What Happens to Health Programs if the Federal Government Shuts Down?
By Julie Rovner | September 27, 2023
For the first time since 2019, congressional gridlock is poised to at least temporarily shut down big parts of the federal government — including many health programs.
If it happens, some government functions would stop completely and some in part, while others wouldn’t be immediately affected — including Medicare, Medicaid, and health plans sold under the Affordable Care Act. But a shutdown could complicate the lives of everyone who interacts with any federal health program, as well as the people who work at the agencies administering them.
Here are five things to know about the potential impact to health programs:Not all federal health spending is the same.The Biden administration decides what stays open.What happens to enrollment in Medicare and Affordable Care Act plans?What if the shutdown is prolonged?Do federal employees get paid during a shutdown?To read more, go to Kaiser Health News.
56% of New Physicians Say They’ve Received 100-plus Job Solicitations During Training
By Marty Stempniak | September 27, 2023
About 56% of new physicians say they’ve received 100-plus job solicitations during training, the highest figure since 1991, AMN Healthcare reported Tuesday.
Despite high interest from hospitals, medical groups and physician recruiters, nearly one-third of those surveyed said they’d choose a profession other than medicine if given the chance. Another 78% said they had received 51 or more job solicitations, also the highest figure since the survey first launched over 30 years ago.
“Physicians coming out of training are being recruited like blue chip athletes,” Leah Grant, president of AMN Healthcare Physician Solutions (formerly Merritt Hawkins), said in a Sept. 26 announcement. “There are simply not enough new physicians to go around.”
About 81% of residents polled said they sometimes, often or always have experienced feelings of burnout during training, while 45% said such feelings are frequent.
To read more, go to Radiology Business.
Claims Reimbursement Speed, Denial Rate Tied to Location
By Jacqueline LaPointe | September 26, 2023
Does your practice experience claims reimbursement delays? That may be because of where your practice operates, according to a recent analysis of financial transaction data.
The new Crowe report, “10 Best and Worst States for Provider Claims Payment,” draws a connection between how quickly and accurately payers reimburse providers and the state in which the hospital or practice operates. The analysis for the report leverages patient financial transaction data from more than 1,800 hospitals and 200,000 physicians nationwide.
Overall, providers in Louisiana, Oregon, and New Mexico receive claims reimbursement faster and more accurately compared to hospitals and practices in other states based on two KPIs: initial denial rate and accounts receivable (A/R) greater than 90 days.
Pennsylvania, Indiana, Wisconsin, Iowa, Arizona, Illinois, and Ohio round out the top ten best states based on claims-paying performance by payors to providers.
Meanwhile, the top ten worst states in the analysis, starting with the worst, were South Carolina, Mississippi, Arkansas, North Carolina, Missouri, Kansas, Georgia, Kentucky, New Jersey, and Idaho.
In general, aged A/R in the bottom five states is twice the amount of aged A/R in the top states. The analysis also found that healthcare claims were more than five times more likely to not get paid at all in the worst-performing states for final denials.
“Final denial rates have been rising nationwide, but this data helps us zero in on the states where payors consistently refused to pay claims during the first half of 2023, Colleen Hall, managing principal of the healthcare group at Crowe, said in a press release. “This ongoing issue is plaguing the industry because it puts an immense strain on health systems’ revenue. Providers’ financial health is inextricably tied to the quality of care they can provide, so this has a direct impact on patients as well.”
To read more, go to Revcycle Intelligence.
The Major Media Coverage of the Whole-body MRI Screening
By Tom Greeson | September 26, 2023
The debate — and the buzz — continues over the use of whole body MRIs performed on asymptomatic individuals, usually who have the means to pay the several thousand dollars of out-of-pocket costs that are not covered by payors. The hope for healthy individuals who undergo these studies is to detect abnormalities as early as possible, or to rule out potentially life-threatening conditions. As reported here earlier, there is widespread skepticism about the value of these studies.
In the past month, articles in The Washington Post andThe Wall Street Journal recently documented the growing popularity of MRI whole body screening preventive testing. Now The New York Times has entered the mix with coverage from their reporters on this hot topic as well.
These screening studies have a growing list of celebrity proponents who stand across an opposite number of mainstream medical organizations that have stated reservations of MRI whole body screening, such as the written statement of the American College of Radiology (ACR).
Those promoting whole body MRI surely welcome the coverage, even when the press pair their reporting with criticism of these scans when performed on patients without any medical symptoms, such as the balanced coverage offered by the Times this week. After all, as P.T. Barnum once said, “There’s no such thing as bad publicity.”
To read more, go to Viewpoints Blog.
Lawsuits Pile Up Against Cigna Over Alleges Mass Claim Denials
By Jakob Emerson| September 26, 2023
The Cigna Group is facing a growing number of lawsuits from members and a shareholder following a ProPublica report that alleges the company denies large batches of members’ claims without individual review, thereby denying them coverage for certain services.
In March, ProPublica reported that Cigna may be violating state laws by allowing its medical directors to deny large batches of claims without reviewing individual members’ files using an automated claims review process called PxDx. The report said Cigna physicians denied more than 300,000 claims over two months in 2022 through the system, which equated to 1.2 seconds of review per claim on average.
In California, two Cigna members filed a class-action complaint against the insurer in July over the alleged issues. Many states, including California, require physicians to review patient files and coverage policies before denying claims for medical reasons. The July complaint claims Cigna bypassed those steps using the PxDx tool.
In late August, a Minnesota member who was enrolled in a self-funded Cigna plan in 2018 also filed a complaint against the company. She alleges she was automatically denied coverage for certain services because of the PxDx tool, leading to $3,200 in medical bills that were eventually sent to collections. She is seeking a class action and a subclass for Minnesota residents.
In September, a shareholder sued Cigna in Delaware’s Court of Chancery to obtain more information about the company’s claims review process. The shareholder said he attempted to seek more information from Cigna directly following the ProPublica report. Once he did not receive the requested information, he filed a complaint to “investigate possible mismanagement and/or breaches of fiduciary duty and other wrongdoing” by Cigna and noted that additional lawsuits could be filed.
“There is reason to believe that the company’s use of automated systems to deny insurance claims will result in regulatory action and has already caused reputational harm,” the complaint said.
Following the ProPublica report, state insurance commissioners and federal lawmakers publicly raised concerns and requested more information from Cigna about the process, with some calling for an investigation. In Pennsylvania, lawmakers have introduced legislation that would require payers to disclose how they use AI in claims review, citing the ProPublica report.
Cigna has previously said the ProPublica report is “riddled with factual errors and gross mischaracterizations.” The company said its claims review process follows industry standards, including processes that have been used by CMS. It also noted that the technology behind PxDx is more than a decade old and does not involve algorithms, artificial intelligence or machine learning. The company has published additional information on its website about the tool and its claims process.
“PxDx allows us to automatically pay providers for claims that are submitted with the correct diagnosis codes and prioritizes our medical directors’ time for more complex reviews,” a Cigna spokesperson previously told Becker’s. “It does not create any impediments to or denials of care because it takes place after a patient receives the service, and even a denial does not result in any additional out of pocket costs for patients using in-network providers.”
To read more, go to Becker’s Payer Issues.
Medical Specialists Order Low Value, Unnecessary Imaging at Higher Rates than Their Peers
By Marty Stempniak | September 25, 2023
Medical specialists appear to order low-value, unnecessary imaging at rates higher than their peers, according to a research letter recently published in JAMA Network Open .
For instance, such specialists ordered or referred patients for nearly 80% of unneeded imaging related to eye disease, compared to 20% for primary care physicians and 0.2% among advanced-practice clinicians. Specialists also ordered emergency department head CTs for dizziness (76%), computed tomography for sudden hearing loss (73%) and MRI for rheumatoid arthritis (63%) at much higher rates than other providers.
The findings are derived from an analysis of 2016 to 2018 fee-for-service Medicare data recorded across 595 U.S. health systems. Emma D. Chant, PhD, and co-authors focused on unnecessary healthcare services, as defined by the Choosing Wisely campaign, including 12 imaging exams.
“In this national analysis, specialists accounted for a higher share of spending relative to volume across 40 low-value services, building on evidence that specialists have greater aggregate low-value spending to suggest they may both offer higher-cost services (e.g., procedures) and use higher cost options within given low-value service definitions,” Chant, with Brigham and Women’s Hospital in Boston, and colleagues wrote Sept. 20. “To encourage employed and affiliated clinicians to reduce these services, health systems could use evidence-based interventions including clinical decision support (e.g., point-of-care alerts) and clinician feedback (e.g., peer comparisons),” the authors added later.
For the analysis, researchers calculated the volume of services received by “system-attributed beneficiaries” between 2017-2018. The authors also deduced whether each low-value service was ordered or referred for by in-system clinicians, including the individual’s attributed primary care physician, other PCPs, advanced-practice clinicians and specialists. Chant et al. calculated overall Medicare spending using a narrower, more conservative approach (counting only payments associated with a claim line identified as low value), along with a broader equation (which included the entire payment, if a component claim line was identified as low value).
The study included 10.9 million beneficiaries at an average age of nearly 75, who received 8.4 million low-value services. Of those, 4.9 million (or 59%) were delivered in-system. Among the in-system services, 2.2 million (or 45%) originated from attributed primary care physicians, 14% from other PCPs, 4% from advanced-practice clinicians, and 37% from specialists.
To read more, go to Radiology Business.
CMS Says 500K Will Regain Medicaid Coverage as it Takes Aim at Autorenewal Issues
By Paige Minemyer | September 21, 2023
As states continue to work through the yearslong backlog of Medicaid eligibility determinations, procedural coverage losses remain a major concern.
The Centers for Medicare & Medicaid Services (CMS) on Thursday issued new, self-reported data from states that offer a look at where they stand with automatic, or ex parte, renewals, which have been circled as a key way to potentially avoid unneeded disenrollments.
In an August letter, CMS urged states to assess their processes and determine whether there is a systems issue preventing them from deploying ex parte renewals at the individual level, per federal rule. Thirty states reported systems issues as of Sept. 21, CMS said.
With those data on hand, CMS barred those states from procedural disenrollments until they could verify that members were removed from the program appropriately, according to an announcement. This will restore coverage to nearly 500,000 people who lose coverage in Medicaid or the Children’s Health Insurance Program (CHIP), CMS said.
“Addressing this issue with auto-renewals is a critical step to help eligible people keep their Medicaid and CHIP coverage during the renewals process, especially children,” CMS Administrator Chiquita Brooks-LaSure said in the press release. “CMS will keep doing everything in our power to help people have the health coverage they need and deserve.”
To read more, go to Fierce Healthcare.
Controversial Reporting Requirement—Opposed by Rad Partners, Rayus, ACR and RBMA—Set to Take Effect
By Marty Stempniak | September 21, 2023
A controversial Centers for Medicare & Medicaid Services reporting requirement, opposed by radiology societies and providers, is set to take effect soon, imaging leaders warned Thursday.
On Oct. 1, CMS will begin enforcing use of the JW or JZ modifiers for claims tied to drugs in single-use vials or packages, paid for separately under Medicare Part B. The American College of Radiology, Radiology Business Management Association, Rayus and Rad Partners challenged this change over the summer, believing it to be too burdensome for physician groups to maintain.
“These requirements add a significant amount of additional time, resource, and administrative costs to providers, with no additional benefit to CMS,” the four organizations wrote in a letter to the agency in July.
The Infrastructure Investment and Jobs Act mandates that manufacturers provide a refund to CMS for any unused portions of drugs that come in single-use packaging. However, the rule does not pertain to radiopharmaceuticals or imaging agents, the four organizations emphasized in their letter. The 2023 Medicare Physician Fee Schedule advises that providers should use one of two modifiers to clarify such scenarios—JW for discarded drug amounts or JZ to attest that there weren’t any leftovers.
Given the volume of studies affected by the change, ACR et al. previously said they are dismayed by the enormity of the undertaking. Each year, providers serve Medicare patients with more than 3 million enhanced imaging studies and 1.5 million diagnostic nuclear medicine exams involving radiopharmaceuticals. Performing exams under the new mandate would call for updated workflows and forms, among other changes. What’s more, the agents in question are often delivered on-demand in premeasured doses, leaving nothing to report.
ACR posted a news update to its members on Sept. 21, urging radiology providers to be ready for the update. It emphasized that the mandate does, in fact, pertain to radiopharmaceuticals and contrast agents used in medical imaging.
“Also beginning Oct. 1, claims for drugs from single-dose containers that do not appropriately use the JW/JZ modifiers will be returned as un-processable until claims are properly submitted,” the college noted.
All four organizations met with CMS to ask the agency to waive the reporting requirement ahead of next month’s go-live date, according to the update.
To read more, go to Radiology Business.