navigate the process and who most need care urgently. Sometimes it takes weeks or months to get insurance company approvals for care.

    To ensure good access to needed care for people with Medicare, the government should standardize the prior authorization process across all Medicare Advantage plans and permit only evidence-based use of prior authorization. At the very least, it should implement an electronic process for prior authorization; physicians and patients should not have to be spending precious time on the phone trying to get approval for needed care.

    Here’s more from Just Care:

  • Cigna plans to sell its Medicare Advantage business

    Cigna plans to sell its Medicare Advantage business

    The Wall Street Journal reports that Cigna is planning to sell its Medicare Advantage book of business. For nearly $4 billion, why not? While Cigna is a big health insurer, it has the smallest Medicare Advantage footprint of the big insurers. The sale signals the inevitable future of Medicare Advantage–one or two mega insurers with the vast majority of the Medicare Advantage business and all the power to undermine access to care in order to maximize profits.

    Currently, Cigna operates in 29 states. A sale to Blue Cross Blue Shield would boost its power in the Medicare Advantage marketplace. Originally, Cigna had considered buying Humana’s Medicare Advantage book of business, but investors did not receive that plan favorably.

    Cigna is a relatively small Medicare Advantage player with only 599,000 Medicare Advantage enrollees as of September 2023.  UnitedHealth has more than twelve times as many enrollees, 7.6 million. Humana has nearly 10 times as many enrollees, 5.9 million.

    Cigna’s departure from the Medicare Advantage marketplace will be unsettling for its enrollees, but should not come as a surprise. Nothing about a Medicare Advantage plan is reliable. Medicare Advantage management, along with coverage and payment practices, can change all the time. Plans can grow larger through acquisitions or shrink in size.

    Medicare Advantage provider networks also are ever-changing and unreliable. Denial rates and prior authorization rules are not even knowable and according to the Office of the Inspector General, there are widespread and persistent inappropriate delays and denials of care and coverage in some Medicare Advantage plans.

    Hospitals and specialists are increasingly canceling their Medicare Advantage contracts, meaning unreliable access to care for tens of thousands of Medicare Advantage enrollees. But, these providers are canceling in part because of patient safety concerns, meaning risks to health and well-being in Medicare Advantage. The AMA’s doctors report serious concerns with MA prior authorization, to the detriment of patients.

    The Medicare Advantage Open Enrollment period began January 1 and continues through March 31. If you want to be sure you get the care you need when you need it, take advantage of it and switch to Traditional Medicare.

    Here’s more from Just Care:

  • For-profit hospitals urge CMS to hold Medicare Advantage plans to account for wrongful denials

    For-profit hospitals urge CMS to hold Medicare Advantage plans to account for wrongful denials

    Over the last several decades, US hospitals, particularly the for-profit hospitals, generally have not been the best of allies with the organizations representing people with Medicare and other Americans. But, when it comes to Medicare Advantage, the hospitals continue to speak out vociferously against corporate health insurers for delaying and denying critical treatment and failing to pay the hospitals appropriately for the care they deliver. The Federation of American Hospitals, which represents the for-profit hospitals, is now asking the Centers for Medicare and Medicaid Services (CMS) to evaluate Medicare Advantage plans based on how frequently their prior authorization denials are overturned, reports Rylee Wilson for Becker’s.

    The star-rating system for evaluating Medicare Advantage plans is a farce. Medicare Advantage plans with five-star ratings could still have high denial and delay rates. The system misleads people. The star-rating system should be an important measure for assessing Medicare Advantage plans. If CMS’s star-rating system gave substantial weight to Medicare Advantage plan denial and delay rates as well as overturn rates for prior authorization denials, it could help warn people about poor performing health plans.

    The Federation of American Hospitals shared its proposal to CMS with Becker’s but does not appear to have posted it online. It argues that adding prior authorization denial overturn rates as a measure in its Medicare Advantage star-ratings system “will enhance CMS’s oversight of MA plans’ denial of prior authorization and payments and provide beneficiaries with needed insight to inform their decision-making.”

    Of course, adding prior authorization denial overturn rates as a measure is only as valuable as the data CMS collects is accurate and timely. Right now, CMS does not get complete, accurate or timely data from the Medicare Advantage plans. Without a complete overhaul in how CMS collects data–prior authorization denials should go to CMS at the same time as they go to providers–it’s not clear that this new measure will help Medicare enrollees or enhance CMS oversight.

    The Medicare Payment Advisory Commission reports that 80 percent of prior authorization denials were ultimately approved on appeal in 2021. The Federation of American Hospitals argues that this high overturn rate shows that insurers are “intentionally” denying and delaying needed care.

    Many members of Congress are also concerned about prior authorization denials and want MA plans to report more data.

    Because insurers know that they can maximize their profits through delays and denials of care and coverage and can do so with near impunity, it appears that inappropriate delays and denials are on the rise. And, hospitals are cancelling their contracts with MA insurers to protect themselves and their patients. CMS has not addressed this issue effectively to date.

    People enrolled in Medicare Advantage plans should beware, especially given the likelihood that they will face these obstacles to care when they develop a complex or costly conditions.

    Here’s more from Just Care:

  • AHA warns Medicare oversight agency about dangers of Medicare Advantage

    AHA warns Medicare oversight agency about dangers of Medicare Advantage

    In a letter to the Medicare Payment Advisory Commission (MedPAC), the American Hospital Association (AHA) expresses serious concerns about the dangers of Medicare Advantage, including the consequences of inappropriate coverage and payment denials and delays. MA is not delivering the health coverage people need; and, prior authorization requirements delay potentially life-saving time-sensitive treatments, such as cancer treatment regimens.

    The AHA explains that the insurers offering Medicare Advantage plans use prior authorization in ways that create “dangerous delays in care.” The AHA’s greatest concern is that MA plans use prior authorization to deny medically necessary care. To show clinical appropriateness, providers are required to spend an excessive amount of resources documenting the need, while patients’ care is delayed, to their detriment.

    The stories the AHA recounts of insurer MA bad acts are disturbing, appearing to put insurers’ profits ahead of patient needs: “For example, an AHA member indicated that a patient with traumatic brain injury was medically ready for discharge but stayed four additional days in the hospital without access to essential [post-acute care] because the insurer had not responded to the provider’s request to move the patient into a rehabilitation facility. Another AHA member … reports that 11% of their MA referrals take 10 days or longer to resolve. Furthermore, another AHA member reported that, in 2022, over 400 MA patients at its academic medical center had delayed discharges due to insurance issues, the vast majority of which were attributable to prior authorization delays, and the delays amounted to 1,233 avoidable inpatient days.”

    More than nine in 10 physicians report patient care delays because of prior authorization and one in three of them say that prior authorization resulted in a “serious adverse event for a patient in their care such as hospitalization or death.” Not only does the prior authorization process endanger the health and well-being of patients, it can be extremely burdensome for providers. Moreover, the process is not transparent or consistent across MA plans. Different rules for different plans and different electronic portals make it all the harder for providers to comply.

    MedPAC is an independent Congressional agency established to advise Congress on the Medicare program. MedPAC can write reports on MA issues, but it has no real authority to do anything. And, neither Congress nor the Centers for Medicare and Medicaid Services seem to respond in meaningful ways to MedPAC recommendations.

    Right now, the benefits of prior authorization appear more than outweighed by the harm to patients and the burdens on providers. That will continue so long as each insurer can develop its own proprietary prior authorization protocols. CMS should mandate that insurers all use one standardized set of public and medically justified prior authorization protocols and one standardized system for handling them. Without standardized and public prior authorization protocols, people cannot know whether the MA plan they enroll in will delay and deny their care excessively and inappropriately, as appears to be the case for people in UnitedHealth and Humana Medicare Advantage plans.

    Here’s more from Just Care:

  • Reps and Dems angry about care denials in Medicare Advantage

    Reps and Dems angry about care denials in Medicare Advantage

    Robert King writes for Politico about the Republican and Democratic anger directed at insurance companies for denying care inappropriately to older adults and people with disabilities enrolled in Medicare Advantage plans. Complaints to members of Congress from people enrolled in Medicare Advantage, as well as from health care providers treating people enrolled in Medicare Advantage, are on the rise. And, for good reason.

    Now, more than half the Medicare population is enrolled in a Medicare Advantage plan, a health plan administered by a corporate health insurer. Whether people have been steered to a Medicare Advantage plan by a friend, an employer, a union or Joe Namath, no one likely told them that they were putting their health and well-being at risk. No one likely told them that insurers offering Medicare Advantage plans can and do too often deny or delay critical care with impunity, as a way to maximize profits.

    Most people don’t appreciate that the government cannot ensure that Medicare Advantage plans cover their care. And, the Centers for Medicare and Medicaid Services, which oversees Medicare Advantage, is hard-pressed to warn people about the Medicare Advantage bad actors, let alone cancel their contracts.

    Senator Ron Wyden, Chair of the Senate Finance Committee, recently held a hearing focused on the misleading marketing in Medicare Advantage. His takeaway: “It was stunning how many times senators on both sides of the aisle kept linking constituent problems with denying authorizations for care.” What’s truly stunning is that corporate health insurers offering Medicare Advantage plans have been denying care inappropriately for years, and it’s only now that Congress is waking up to this horror show, which is literally leading to tens of thousands of unnecessary deaths each year, according to one academic study.

    Corporate health insurers use prior authorization tools, which require insurer approval in order to ensure coverage, as a way to delay urgent care as well as to deny it. Insurers also use artificial intelligence or AI to make sweeping acr0ss-the-board denials of care, without regard to particular patient conditions, in violation of their Medicare contracts. Stat News recently reported on the grave harm to patients entitled to rehabilitation services when enrolled in some Medicare Advantage plans.

    Here’s more from Just Care:

  • AMA unhappy with Medicare payments, silent on health insurer interference in the practice of medicine

    AMA unhappy with Medicare payments, silent on health insurer interference in the practice of medicine

    The AMA President, Jesse Ehrenfeld, MD, says he is concerned about “government interference in the practice of medicine.” He is also unhappy with Medicare payments. But, his complaints focus heavily on the behaviors of the health insurers and corporate interference in the practice of medicine. Why is he not calling out the health insurers?

    The health insurers impose huge administrative challenges on physicians, in the form of paperwork and prior authorization requirements that drive up costs and create obstacles to care, which Ehrenfeld decries.

    In fact, Ehrenfeld claims progress for the AMA because it successfully advocated for some prior authorization fixes in Medicare Advantage, without criticizing the insurers offering Medicare Advantage plans and imposing all sorts of valueless prior authroization requirements. Why is Ehrenfeld withholding criticism of the Medicare Advantage plans when his members have said that the insurers offering these plans are denying, delaying and downgrading needed care to the detriment of their patients?

    One in three AMA members have said that insurers’ prior authorization rules have “led to a serious adverse event for a patient in their care.” One in four physicians have said that prior authorization has led to an unnecessary hospitalization. And, almost one in five physicians have said prior authorization has led to “a life-threatening event or required intervention to prevent permanent impairment or damage.”  Nine percent of physicians report that “PA has led to a patient’s disability/ permanent bodily damage,”

    Ehrenfeld says that physicians are facing a 26 percent revenue cut in Medicare. To what extent are the Medicare Advantage plans to blame for their inadequate payments, as a result of low rates and inappropriate claim denials? We know that the insurers deny payment to physicians inappropriately and, sometimes, often.

    The AMA has a new website called Fix Medicare Now. It opposes proposed cuts to Medicare provider payments. But, it also talks about promoting “value-based” care. In my book, that’s code for give the insurance industry the money to oversee care and coverage, to come between patients and their doctors. I hope that’s not what the AMA is saying.

    Here’s more from Just Care:

  • How big insurers please Wall Street’s investors

    How big insurers please Wall Street’s investors

    The big for-profit insurers made more than $40 billion in profits during the first six months of this year but Wall Street doesn’t consider that nearly enough. Investors have been shifting money away from those companies, which, I can assure you, has set off alarm bells in the C-Suite.

    Because top executives’ compensation is tied to meeting specific financial metrics, including shareholders’ return on investment, the CEOs are especially motivated to right the ship and reduce the percentage of revenues their companies pay out in claims to provider groups and facilities the companies don’t own. You can be certain they’ll be pulling all the levers they can think of.

    I would be surprised if some of them haven’t already called in McKinsey & Co. or another big consulting firm to look under the hood. (When I worked in the industry, the chief financial officer of one of my employers had McKinsey on a $50,000-a-month retainer.) But with the stock price falling at all of the companies while the Dow and other Wall Street indices are humming along, the consultants will be called in for a special assignment beyond any retainer. They’ll do a deep dive into the companies’ operating and staff divisions and develop recommendations to “streamline” operations, cut expenses and reallocate resources.

    Here are some things to expect in the coming weeks and months at these companies:

    Increased hardball with hospital systems: As I’ve reported, Elevance/Anthem, which owns several for-profit Blue Cross plans around the country, is in a protracted dispute with Bon Secours Mercy Health, a hospital system in Ohio and Virginia, over Medicaid and Medicare Advantage reimbursements. Earlier this month, BSMH sued Elevance/Anthem for $93 million in unpaid and disputed claims. The suit claims that Elevance/Anthem’s audits are a “bad faith attempt to bludgeon BSMH Virginia into submission in the contract negotiations, as opposed to a good faith exercise of Anthem’s discretion.”

    The dispute between the two parties has attracted considerable media attention, but there are many others across the country. Modern Healthcare reports that so far this year, 49 provider-payer contracting disputes have become public, compared to only 20 through August 2022. 

    Modern Healthcare is also reporting that many rural hospitals, which typically operate on thin margins, are considering withdrawing from Medicare Advantage networks operated by big insurers because their payments are increasingly inadequate.

    Take it or leave it pay cuts to doctors: Just as the pandemic was reaching the United States in early 2020, UnitedHealth Group sent letters to numerous physician groups demanding pay cuts of up to 60%. If the doctors — many of whom were on the front lines trying to keep Covid patients alive — refused, they’d be kicked out of UnitedHealth’s provider network. UnitedHealth rescinded or postponed some of those planned cuts temporarily, but physicians should expect to see those demands again from big insurers.

    Layoffs: I know from personal experience that when McKinsey shows up, layoffs are almost always inevitable. Job security for many employees goes out the window. I had to lay off members of my own staff over the years because of the “restructurings” and downsizing McKinsey recommended.

    Sure enough, late last month, CVS/Aetna told regulators in eight states that it would eliminate about 5,000 position — even as the company made additional acquisitions, including paying $8 billion for Signify Health, a nationwide network of 10,000 clinicians, and $10 billion for Oak Street Health, a primary care company.

    Divestitures: Speaking of CVS/Aetna, I’ve seen reports that investors are questioning the company’s “transformation” efforts, especially in light of the fact that the company’s shares have been down more than 25% since the first of the year. When Wall Street financial analysts signal dissatisfaction with the performance of a company’s operating divisions, the CEO and other executives will assess which operations have become a drain on earnings or are not working synergistically with other and more profitable divisions.

    Big insurers are like chameleons, constantly recasting themselves based on Wall Street’s whims. When I joined Cigna in 1993, the company was a large multi-line insurer with a property and casualty division, an individual insurance business, a reinsurance division and a financial services company. Aetna had similar lines of business back then. Both companies shed those operations at the behest of investors and analysts to focus exclusively on health care.

    Exiting some Obamacare markets: When the Affordable Care Act marketplaces became active in 2014, most insurers rushed in, and many, the big ones in particular, quickly rushed out. They couldn’t make enough money fast enough to satisfy Wall Street. Since then, the government has increased subsidies (at least temporarily) to help people afford their premiums and out-of-pocket obligations, and many insurers, smelling higher profits, have returned. However, this marketplace can be volatile. Cigna announced last month it is exiting some of the Obamacare markets it had recently entered.

    Redoubled efforts to enroll more seniors into Medicare Advantage: Insurers have learned that the federal government is a much more generous customer than the nation’s employers, who once were the primary source of insurers’ revenues and profits. When looking at 2021 data, Kaiser Family Foundation researchers found that “Medicare Advantage insurers reported gross margins averaging $1,730 per enrollee, at least double the margins reported by insurers in the individual/non-group market ($745), the fully insured group/employer market ($689), and the Medicaid managed care market ($768).

    Purging customers: The Affordable Care Act makes it illegal for insurers to refuse to sell coverage to people with pre-existing conditions or to charge them more based on their health, but it doesn’t stop them from making premiums unaffordable. Insurers learned long ago that a way to drive away unprofitable individual and small-business customers is to jack up the rates so high those customers will leave. This is known as purging in the health-insurance business. Cigna and other insurers are planning double-digit premium increases for many of those customers in 2024 to boost profits. Cigna’s chief financial officer told investors last month that, “We are likely to have fewer customers in the individual exchange business in 2024 relative to where we are in 2023.” Getting rid of some of those people, he said, should increase the company’s profit margin.

    Aggressive use of prior authorization: Federal investigators found in July that some of the big insurers make much more aggressive use of prior authorization in Medicare Advantage and Medicaid than in their commercial health plans, meaning they are refusing to cover the cost of care for many seniors and low-income Americans to boost profits. Doctors have complained for years that insurers are increasingly refusing to pay for care their patients need, regardless of plan type. In the face of congressional scrutiny, Cigna, UnitedHealth and some other companies recently announced they will reduce the number of treatments requiring advanced approval, but don’t be surprised if that applies to a small percentage of patients — and primarily patients receiving care from doctors they employ or who work in clinics and other facilities the insurers own.

    Benefit buydowns: An age-old trick insurers have used for decades to improve profit margins is to reduce the value of their health benefit plans while they also increase premiums. Behind closed doors, this is called “benefit buydown.” It manifests in many ways, including making health-plan enrollees pay more out of their own pockets before the coverage kicks in, removing doctors and hospitals from their provider networks, increasing prior-authorization requirements, and refusing to pay claims after medical care has been provided. Cigna reportedly used a software program to reject more than 300,000 requests for payment over two months in 2022. Lawyers in California have filed a class-action lawsuit against the company, claiming it uses an algorithm to deny claims en masse and without human review.

    Increase in inter-company eliminations: The ACA requires insurers to pay 80-85% of revenues on patient care. If they spend less than that, they have to send rebate checks to their customers. But the big companies that have moved swiftly into health care delivery have found they can circumvent that requirement — and congressional intent — by paying themselves. The ACA requirement doesn’t apply to health care providers, so UnitedHealth, Cigna and CVS/Aetna in particular are steering their health-plan enrollees to care delivery entities they own. UnitedHealth, which employs more than 70,000 doctors, is clearly the pack leader. During the first half of this year, UnitedHealth categorized $66 billion as “eliminations.” That amounted to 25% of total revenues.

    Bottom line: Expect to pay more for your health insurance AND your health care next year — if you can get it at all — to make Wall Street financial analysts and investors (including those in the C-Suite) a little happier and richer.

    This article was originally published on Substack, HEALTH CARE un-covered.

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  • Congress urges administration to address delays of care in Medicare Advantage

    Congress urges administration to address delays of care in Medicare Advantage

    Last week, 294 members of Congress sent a letter to Secretary of Health and Human Services, Xavier Becerra and the Centers for Medicare and Medicaid Services (CMS) seeking greater protections for people in Medicare Advantage plans. The letter focuses on the need to speed up the prior authorization process in Medicare Advantage and alludes to the risk to Medicare Advantage enrollees from delays and denials of care. Congress wants the Centers for Medicare and Medicaid Services to help ensure that people in Medicare Advantage get timely access to care, which people cannot count on today.

    CMS has proposed a rule that is designed to help ensure people in Medicare Advantage are not waiting to get the care they need. But, a bipartisan majority of members of Congress correctly appreciate that the rule does not go far enough. They want to help ensure that the Medicare Advantage plans use an electronic prior authorization system and that they are transparent about what they are doing. They know full well that right now, people in some Medicare Advantage plans are dying or being harmed needlessly because their Medicare Advantage plans are not providing them the care they need when they need it.

    The problem, as many see it, is that the government pays the Medicare Advantage plans upfront for their services, with too little regard as to whether the Medicare Advantage plans are providing their enrollees with the Medicare benefits they are due. The Medicare Advantage plans have a powerful incentive to delay and deny care in order to maximize profits. CMS does not have the resources to undertake annual audits of these plans to ensure they are complying with their contractual obligations. And, CMS does not have the political will to penalize them appropriately for their bad acts when it uncovers them.

    People in Medicare Advantage plans cannot even know whether their Medicare Advantage plans are engaged in widespread inappropriate delays and denials of care, as some of them are, according to the HHS Office of the Inspector General. The letter from members of Congress requests that CMS go further than it has in its proposed rules to improve the prior authorization process and ensure a “real time process for items and services that are routinely approved.” It also seeks a 24-hour prior authorization turnaround time for urgently needed care, recognizing that delays could “jeopardize a patient’s life, health or ability to regain maximum function.”

    Here’s more from Just Care: