|CMS Finalizes Reforms to Address Prior Authorization Problem that has Plagued Radiology|
By Marty Stempniak | April 6, 2023
The Centers for Medicare & Medicaid Services released a final rule Wednesday aimed at reforming prior authorization—a health insurer utilization management tactic that has plagued radiology and other specialties.
CMS said the changes will streamline prior authorization, reducing disruptions while preserving continuity of care for Medicare Advantage beneficiaries. The agency’s goal, in part, is to ensure that seniors on these plans have the same access to care they would under traditional Medicare.
“People with Medicare deserve to have access to accurate information when making coverage choices, and to be able to get the care they need without excessive burden or delays,” Meena Seshamani, MD, PhD, CMS deputy administrator and director of the Center for Medicare, said in a statement.
The final rule will require that, once a health plan grants prior authorization for a service, that approval will remain valid “for as long as medically necessary” to help patients avoid disruptions in care. It also will require Medicare Advantage plans to review their utilization management policies on an annual basis. Any denials based on medical necessity must be reviewed by healthcare professionals with relevant experience related to the service, prior to a plan issuing a denial, according to a CMS fact sheet.
“CMS has received numerous inquiries regarding the use of prior authorization by Medicare Advantage plans and the effect on beneficiary access to care,” the agency said. “In the rule, CMS finalizes impactful changes to address these concerns and to advance timely access to medically necessary care for enrollees.”
Prior to the announcement from CMS, commercial insurers has already started sharing their intent to reform prior authorization—a key area of contention for the AMA and other doc groups. About 94% of physicians surveyed recently said that prior authorization results in care delays, while 80% said it can at least sometimes lead to patients abandoning care.
To read more, go to Radiology Business.
ChatGPT Offers ‘Pretty Amazing’ Recommendations on Breast Cancer Screening, but Oversight Remains Critical
By Hannah Murphy | April 4, 2023
Experts recently described ChatGPT’s utility in advising patients on breast cancer screening as “pretty amazing,” but warned that others should proceed with caution when seeking medical advice from the chatbot.
A team of experts with the University of Maryland School of Medicine (UMSOM) presented ChatGPT with a set of 25 questions relative to breast cancer screening recommendations to determine whether the program could reliably offer appropriate guidance. The questions covered everything from symptoms of breast cancer and who is most at risk, to costs associated with exams and how often women should undergo screening.
The same questions were presented to the chatbot three separate times to assess its consistency, which has been questioned by many of its users since its launch. Three radiologists who were fellowship-trained in mammography reviewed its responses for accuracy, consistency and appropriateness. They found that it provided adequate answers to 22 out of the 25 queries.
The findings were shared April 4 in Radiology.
“We found ChatGPT answered questions correctly about 88 percent of the time, which is pretty amazing,” noted corresponding author of the new paper Paul Yi , MD, assistant professor of diagnostic radiology and nuclear medicine at UMSOM and director of the UM Medical Intelligent Imaging Center (UM2ii).
Yi also suggested that the responses generated by ChatGPT were summarized into lay language that consumers could understand without difficulty.
To read more, got to Health Imaging.
American College of Radiology ‘Deeply Concerned’ by Ruling Striking Down Key ACA Provision
By Marty Stempniak | April 5, 2023
The American College of Radiology said Monday that it is “deeply concerned” by a recent ruling, which could strike down a key piece of the Affordable Care Act.
A Texas district court judge on Thursday, March 30, declared an ACA provision—requiring insurers to cover preventative care services with no patient cost-sharing—unconstitutional. The Department of Justice quickly filed an appeal of the decision on Friday. But physician groups are sounding the alarm in the meantime.
Currently, law requires insurers to provide no-cost coverage for screening services endorsed by the United States Preventive Services Task Force, among other such entities.
“If the link between the ACA and USPSTF recommendations is dropped, the judge’s ruling will have major public health ramifications across a broad range of preventative services,” the American College of Radiology said in a news update published on Monday, April 3. “If not overturned by appeal, this decision will have a significant negative impact on patients’ access to lifesaving cancer screening services.”
The ruling applies to all USPSTF recommendations issued on or after March 23, 2010, which was the day President Obama signed the Affordable Care Act into law, ACR noted. This would include the task force’s December 2013 endorsement of regular lung cancer screening, with CT-based imaging of the colon likely also impacted.
“The effects of co-pays and deductibles would severely impact individuals most at risk and with the least ability to pay, including minorities and those in underserved areas,” the college said in its update. “The ACR and other stakeholders are hopeful the ruling will not be implemented during what could be a lengthy appeal process,” it added later.
Other provider groups such as the American Medical Association also voiced concern about the “deeply flawed” court ruling. Millions of patients could stand to lose access to preventative healthcare services. Patient advocacy groups including the American Lung Association and Susan G. Komen similarly blasted the decision on March 30, while insurer lobbying group AHIP said it’s reviewing the ruling.
“Providing insurance coverage for screenings and interventions that prevent disease saves lives—period. Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients,” AMA President Jack Resneck Jr., MD, said in a statement.
Christian business owners first filed the suit, contending that the ACA requirement violates their religious rights. The Kaiser Family Foundation and the Advisory Board have more on the ramifications from U.S. District Court Judge Reed O’Conner’s ruling.
To read more, go to Radiology Business.
Private-payer Billings Not Radiology’s Revenue Category to Lead
By Dave Pearson | April 3, 2023
Going by claims submitted to commercial insurers, radiology ranks 15th out of 18 physician specialties, according to a new report from the healthcare staffing company AMN Healthcare.
With average private-payer billings of approximately $2 million per year, radiology falls well below the all-specialty annual average, $3.8 million, the report shows.
Many practices generate revenues ‘considerably higher than the remuneration they receive’
AMN further found the push for quality-based payments is still mostly aspirational: The analyzed billings reflect widespread reliance on volume, whether measured by relative value units, number of patients seen or other productivity metrics.
The report, posted April 3, does not analyze real-world amounts physicians collect. AMN notes the commonness of commercial bills getting only partially paid as insurers apply discounts or deny claims outright. Further, collection rates can vary widely by individual practice as well as specialty, the firm points out.
However, given a hypothetical collection rate of 50%, the average collection amount for all providers in the report is $1.9 million, the company suggests.
Also unaccounted for in tallies of commercial claims are revenues produced by downstream services ordered after initial diagnostic testing.
The report shows that physicians practicing in procedure-oriented specialties “consistently generate higher billing amounts than those in consultative specialties,” AMN concludes.
The project also provides an interesting measure of productivity while demonstrating that physicians and advanced practitioners “generate revenues considerably higher than the remuneration they receive.”
AMN is offering the report free in exchange for name and email here.
To read more, got to Becker’s Payer Issues.
Biden Appeals Texas Ruling Tossing Range of Preventive Care Coverage Under ACA
By Andrew Cass | April 3, 2023
The Biden administration appealed a federal Texas judge’s ruling that struck down an ACA provision that requires insurance companies to provide coverage for preventive services such as certain cancer screenings and HIV prevention drugs, CNBC reported March 31.
U.S. District Judge Reed O’Connor said in his March 30 ruling that preventive care recommendations made by the U.S. Preventive Services Task Force do not need to be complied with and blocked the federal government from enforcing its recommendations.
“Preventive care is an essential part of health care: it saves lives, saves families money, and improves our nation’s health,” an HHS spokesperson said, according to the report. “Actions that strip away this decade-old protection are backwards and wrong.”
The case will go before the 5th Circuit Court of Appeals.
The new ruling only applies to task force recommendations made by the panel on or after March 23, 2010 (when the ACA became law), such as statins, lung and skin cancer screenings, and preexposure prophylaxis, or PrEP, an HIV prevention drug. STI screenings and cancer screenings such as mammograms and cervical screenings would still be included for preventive coverage.
It’s likely that most insurers will still cover preventive services, but they may raise cost-sharing for members for certain services, according to the Kaiser Family Foundation. An increase in costs will not happen immediately because of current contracts, but that could change in the next calendar year. For PrEP specifically, there could be substantial cost-sharing. Generic PrEP costs around $360 a year, while branded prescriptions can reach upward of $20,000 annually.
To read more, go to Beckers Payer Issues.
7 Lessons Learned During Joint Big Business/Healthcare AI Projects
By Dave Pearson | March 31, 2023
Big Tech players have been investing in partnerships with large healthcare providers on AI endeavors for several years now. According to both sides in one such collaboration, the resulting synergy offers “immense potential” to improve patient access, care and outcomes.
The collaborators making the claim hail from Microsoft Corp. and Johns Hopkins Medicine. JACR published their opinion piece discussing the matter March 30 .
“One of the first lessons we learned was that, if you want to impress people, your solution can be complex,” they write, “but if you want to have an impact on the world, your solutions need to be simple enough to be implemented.”
The paper is lead-authored by Juan Lavista Ferres, MSc, chief scientist and lab director of Microsoft’s AI For Good research lab.
Its corresponding author is Johns Hopkins radiologist Linda Chu, MD.
Noting Microsoft’s investments of $40 million in general global health and $20 million specifically for COVID-19 relief and research—both via AI for Good sub-initiative AI for Health—the authors list seven discrete lessons they’ve learned while doing the work.
To read more, go to Radiology Business.
United Healthcare Cutting 20% of Prior Authorizations
By Andrew Cass | March 30, 2023
UnitedHealthcare is moving forward with a plan to eliminate 20 percent of its current prior authorizations and implement a national gold-card program.
Code reductions will begin this summer and continue through the rest of the year for most commercial, Medicare Advantage and Medicaid plans, according to a March 29 UnitedHealthcare news release.
The national gold-card program will be implemented in early 2024, according to the release. The program will apply to most UnitedHealthcare members across commercial Medicare Advantage and Medicaid plans. Qualifying provider groups will follow a simple notification process for most procedure codes rather than the prior authorization process.
“Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members,” Anne Docimo, MD, chief medical officer of UnitedHealthcare, said in the release. “We need to continue to make sure the system works better for everyone, and we will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure. We hope other health plans will make similar changes.”
American Medical Association President Jack Resneck Jr., MD, told The Wall Street Journal March 29 that he is cautiously optimistic about UnitedHealthcare’s changes but wants to see the details to be sure they will bring meaningful improvements.
Molly Smith, the American Hospital Association’s group vice president for policy, told Becker’s that while AHA has not yet seen the specifics, “cutting back on unnecessary prior authorization is a much-needed step forward.” She added that AHA will work with its members to monitor the implementation of the policies to “ensure they do indeed remove unnecessary barriers to care for patients and wasteful administrative burden on providers.”
Two lawmakers who sponsored a Medicare Advantage prior authorization reform bill that passed the House last year applauded UnitedHealthcare’s announcement.
To read more, go to Becker’s Payer Issues.