30 States Have Introduced Prior Authorization Reform Bills This Year, AMA Says
By Andrew Cass | May 11, 2023
Nearly 90 prior authorization reform bills have been introduced in 30 state legislatures this year, according to the American Medical Association.
The AMA said in a May 10 post on its website that many of the bills draw on the group’s model legislation.
Those proposed reforms include establishing quick response times (24 hours for urgent care, 48 hours for nonurgent care) and reducing volume through the use of prior authorization exemptions or gold-carding programs. Other proposed reforms include prohibiting retroactive denials if care is preauthorized and making authorization valid for at least one year, regardless of dose changes.
“These efforts join major reforms at the federal level being proposed and finalized,” AMA President Jack Resneck Jr., MD, said in the post. “Policymakers and other stakeholders seem to be realizing what patients and physicians have known for a long time — prior authorization harms patients, undercuts clinical decision making and wastes valuable health care resources.”
To read more, go to Becker’s Payer Issues.
1 in 3 Physicians Sued During Career, With Radiologists ‘Significantly’ More Likely to Face Litigation
By Marty Stempniak | May 11, 2023
About 1 in 3 physicians are sued over their course of their career, with radiologists “significantly” more likely to face litigation, according to new data from the American Medical Association.
For most docs, it’s “only a matter of time” before they’re taken to court. Typically, the longer a radiologist or other specialist is in practice, the more likely they can expect to be served, experts noted. Over 40% of radiologists said they’ve been sued during their career, according to AMA survey data, while 4.2% of rads said they were named in a complaint during the previous year.
“General surgeons, other surgeons, OB/GYNs, orthopedic surgeons, radiologists and emergency medicine physicians are the specialties whose physicians are significantly more likely to have been sued recently than general internists (the reference group),” according to the analysis, published on Wednesday, May 10.
Between 2020-2022, there were about 66 claims filed per 100 radiologists, and a total of 254 lawsuits across the specialty, the AMA reported. About 30.8% of radiologists under 55 said they’ve been sued during their career, which leapt to 52.1% for those older than that age.
Female physicians faced lower liability risk than men, the AMA noted. About 23.8% of women in medicine said they’ve been sued versus 36.8% of men. Among female doctors, 42 per 100 experience a claim compared to 75 per 100 for males.
The American Medical Association said it continues working with state and specialty medical associations hoping to spur liability reforms. Its goal is to “strike a reasonable balance” between the needs of patients who have experienced harm while also helping to keep down the overall costs of care.
To read more, go to Radiology Business.
MGMA: Medicare Advantage Growth Exacerbates Prior Authorization Burdens
By Victoria Bailey | May 10, 2023
As Medicare Advantage enrollment grows, medical practices are experiencing more prior authorization burdens, including higher administration costs and disrupted workflows, a report from the Medical Group Management Association (MGMA) found.
MGMA surveyed over 600 medical groups in March 2023 to further understand the impact of prior authorization in the Medicare Advantage program.
The majority of practices (95 percent) provide care to patients covered by Medicare Advantage, and 75 percent report they are seeing an increasing number of these patients. Compared to commercial plans, traditional Medicare, and Medicaid, practices said Medicare Advantage was the most burdensome when it came to obtaining prior authorization.
Nearly 85 percent of respondents said that prior authorization requirements for Medicare Advantage have increased in the last 12 months, compared to less than 1 percent who reported a decrease.
Almost 6 in 10 practices saw 15 percent or more of their patients either switch from traditional Medicare to Medicare Advantage or between Medicare Advantage plans. This led to 84 percent of practices having to reauthorize existing services covered by Medicare for those beneficiaries who switched plans.
Prior authorization has historically disrupted workflows for medical groups and diverted time away from delivering patient care.
Thirty-five percent of medical groups said they spend upwards of 35 minutes on an average prior authorization request. Nearly 5 percent reported spending 91 minutes or more on a single request.
Most respondents said insurers required them to utilize a health plan proprietary web portal (91 percent), fax machine (90 percent), or an electronic portal (85 percent) to submit prior authorizations. Three in ten practices reported having to interface with 11 or more health plan proprietary web portals, while 76 percent had to interface with five or more portals.
Not only is prior authorization creating burdensome tasks, but it is also increasing practice costs.
To read more, go to Revcycle Intelligence.
USPSTF Recommends Women Begin Breast Cancer Screening at 40, Boosting Stocks at Mammo-related Firms
By Marty Stempniak | May 9, 2023
The U.S. Preventive Services Task Force issued new breast cancer screening recommendations on Tuesday, now urging all women to begin undergoing screening every other year starting at age 40.
Its draft guidelines mark a shift from the USPSTF’s previous standards, which endorsed screening starting at age 50. Vendors in the women’s imaging space such as Hologic and iCAD saw their stock prices rise sharply Tuesday morning following the news, with screening volumes expected to swell.
The influential USPSTF had previously urged women to “make an individual decision” on when to begin screening prior to 50, but now is reversing course and matching guidelines outlined by medical societies.
“New and more inclusive science about breast cancer in people younger than 50 has enabled us to expand our prior recommendation and encourage all women to get screened every other year starting at age 40,” task force immediate past Chair Carol Mangione, MD, said in a May 9 announcement. “This new recommendation will help save lives and prevent more women from dying due to breast cancer.”
Meanwhile, the group said more research is needed on whether women with dense breasts should have additional screening with ultrasound or MRI. Same for the benefits and harms of screening women older than age 75, according to the draft recommendations. Experts with the task force also highlighted inequities in cancer care. Black women, in particular, are 40% more likely to die of the disease, which is the second leading cancer-killer in America. USPSTF is advocating for additional research to better understand this gap.
“Ensuring Black women start screening at age 40 is an important first step, yet it is not enough to improve the health inequities we face related to breast cancer,” task force Vice Chair Wanda Nicholson, MD, MBA, added in the announcement. “In our draft recommendation, we underscore the importance of equitable follow-up after screening and timely and effective treatment of breast cancer and are urgently calling for more research on how to improve the health of Black women.”
The draft recommendations pertain to women at average risk of breast cancer, including those with a family history or dense breasts. However, it does not apply to women with a personal history of breast cancer, nor those at “very high risk” because of genetic markers.
USPSTF is accepting comments on the document until June 5.
To read more, go to Radiology Business.
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 .
Radiology Societies Urge Commercial Insurers to Align with Medicare on Payment Policy for Key Procedures
By Marty Stempniak | May 8, 2023
Radiology societies are urging several commercial insurers to realign their payment policies for a key procedure to match with Medicare.
Nearly a dozen national medical groups voiced their concerns in a May 1 letter to Humana, Aetna and others. Their frustration stems from policies pertaining to coverage for a minimally invasive procedure to treat compression fractures in the vertebral body.
The American College of Radiology—alongside similar groups representing neuro, spine and interventional radiologists—criticized payer policies that forbid coverage for such surgery in the initial days following a fracture.
“We believe limiting surgical procedures to fractures over six weeks old should be revised/eliminated as this requirement has the potential to negatively impact patient outcomes and providers’ ability to deliver evidence-based, appropriate spinal care to all patients,” ACR et al. wrote. “Notably, recent literature supports this suggestion with positive impacts to patient biomechanical changes, pain scores, quality of life metrics, mortality rates, and long-term economic benefits.”
In a May 5 news post, the college estimated that “at least” six commercial insurers now require four to six weeks of conservative management before patients can receive a percutaneous vertebral augmentation procedure. However, this contradicts the medical literature, along with Medicare payment policies in place since 2021. Delaying surgical management in an often frail and elderly patient population can result in prolonged bed rest, immobility and the use of narcotics—potentially leading to decreasing physical conditions, poor pulmonary function and increased risk of death.
Insurers targeted in the effort also include Cohere Health, Evicore, Health Care Services Corp. and Aim Specialty Health. The latter has already responded to the letter “and is reviewing the issue,” the ACR reported Friday.
Meanwhile, other medical groups joining the campaign are the American Academy of Pain Medicine, the American Society of Anesthesiologists, and the North American Spine Society.
To read more, go to Radiology Business.
ACR Shares ‘Concern’ After CMS Yanks Coverage for Certain Exams, Retroactive to 2019
By Marty Stempniak | May 5, 2023
The American College of Radiology is expressing “concern” after the Centers for Medicare & Medicaid Services removed coverage for certain exams, retroactive to 2019.
CMS’ noncoverage decision pertains to CPT codes 0554T-0558T, (biomechanical computed tomography, or BCT) used to describe services for measuring bone density. The agency issued transmittals earlier this year, asserting that these BCT codes should be removed from coverage, as they were “added in error.” And it wants the decision to date back to July of 2019, the college noted in a Thursday, May 4, news update.
ACR believes the move will sow confusion and is asking the agency to rescind its noncoverage determination.
“The ACR seeks guidance from CMS on how healthcare providers should handle claims using these codes going forward,” Chief Executive Officer William T. Thorwarth Jr., MD, wrote in an April 27 letter to a key agency leader. “We believe that claims paid using these codes should not be adjusted unless there is concern that these services were not properly furnished.”
Back in March, the agency directed contractors to adjust any claims for such services that were processed in error. But ACR emphasized that these codes have been contractor-priced under the Medicare Physician Fee Schedule since 2019. Plus, four Medicare Administrative Contractors have local coverage articles that include the CPT codes as covered services.
CMS’ transmittals have indicated that the services described in these codes “do not meet Medicare’s definition for bone mass measurements.” But the agency has failed to share any further facts to support these claims, the college said. Thorwarth and colleagues also believe CMS should have given providers a chance to comment on the change and plead their case against it.
“We think that a public notice period is warranted before any policy or article changes take effect on beneficiary access to care,” he wrote to Gift Tee, the director in the Division of Practitioner Services. “This allows time to educate and prepare healthcare providers about these policy changes, especially when code changes have the effect of limiting coverage for Medicare beneficiaries.”
To read more, go to Radiology Business.