Imaging Advocacy Group Slams ‘Extremely Restrictive’ Medicare Coverage Determination
Marty Stempniak | May 30, 2023
An industry advocacy group is slamming one Medicare Administrative Contractor’s “extremely restrictive” payment policy related to PET imaging.
Earlier this year, the MAC in Tennessee issued a proposed local coverage determination, rejecting reimbursement for positron emission tomography for inflammation and infection. Nashville-based CGS Administrators contend that PET use in such cases is experimental or investigational, advocates reported Friday.
The Society of Nuclear Medicine and Molecular Imaging criticized the claim, and any notion that physicians are overusing PET for this indication, in a May 26 news update.
“The SNMMI is most concerned that your extremely restrictive proposed coverage criteria will limit the delivery of highly appropriate imaging care to your beneficiaries to the detriment of their care,” the society wrote in a March letter to the chief medical officer at CGS Administrators. “SNMMI strongly believes that PET scans will not be overused in cases of suspected infection/inflammation but rather will be applied as a problem-solving tool when other diagnostic methods have come up negative or equivocal, often in critically ill patients.”
CGS Administrators’ coverage determination “incorrectly rejects” PET coverage, SNMMI added, and “wrongly classifies” several uses of the technology as experimental or investigational. Those include fever of unknown origin in immunocompromised patients, native endocardial valve infections, total knee replacement, chronic swelling in the bone, diabetic foot, and infections in the vertebrae.
The society wants the local Medicare Administrative Contractor to withdraw its coverage determination. Or, at a minimum, MACs should cover all indications that have an appropriate-use criteria score of 7 or higher. It also wants coverage for imaging tied to fever of unknown origin “regardless of category.” SNMMI noted that the immunosuppressed patient population is especially susceptible to unusual infections, and “more rapid diagnosis is often needed.”
“SNMMI strongly recommends that substantial revisions be made to the proposed LCD to align it with the clinical evidence,” SNMMI President Munir Ghesani, MD, wrote in his March 19 letter. “SNMMI understands that for a number of inflammation/infection indications, use of PET and PET/CT may not be first-line diagnostic tools. In those cases, CGS should cover PET and PET/CT as second-line tools when the primary tools (e.g., echocardiography for suspected native cardiac valve infection) are inconclusive. As a general matter, that is a much better approach to coverage than not covering PET and PET/CT at all.”
CMS also previously discussed possible restrictions around covering PET for inflammation and infection in 2021.
To read more, go to Radiology Business.
Healthcare Costs Exceed $31K For Family of Four
By Jeff Lagasse | May 30, 2023
Healthcare costs for a typical American family of four reached $31,065 this year, according to the new 2023 Milliman Medical Index, which measures healthcare costs for individuals and families receiving coverage from an employer-sponsored preferred provider plan.
Costs for the average person, meanwhile, reached $7,221.
Overall, healthcare costs increased 5.6% this year, and have increased by about 4.8% annually since 2021 – the kind of year-to-year increase that was seen prior to the COVID-19 pandemic. Whether it’s a return to the status quo or a pandemic rebound, family healthcare costs have resumed their steady climb, the data showed.
“Healthcare cost inflation tends to trail general inflation by six to 12 months,” said Doug Norris, co-author of the Milliman Medical Index. “While there have been some encouraging numbers on the general inflation front recently, we have a while before healthcare cost inflation catches up.”
Macroeconomic forces are further contributing to the upward direction in healthcare costs, authors noted. It’s not just inflation – the supply chain, labor shortages and strong job markets are all contributing factors.
WHAT’S THE IMPACT
Employees are shouldering close to 60% of this year’s cost increase, the data showed, which is a possible sign that increased job mobility, along with the complexities of remote work, are giving employers a good reason to invest in benefits.
To read more, go to Healthcare Finance News.
CMS: ‘Substantial’ Portion of Medicaid Terminations Due to Red Tape
By Jakob Emerson | May 30, 2023
With Medicaid redeterminations underway nationwide, CMS is urging states to ensure they do not terminate coverage for eligible individuals.
“A substantial portion of the terminations that we’ve seen in April were due to folks not responding, or red tape,” Daniel Tsai, CMS deputy administrator and director of the Center for Medicaid and CHIP, said during a May 30 call with reporters. “Discussions with on-the-ground stakeholders indicate that most Medicaid enrollees are not aware that Medicaid eligibility checks have restarted.”
States could begin terminating coverage for ineligible Medicaid recipients in April following a three-year period of continuous Medicaid/CHIP enrollment under the COVID-19 public health emergency. All states have begun initiating renewals, but the majority will begin terminating coverage in June or July. A May 24 survey from the Kaiser Family Foundation found that 65 percent of Medicaid recipients were unaware states could begin terminating coverage.
In Florida, Arkansas and Indiana, which began terminations in April, more than 80 percent of those disenrolled so far saw their coverage terminated because their information was not updated with the state — not because they were ineligible for the program based on income.
In addition, more than 50 health advocacy groups and other organizations have called on Florida Gov. Ron DeSantis to pause redeterminations over the early results.
“When governors see such large numbers of terminations of coverage for procedural reasons, they should pause the process and see what is going wrong,” Joan Alker, executive director and co-founder of the Georgetown University Center for Children and Families, wrote in a blog post May 16. She noted that it is difficult to compare states’ redetermination processes because each Medicaid program is prioritizing different groups and reporting data independently.
Mr. Tsai said CMS is monitoring state Medicaid programs to ensure compliance with federal rules and said the agency would have more complete national data around the process “in early summer.” He urged states to do additional outreach to unresponsive individuals before terminating coverage and to take advantage of new tools and flexibilities available during the unwinding period.
“Where and if we do find there are instances of folks not following what’s required under federal rules, we will use all the levers at our disposal to ensure that everyone eligible for Medicaid is able to maintain the coverage they are entitled to,” he said. “This really is an all-hands-on-deck moment. Even when states are following all the federal rules required for Medicaid renewals, we are looking for everybody to do more.”
HHS has estimated that 15 million people total will lose Medicaid coverage during redeterminations. The Congressional Budget Office estimated May 24 that 9.3 million people will transition to other forms of health insurance through 2024, and 6.2 million will remain uninsured.
To read more, got to Becker’s Payer Issues.
Breast, Lung Cancer Incidence to Rise Due to COVID Screening Delays
By Kate Madden Yee | May 30, 2023
The incidence of breast, colorectal, and lung cancer will likely rise due to screening delays caused by COVID-19, according to a study published May 25 in the Journal of the American College of Surgeons.
These cancers are now liable to be diagnosed at later stages as well, which will burden the healthcare system, noted senior author Dr. Teviah Sachs, chief of surgical oncology at Boston Medical Center in Massachusetts.
“These are all cancers that have very profound incidences in our patient population across the U.S.,” Sachs said in a statement released by the journal. “They are much better managed and often curable when found early, and devasting when caught late.”
The COVID-19 crisis disrupted healthcare services, including cancer screenings, the authors noted. But how this disruption may have affected cancer incidence has not been explored.
“The reported incidence of screenable cancers significantly decreased during the COVID-19 pandemic (2020), suggesting that many patients currently harbor undiagnosed cancers,” the group wrote. “In addition to human toll, this will further burden the healthcare system and increase future healthcare costs.”
Lead author Dr. Kelsey Romatoski, also of Boston Medical Center, and colleagues developed and used a predictive statistical model to assess missed diagnoses of breast, colorectal, and lung cancers though comparing pre-pandemic cancer rates (2010 to 2019) to 2020 cancer rates. The group used data from the National Cancer Database and from the U.S. Census, including information from 2.2 million breast cancers, 1.1 million colorectal cancers, and 1.7 million lung cancers.
The investigators found the following:
Breast cancer observed incidence decreased by 14.6%.Colorectal cancer observed incidence decreased by 18.6%.Lung cancer observed incidence decreased by 18.1%.Of even more concern, these missed screenings — and ensuing delayed diagnoses — disproportionately affect certain patient groups such as non-white and Hispanic patients and those treated in the northeastern and western parts of the U.S., the authors noted.
To read more, go to Aunt Minnie.
Denials of Health Insurance Claims Are Rising – And Getting Weirder
By Elisabeth Rosenthal | May 30, 2023
Millions of Americans in the past few years have run into this experience: filing a health care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims—sometimes bundles at a time—without reviewing the patient’s medical chart. A job title at one company was “denial nurse.”
It’s a handy way for insurers to keep revenue high—and just the sort of thing that provisions of the Affordable Care Act (ACA) were meant to prevent. Because the law prohibited insurers from deploying previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.
And so, the law tasked the Department of Health and Human Services (HHS) with monitoring denials (PDF) both by health plans on the Obamacare marketplace and those offered through employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out-of-pocket or, faced with that prospect, forgoing needed medical help.
A recent KFF study of ACA plans found that even when patients received care from in-network physicians—doctors and hospitals approved by these same insurers—the companies in 2021 nonetheless denied, on average, 17% of claims. One insurer denied 49% of claims in 2021; another’s turndowns hit an astonishing 80% in 2020.
Despite the potentially dire impact that denials have on patients’ health or finances, data show that people appeal only once in every 500 cases.
To read more, go to Fierce Healthcare.
10 Trends to Watch in Diagnostic Imaging
By Marty Stempniak | May 26, 2023
There are 10 trends that warrant leaders’ close attention, according to a new report from Sg2, published May 25.
The Chicago-headquartered consultancy is forecasting double-digit volume growth in the field during the next decade, driven by both demand and advances in imaging technology. In particular, PET and CT are expected to see 15% growth by 2030, the Vizient-owned firm reported.
“To achieve organizational objectives in an ever-evolving landscape, imaging providers must develop strategies to meet increased demand for services,” Sg2 experts advised. “Diagnostic imaging remains a cornerstone for high-quality patient care, and providers who plan well will be positioned to further advance their imaging offerings,” the authors added later.
Here is a quick rundown of the list. Radiology Business added the numbers, as Sg2 did not rank each item in order of importance. You can find the full report for free here.
1. Workforce challenges
2. Asset management
3. Artificial intelligence
4. Reimbursement pressure
5. Intraoperative imaging
6. Mergers and acquisitions
7. Enterprise imaging partnerships
9. Patient consumer innovation
To read more, go to Radiology Business.