Top 10 Hospital and Payer Trends to Watch in 2023
December 5, 2023
As 2022 comes to an end, Healthcare Finance News editors reflect on how much has changed over the past year and what that means for trends in 2023. The public health emergency is ongoing and will remain in place past January 11, 2023, putting the popularity of home health and telehealth in the balance.
Hospitals continue to see surges, this time from a combination of COVID-19, flu and Respiratory Syncytial Virus; CEOs and CFOs carry on juggling finances, inflation, increased expenses for labor as well as shortages and the need to determine investments in digital health, AI and automation. And, as always, the demand for interoperable systems and price transparency grows.
Here are the Top 10 trends from 2022 that are likely to influence hospital and payer decisions in 2023:
The end of the public healh emergency: What happens next?Technology, digital health and automation: Strategies to streamline, reach patients and goals.Hospital finances: Cutting expenses, where to save?The retail competition: Amazon, CVS, Walgreens, UnitedHealth move into primary care.Payers: Meeting the Transparency in Coverage rule that goes into effect January 1, 2023.Hospital at home checks the boxes: an aging demographic and a less expensive alternative.Medicare Advantage: Who’s in, who’s out?Telehealth: Fad or future?Mergers, acquisitions and partnerships.Interoperability for providers and payers.To read more, go to Healthcare Finance News.
Where No Surprises Act Disputes are Happening the Most
By Jakob Emerson | January 5, 2023
Five states represent the majority of where No Surprises Act disputes occurred between April 15 and Sept. 30, according to CMS’ initial report on the independent dispute resolution process.
The report noted that the five states where disputes happen the most have their own laws that would apply to many payment disputes. Because of that, the report said it’s possible that the reported disputes involve self-insured plans, which aren’t subject to state laws.
Top 10 disputes by state:
Texas: 24,987Florida: 9,695Georgia: 7,288Tennessee: 6,819North Carolina: 5,040Virginia: 4,079New York: 3,603Arizona: 3,469Indiana: 2,434New Jersey: 2,276View the full ranking here.
To read more, go to Becker’s Payer Issues.
Medical Bills Heading to Dispute Resolution Far More Often Than Anticipated
By Tina Reed | December 30, 2022
Insurers and providers are overwhelming an arbitration system Congress set up to resolve billing disputes as part of the law to prevent surprise medical bills, according to CMS data.
Why it matters: The No Surprises Act, which went into effect earlier this year, protected privately insured patients from getting stuck holding the bag when there’s a disagreement over the cost of out-of-network care.
But the mechanism for deciding who ultimately pays — which allows providers to appeal out-of-network payments they find unreasonable with a third-party arbitrator — has been bogged down by onerous backlogs.By the numbers: Federal agencies estimated there would be 17,333 claims a year submitted to the independent dispute resolution process.
But, CMS data shows, there were more than 90,000 disputes initiated in less than six months.Determining which disputes are eligible for review is taking longer than anticipated as well, CMS officials said in the report.An analysis released last month by AHIP and the Blue Cross Blue Shield Association (BCBSA) found there have been at least 275,000 claims submitted for dispute resolution during the first three quarters of 2022.The big picture: Health insurers lay the blame on some provider groups, especially ones backed by private equity firms, who are abusing the process and overwhelming the system in a way that could increase health care costs.
They urged the administration to “make clear that IDR is meant to be used sparingly as a backstop.”But providers say since the law took effect, the arbitration process has been skewed in favor of insurers because arbitrators consider factors including the median of contracted rates for a specific service in an area as calculated by health plans.Earlier this month, the Texas Medical Association filed its third lawsuit challenging the methodology for calculating these so-called qualified payment amounts, or QPAs, saying it will “deflate” payments, Healthcare Dive reported.To read more, go to Axios.
Want a Clue on Health Care Cost in Advance? New Tools Take a Crack at It
By Julie Appleby | January 3, 2023
Need medical treatment this year and want to nail down your out-of-pocket costs before you walk into the doctor’s office? There’s a new tool for that, at least for insured patients.
As of Jan. 1, health insurers and employers that offer health plans must provide online calculators for patients to get detailed estimates of what they will owe — taking into account deductibles and copayments — for a range of services and drugs.
It’s the latest effort in an ongoing movement to make prices and upfront cost comparisons possible in a business known for its opaqueness.
Insurers must make the cost information available for 500 nonemergency services considered “shoppable,” meaning patients generally have time to consider their options. The federal requirement stems from the Transparency in Coverage rule finalized in 2020.
So how will it work?
Patients, knowing they need a specific treatment, drug, or medical service, first log on to the cost estimator on a website offered through their insurer or, for some, their employer. Next, they can search for the care they need by billing code, which many patients may not have; or by a general description, like “repair of knee joint,” or “MRI of abdomen.” They can also enter a hospital’s or physician’s name or the dosage amount of a drug for which they are seeking price information.
Not all drugs or services will be available in the first year of the tools’ rollout, but the required 500-item list covers a wide swath of medical services, from acne surgery to X-rays.
Once the information is entered, the calculators are supposed to produce real-time estimates of a patient’s out-of-pocket cost.
Starting in 2024, the requirement on insurers expands to include all drugs and services.
To read more, go to KHN.
HHS Proposes New Provider Conscience Rule
By Kara Hartnett | December 29, 2022
The Health and Human Services Department will publish a draft regulation to revise federal standards for conscience- and religious-based objections to providing some types of healthcare, the department announced Thursday.
The proposed rule rescinds most of a rule, widely opposed within the healthcare sector, which President Donald Trump’s administration promulgated that never took effect after federal courts struck it down. President George W. Bush implemented the first federal “conscience clause” regulation in 2008 and its reach has varied as the White House shifted between Republicans, who support stronger protections for providers, and Democrats, who favor promoting broad access to healthcare.
The Trump administration’s rule would have expanded the right of healthcare providers, health insurance companies and their employees to refuse to perform procedures or dispense products based on moral or religious objections, and would have cut off federal dollars to organizations that didn’t comply.
At the time, the American Medical Association said the rule would have allowed physicians to “refuse medically appropriate care even when their refusal jeopardizes another’s life and safety.”
The proposed rule unveiled Thursday would strip most of those provisions and create additional safeguards to protect against religious discrimination, according to HHS. The portions the department proposes to eliminate are “redundant, unlawful, confusing or undermine the balance Congress struck between safeguarding conscience rights and protecting access to healthcare, or because significant questions have been raised as to their legal authorization,” the draft regulation says.
“No one should be discriminated against because of their religious or moral beliefs, especially when they are seeking or providing care,” HHS Secretary Xavier Becerra said in a news release. “The proposed rule strengthens protections for people with religious or moral objections while also ensuring access to care for all in keeping with the law.”
To read more, go to Modern Healthcare.
Healthcare Leaders React to $1.7T Government Funding Bill
Dave Pearson | December 22, 2022
Congress’s $1.7 trillion spending bill appears likely to become law within a matter of hours, funding the federal government through fiscal 2023.
But healthcare stakeholders throughout U.S. medicine, including radiology leaders, aren’t waiting for the ink to dry before speaking their minds.
If the bill passes mostly as is, its most sweeping effect on healthcare will be cutting pay rates in the Medicare physician fee schedule (MPFS) by only 2% rather than the earlier proposed 4.5%. (The cuts would rise to 3.25% in fiscal year 2024.)
Also, the Medicare conversion factor will get a decidedly modest 2.5% increase. Provider groups had lobbied hard for 4.5%.
While the mitigation of the expected overall hit is striking many healthcare leaders as an appreciated lifeline, the final numbers are getting little love from physicians and the groups that represent them.
To read more, go to Radiology Business.