|1,129 Hospitals Reporting Losses on Patient Services, State-by-state|
By Laura Dyrda | May 23, 2023
Rural hospitals across the U.S. are taking losses on patient services, meaning insurers aren’t paying enough to cover the cost of care delivery, according to a report from the Center for Healthcare Quality & Payment Reform.
Losses on patient services have forced some hospitals to close service lines and reduce access to care in already underserved communities. There are more than 600 hospitals at risk of closure across the U.S. as well due to financial constraints and inflation.
The Center for Healthcare Quality & Payment Reform compiled data on hospitals that lost money delivering patient services over a multiyear period, excluding the first year of the pandemic. Texas reported the most hospitals with losses on services at 105, while Nevada has the highest percentage of hospitals reporting losses on services at 85 percent.
Breakdown by state.
At-risk Rural Hospitals Fact Sheet.
Lawmakers Press UnitedHealthcare, Aetna, Humana on Medicare Advantage Claims Denials
By Rylee Wilson | May 22, 2023
Lawmakers are seeking more information about claims denials from the largest Medicare Advantage insurers.
On May 17, the Senate Permanent Subcommittee on Investigations sent letters to CVS Health, Humana and UnitedHealth Group seeking internal documents detailing how the companies decide to approve or deny claims, including how the payers use artificial intelligence in the process.
“I want to put these companies on notice. If you deny lifesaving coverage to seniors, we’re watching, we will expose you, we will demand better, we will pass legislation, if necessary,” subcommittee Chair Sen. Richard Blumenthal said in a news release.
Around 13 percent of prior authorization claims denials in Medicare Advantage were for services that met Medicare coverage rules, Megan Tinker, chief of staff for HHS’ Office of Inspector General, told the subcommittee May 17.
These denials likely delayed or prevented Medicare Advantage beneficiaries from receiving needed care, she said.
CMS is implementing new rules aimed at curtailing the use of prior authorization in Medicare Advantage.
Ms. Tinker told the subcommittee the OIG needs more resources to fully investigate claims denials in Medicare Advantage. The agency is turning down 300 to 400 viable healthcare fraud cases each year because of a lack of sufficient staff, she said in her testimony.
“Despite extensive reviews and enforcement, our limited resources do not allow us to provide comprehensive oversight of Medicare and Medicaid,” Ms. Tinker said. “Notwithstanding rigorous efforts by OIG and support from Congress, the administration and HHS for OIG work and resources, serious fraud, waste, and abuse continue to threaten HHS programs and the people they serve.”
Sen. Ron Johnson, a member of the subcommittee, said the prior authorization process can be improved by reintroducing “consumerism and free market competition into healthcare.”
“Under a third-party payment system, everyone wants the best quality treatment and couldn’t care less what it costs. That is what is driving our healthcare costs through the roof,” Mr. Johnson said at the May 17 hearing. “Pre-approval programs for some treatments and tests are the third-party payer’s attempt to limit wasteful spending.”
To read more, go to Becker’s Payer Issues.
Medicaid Redeterminations Are Going Worse than Expected, Experts Say
By Jakob Emerson | May 19, 2023
After a three-year period of continuous Medicaid/CHIP enrollment under the COVID-19 public health emergency, states could begin terminating coverage for ineligible residents in April. With redeterminations underway, health policy experts say too many people in some states are losing health coverage for the wrong reasons.
“Too many people are falling through the cracks in the system,” Alison Yager, executive director of the Florida Health Justice Project, told Vox on May 19. “This should be of grave concern to all those charged with protecting the health of our residents.”
In Florida, nearly 250,000 individuals have been disenrolled from the state’s Medicaid program over the last month, but 82 percent of those disenrolled saw their coverage terminated because their information was not updated with the state. About 44,300 individuals made too much to be eligible and were referred to other coverage options.
“This is extremely troubling and is similar to the scary numbers we saw in Arkansas last week, where approximately 80 percent of the terminations were for procedural reasons,” Joan Alker, executive director and co-founder of the Georgetown University Center for Children and Families, wrote in a blog post May 16. “When governors see such large numbers of terminations of coverage for procedural reasons, they should pause the process and see what is going wrong.”
In Indiana, which began terminating coverage in May, nearly 53,000 people have been disenrolled from Medicaid, with 88 percent of the terminations due to procedural reasons, according to Ms. Alker.
She noted that it is difficult to compare states’ redetermination processes because each Medicaid program is prioritizing different groups and reporting data differently.
Other states, however, such as Pennsylvania, are reporting fewer terminations due to procedural reasons, according to Ms. Alker. In Pennsylvania, more than 77,000 people have been reviewed, about 8,000 people have lost coverage, and 45 percent lost coverage due to procedural reasons.
HHS has estimated that 15 million people total will lose Medicaid coverage during redeterminations.
More from Zotec Answers Podcast here.
See video of the Zotec Shares’ presentation here.
To read more, go to Becker’s Payer Issues.
ASA Applauds Rep. David Scott for Introducing Legislation to Protect Veterans
May 18, 2023
Today, Representatives David Scott (D-GA-13), Yvette Clarke (D-NY-9), Andrew Gabarino (R-NY-2), and Michael Turner (R-OH-10) reintroduced H.R. 3347, the Protect Lifesaving Anesthesia Care for Veterans Act. This ASA-supported bill would prohibit the Secretary of Veterans Affairs from removing physician anesthesiologists from the anesthesia care team in the Department of Veterans’ Affairs (VA) health care system.
ASA proudly endorses this important legislation which would guarantee Veterans access to the exact same standard of anesthesia care as other citizens. Physician anesthesiologists earn between 12,000 and 16,000 hours of clinical training, whereas nurse anesthetists are only required to earn 2,500 hours of clinical training.
Read Rep. Scott News Release here.
Read the bill text here.
Insurance Commissioners Eye Cigna Following Report of Physicians Denying Claims Without Reading Them
By Jakob Emerson | May 17, 2023
State insurance commissioners and federal lawmakers are raising concerns with Cigna’s internal claims review process following reporting from ProPublica in March that said the payer denies large batches of claims without reviewing them first.
Many states require medical directors to review patient files and coverage policies before denying claims for medical reasons. ProPublica alleges that Cigna has bypassed these steps by having a computer algorithm complete the review and then having physicians sign off on groups of denied claims.
“It’s hard to imagine that spending only seconds to review medical records complies with the California law,” Dave Jones, California’s former insurance commissioner, told ProPublica. “At a minimum, I believe it warrants an investigation.”
“I’m afraid it might be the tip of the iceberg,” Washington’s insurance commissioner, Mike Kreidler, told the publication. “We darn well better start paying attention to it.”
“Given your article, this will likely warrant a closer look,” a spokesperson for Delaware’s insurance department told ProPublica.
“This is very concerning,” an anonymous Labor Department official told ProPublica. “I don’t see a scenario where we’re not taking a hard look at these kinds of practices.”
On May 16, Rep. Cathy McMorris Rodgers of Washington and chair of the House Committee on Energy and Commerce, said that Cigna’s Medicare Advantage members appeal 20 percent of denied claims, and about 80 percent of those denials are overturned.
“If these figures are at all illustrative of Cigna’s commercial appeal and reversal rates, it would suggest that the PXDX review process is leading to policyholders paying out of pocket for medical care that should be covered under their health insurance contract,” Ms. Rodgers said in a letter to Cigna.
To read more, go to Becker’s Payer Issues.
Independent Dispute Resolution Case Load 14X More Than Expected
By Jaqueline LaPointe | May 15, 2023
Nearly a year after the federal government launched the independent dispute resolution (IDR) process under the No Surprises Act, over 330,000 balance billing disputes have been filed, nearly 14 times more than the Departments of Health and Human Services (HHS), Labor, and the Treasury expected.
CMS recently published the status update on the federal dispute resolution process containing the latest numbers on initiated disputes, dispute eligibility, and results of payment determinations. In addition to confirming an ongoing backlog of IDR cases, the update also revealed a high success for initiating parties, which have largely been providers.
From when the IDR portal opened on April 15, 2022, through March 31, 2023, certified IDR entities rendered payment determinations in 42,158 disputes. Parties that filed the dispute — known as initiating parties — were the prevailing party in nearly three-quarters of those cases.
A separate report on the IDR caseload for the fourth quarter of 2022 showed that practice management companies, medical practices, or revenue cycle management companies representing hundreds of individual practices, providers, or facilities filed the most cases. The caseload was also up by 53 percent compared to the previous quarter, the report also said.
The federal IDR process is available to resolve disputes over surprise bills, which typically involve out-of-network payments. The No Surprises Act prohibits surprise bills in most scenarios involving an out-of-network provider treating patients at in-network facilities.
The IDR process continues to face a significant backlog of disputes because disputes filed earlier in 2022 more often required additional outreach and analysis in order for certified IDR entities to determine eligibility, according to the status update.
The status update found that non-initiating parties challenged the eligibility of 122,781 disputes in the first 50 weeks of the IDR process. Of the disputes closed during that period, about 39,890 were ultimately deemed ineligible for the federal IDR process.
But even if the non-initiating party does not challenge the eligibility of the dispute, the certified IDR entity must review and confirm that it is eligible before it proceeds further in the federal IDR process, the status update explained.
“These reviews involve complex eligibility determinations that required certified IDR entities to expend considerable time and resources,” the update stated.
To read more, go to Revcycle Intelligence.
Administration Ends Waiver of Medicare Supervision Rule
May 12, 2023
On Thursday, May 11, the Public Health Emergency (PHE) related to the COVID-19 expired. The PHE was declared by the Secretary of the Department of Health and Human Services (HHS) starting in January 2020 and renewed until now.
The PHE includes emergency waivers by the Centers for Medicare and Medicaid Services (CMS) of a full range of existing Medicare and Medicaid regulations, including the CMS Medicare anesthesia supervision requirement. ASA met with senior officials throughout the PHE to highlight the patient safety implications of removing the Medicare supervision requirement and submitted formal comments.
ASA applauds the Administration’s commitment to patient safety in concluding the waiver of the Medicare supervision requirement for nurse anesthetists.
To read more, go to ASA’s website.
UnitedHealth Extends Its Hot Streak as the Most Profitable Payer in Q1
By Paige Minemyer | May 8, 2023
UnitedHealth Group extended its streak as the most profitable company among major national insurers in the first quarter of 2023, reporting $5.6 billion in earnings.
By comparison, fellow healthcare giant CVS Health reported the second-highest profit in the quarter at $2.1 billion, less than half of UnitedHealth’s haul. CVS’ profit also declined year over year, as it posted nearly $2.4 billion in the first quarter of 2022.
UnitedHealth also takes the top spot on revenue for the quarter, reporting $91.3 billion. That’s up from $80.1 billion in the prior-year quarter. CVS again lands at No. 2 on revenue, posting $85.3 billion.
UHG’s rising profits and revenue came on the back of growth at both of its core segments, UnitedHealthcare and Optum. Revenues at UHC were up by 13% and up by 25% at Optum, according to the company’s earnings report.
UnitedHealthcare added 2 million members compared to the first quarter of 2022, reflecting growth across its commercial and government plans. Optum, meanwhile, has been the company’s growth engine for some time, and, in the first quarter, it reported 34% higher revenue per customer served at Optum Health compared to the prior year quarter.
Optum Insight’s revenue backlog increased by 35% year over year, thanks in large part to UHG’s acquisition of Change Healthcare, and Optum Rx reported revenue growth of 15%.
To read more, go to Fierce Healthcare.