The payer is adding four new states to its offering of individual and family health plans in 2023.
UnitedHealthcare announced it is expanding its footprint in the ACA marketplace to 22 states for 2023 ahead of open enrolment for ACA plans beginning November 1.
The insurer is adding four new states—Kansas, Mississippi, Missouri, and Ohio—to its individual and family health plan offerings, while continuing to be available in Alabama, Arizona, Colorado, Florida, Georgia, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Nevada, New York, North Carolina, Oklahoma, Tennessee, Texas, Virginia, and Washington.
After significantly contracting its ACA markets from 34 states in 2016 to just a handful in 2017, the payer giant has steadily its offerings.
UnitedHealthcare sold plans in 11 states in 2021 before adding seven more states to bring its total to 18 for this year.
"Everyone should have access to quality affordable health care coverage, particularly now as many Americans are working hard to keep their costs down," said Marcus Robinson, senior vice president at UnitedHealthcare Individual and Family Plans. "With extended eligibility and subsidies, we have created even more options for the 2023 Health Insurance Marketplace that meet the diverse needs of our members and help people make the best choice for themselves and their families."
The announcement of the ACA plans comes after the company announced its third-quarter earnings, which included $7.5 billion in earnings from operations, up from $5.7 billion in the third quarter of the previous year.
The insurer said the growth was driven by expansion in the number of people served throughout UnitedHealthcare and in the value-based care initiatives at Optum Health.
The payer's senior director of business operations speaks on a new pilot program that significantly reduces approval times.
Leveraging automation is a strategy healthcare organizations everywhere are exploring, if they haven't adopted it already.
For Blue Cross Blue Shield of Massachusetts, the benefits of automation are already apparent in their new pilot program designed to streamline prior authorization. The initiative, called FastPass, is piloted at New England Baptist Hospital and successful in speeding up review time, reducing administrative burden, and cutting down on costs.
The technology cross-checks Blue Cross' prior authorization requirements in real-time to determine if approval is needed. When prior authorization isn't required, the provider receives instant notification so they can proceed with scheduling the procedure. When prior authorization is needed, FastPass cross-checks clinical history against Blue Cross' criteria to automatically generate a recommendation. For complex cases, the program automatically packaged the necessary clinical documentation for the clinical review team.
According to Blue Cross, the pilot, focused on hip and knee procedures for 32 orthopedic providers over a four-month span, resulted in 88% prior authorization submissions processing automatically in real-time. Overall, approval time was slashed significantly from an average of nine days to an average of less than one day.
Deb Vona, Blue Cross Blue Shield of Massachusetts senior director of business operations, spoke with HealthLeaders about the payer's vision for FastPass, the importance of reducing prior authorization burden, and how automation can make healthcare organizations' lives easier.
This interview has been edited for clarity and brevity.
HealthLeaders: What factors led Blue Cross to explore this pilot?
Vona: We've been looking at prior authorization innovation for a couple of years. I think it was just the fall of 2020 that we really dug in deeply with our internal innovation team and our IT partners in that 'we need to think of a different way to do this.' We have largely fax and phone based prior process and as we started looking at different vendors and really setting out our goal, one of our key goals from the beginning was we wanted to develop a solution that was truly a win-win-win, as we call it, for all of the stakeholders: ourselves, the provider partners, and our members. Ultimately, there were a lot of solutions that we saw out there that really were just pushing a lot of work to the provider partners. We didn't see that as true innovation.
And as we were scanning the different options in the marketplace, the thing that made Olive stand out from the other vendors and why we launched the proof of concept with them was that they had a system called Pathways that was already installed in some of the provider offices at an orthopedic specialty hospitals in our network. But Pathways give us a small condensed package of really just what we needed so that was already there. And we said that gives all of the advantages that other vendors didn't have.
Pictured: Deb Vona, senior director of business operations, Blue Cross Blue Shield of Massachusetts.
HL: Prior authorization, especially right now from the provider side, is associated with administrative burden and affected by the labor shortage. From the payer side, what makes the investment in streamlining prior authorization worthwhile?
Vona: It's a lot of the same work as on the provider side. We have the exact same recruitment and retention issues today. We have a very high vacancy rate and despite all of our best efforts to fill positions, always have vacancies. So it's to remove that work, particularly remove the work that can be done in a more automated way so that we're really saving those cases that require the human intervention for those people. So there's a lot of it that can be automated. And we know we'll always have nurses, we'll always have doctors, will always have my operations team that needs to handle some of these cases manually. But the value proposition for us is being able to do this in a more affordable way, in a faster way, and see our highly talented, highly expensive clinical team, for those most complex cases, they're not reviewing the cases that are pretty standard.
HL: Why do you see the necessity for automation right now across healthcare organizations?
Vona: I separate this into two things and I think sometimes things get lumped together, but there's automation, which to me is getting our systems to speak to each other. This is all of the information that we need about that member who is going to be scheduled for surgery exists today in that provider's EMR. But without automation what we're doing is printing it out, faxing it over, and somebody on our end is typing it into a different system. The automation part is just how do we get these two systems to connect to each other, to share all that data. It's all exists, it's right there. But we're wasting time by the manual processes that exist. That to me is the first step and the first value add in this process. It's just removing the manual hand off.
Then, where can we use AI once we have that automation to speed up the clinical decision-making components of it? Not every case gets reviewed by a clinician and so that's a narrowing funnel. But the biggest opportunity is the automation piece and getting the systems connected to one another through mobile manual work.
HL: What are Blue Cross and payers in general focusing on to work with providers to make revenue cycle processes more seamless?
Vona: Previously I was on the provider side of operations and financials. I know that this prior authorization and referrals is a big component of that because there's nothing worse than doing the work and then not getting paid because some administrative step was missed. So I think looking at solutions like this to automate that work is a key piece of it.
There's also a lot around trying to give their team a comprehensive view of the different services. And this is where we've been really sensitive to not wanting to develop solutions that would only be Blue Cross-centric. We have heard from the practices loud and clear that 'I'm not just managing this for my Blue Cross members. You're 20% of my business but I have to manage this for all these different health plans.' And that's where I feel like providers are really focused, 'who can pull that all together in one place for my team to be able to manage.' I think that's where we're finding a lot of interest right now.
And again, as we were looking at our solution right from the start, we said we want something that's going to be scalable beyond us. We know that it's in our best interest to try to develop a solution that could be expanded because that's where we can get the best adoption by the provider community.
State systems that are friendlier to providers have inflationary potential by driving up awards and health costs.
Most states are partnering with the federal government to enforce protections under the No Surprises Act, but some state systems for resolving the independent dispute resolution (IDR) process are more favorable to providers, according to a report by the Commonwealth Fund.
The research finds nine states—Alaska, Connecticut, Florida, Illinois, Missouri, New Jersey, New York, Ohio, and Texas—are friendlier to providers than insurers compared to the federal system and could lead to higher payments for providers.
The No Surprise Act features an IDR process to determine out-of-network payment amounts between providers and health plans. When providers reject insurers' initial payment or denial, the law calls for the parties to negotiate. If the two sides can't reach an agreement, they can trigger the arbitration process and have an independent entity determine the rate, which places an emphasis on the qualifying payment amount, or the median in-network rate.
The federal law takes precedence except for in states that have their own systems of determining payments to out-of-network providers in place of the federal IDR system, the report states.
Analysis of state and federal regulations, supplemented with interviews with insurance regulators in 12 states, finds variation in how states enforce the protections under No Surprises Act.
Five states (Idaho, Iowa, Maryland, Pennsylvania, and West Virginia) have full state enforcement, while seven states (Alabama, Hawaii, Indiana, Louisiana, Missouri, Oklahoma, and Wyoming) are fully federally enforced. Three-fourth of states have chosen to share enforcement.
The report finds that twenty-two states use existing state processes to determine payments, with some state laws having a narrower scope than the No Surprises Act. Additionally, state payment determination processes usually do not apply to air ambulance payment disputes.
Overall, 25 states intend to enforce all payment determinations for providers and insurers, whether they use the federal IDR process or their state system. Around half of those states will do this with a collaborative enforcement agreement, which allows the federal government to enforce the outcomes of state process, the report mentions.
While the No Surprises Act is essential for protecting patients, it has placed responsibility on the federal government to get enforcement right. The authors of the report believe enforcement processes will evolve over time and that state policymakers will consider changes to their existing surprising billing laws.
"The long-term success of the law also will rely on oversight from state and federal agencies, both to monitor the law's efficient operation and to identify any adverse consequences," the authors conclude. "The No Surprises Act calls for various studies of its impact on provider networks, health costs, provider concentration, and the role of private equity. Some states already report on the impact of their state laws on both costs and the prevalence of out-of-network claims.
"A focus on these issues by government agencies and researchers will be critical to identifying adverse effects and opportunities for adjustments."
A new report reveals the top factors members care about when evaluating payers.
Beneficiaries are holding health insurers more accountable and weighing experience factors when considering a switch in plans, according to a report by Accenture.
The benchmark surveycompiles responses from almost 11,000 adults between March and May to examine how their insurers perform across nine healthcare consumer touchpoints.
Results show that younger generations are less likely than older adults to consider price, medical benefits, and network coverage to be primary factors when choosing a health plan. Instead, younger generations value experience factors like customer service, convenience, and trust.
The survey finds the top three reasons why beneficiaries leave their payers to be:
Ease of navigation (49%) — Respondents identified issues such as inconsistent or inaccurate information, unanswered questions, poor experiences using digital tools, poor customer service, and discomfort with how payers used their personal data.
Clinical experience/expertise (35%) — Switching factors included prescription drug benefits not meeting needs or expectations, condition management programs not being robust enough to meet needs, and the wellness or supplemental benefits not being strong enough.
Access/network (32%) — Preferred providers not being in the prior plan network and lack of convenient options were cited as deterrents.
To retain members and deliver the experience that is expected, the report highlights four factors payers should focus on: access, ease of doing business, digital engagement, and trust.
For access, more than two-thirds of respondents (69%) strongly agree that insurers that make it easy to find necessary information to select new providers deserve a positive healthcare rating.
"One of payers' primary roles is enabling people to access the quality care they need," the authors of the report state. "People want that to happen with the right information, minimal hassle and flexibility. Payers' effectiveness across these factors has a significant impact on people's perception of their health experiences, and as such, on their likelihood of staying."
Ease of doing business is similarly held in high regard, with respondents being four times more likely to stay with insurers they find are easy to work with compared to those that find their payer difficult.
Digital engagement, meanwhile, is another indicator of loyalty to insurers. The survey finds highly digitally engaged people are more likely to stay (64%) than the national average (55%) and more likely to consider their payer very easy to do business with (74% versus 50%).
Building trust with beneficiaries is essential, which means providing consistent information, helping members understand their coverage, and minimizing hassles. Based on respondents' answers, those who are trusting of their payers are four times more likely to stay than those that are distrusting and almost twice as likely as those who remain neutral.
"Healthcare organizations want to make meaningful progress in responding to people's rapidly evolving health experience expectations," the report states. "After all, loyalty and engagement hang in the balance."
More benefits and a limit on out-of-pocket costs are the top reasons older adults are opting for Medicare Advantage (MA).
With the open enrollment period under way, millions of Americans are weighing their coverage options to make the best decision for their health needs.
The choice between traditional Medicare and MA plans can come down to preference, guidance, and information.
According to a survey by the Commonwealth Fund, more benefits and out-of-pocket cost limits are the primary drivers for enrollees selecting MA plans, while greater choice in providers leads the way for those choosing traditional Medicare.
The 2022 Biennial Health Insurance Survey uses responses from 1,605 older adults aged 65 and above who were enrolled in Medicare to determine why they chose MA or traditional Medicare, and what resources they utilized.
About one in four (24%) respondents cited additional benefits as their reason for choosing MA, followed by out-of-pocket cost limits (20%), recommended by trusted people (15%), offered by my/partner's former employer (11%), maintain same insurer (9%), help managing healthcare (8%), and doctor recommended (3%). 'Other' was chosen by 8%.
For traditional Medicare, more provider choice led the way for 40% of respondents, followed by recommended by trusted people (9%), continuing coverage from employer (7%), VA healthcare/Tricare for Life (6%), lower cost (4%), and have supplemental insurance (4%). Nearly a quarter of those surveyed chose 'other.'
While most of the respondents (40%) said they did not receive help to guide their plan choice, the ones that did receive help relied primarily on an insurance broker for Medicare (30%) and MA (31%). About one in five (18%) were guided by friends and family, with a small percentage using the Medicare.gov website and hotline or the state health insurance assistance program.
"Medicare beneficiaries, regardless of their source of coverage, seem to most frequently rely on the one-on-one help provided by brokers and agents in choosing a Medicare plan," authors of the survey said. "But brokers and agents are paid commissions by insurers, which can influence the kind of information they provide."
How MA is advertised and marketed has been a source of frustration for some, who argue beneficiaries are being misled and tricked. According to the survey, 6% of enrollees used marketing as a source of information in choosing a plan. The rate varied among respondents who were Black (12%) and white (5%), as well as between those in the lowest income category (12%) and those in the highest (2%).
The findings show that where and how beneficiaries get their information on coverage options matters not only for enrollees at large, but within different subsets as well.
"It’s important to learn how these sources inform beneficiaries, whether they are equitably accessible, and what kinds of services and information are needed to fill any gaps," the authors conclude. "Regardless of where beneficiaries get information for making their coverage decisions, having accurate, easy-to-use tools would help them evaluate their options."
The agency will pay 340B hospitals the average sales price plus 6% for all calendar year 2022 drug claims billed with modifier -JG.
Following the recent ruling on the 340B hospital reimbursement timeline, CMS has disclosed its payment rate to cover 340B drug costs.
CMS will pay 340B hospitals the average sales price plus 6%, instead of the average sales price minus 22.5%, for all calendar year 2022 drug claims billed with modifier -JG (drug or biological acquired with 340b drug pricing program discount), the American Hospital Association (AHA) said.
The payment rate arrives weeks after a judge rejected HHS' plan to wait until January 1, 2023, to restore drug payments to 340B hospitals, instead ordering them to immediately end the cut.
AHA said of the ruling: "We continue to urge the administration to promptly reimburse all the hospitals that were affected by these unlawful cuts in previous years and to ensure the remainder of the hospital field is not penalized for their prior unlawful policy, especially as hospitals and health systems continue to deal with rising costs for supplies, equipment, drugs, and labor."
After the decision, HHS stated on September 30 it would need two weeks to adjust payment rates because it "requires revisions to four different electronic data files and then testing by multiple offices to confirm that the revised files function appropriately before the files are loaded to the production environment where they will be used to calculate OPPS reimbursements on a prospective basis."
With the payment rate now set, CMS said it will reprocess claims Medicare administrator contractors paid on or after September 28 using the default rate.
Both smaller and larger provider organizations can benefit from software that can automate tasks and increase productivity.
Coming off the heels of the COVID-19 pandemic, providers are doubling down on software investments and prioritizing revenue cycle management to alleviate macroeconomic challenges, according to a report from Bain & Company and KLAS.
The research finds that 45% of providers accelerated software investment over the past year, with 10% pulling back on spending, to better deal with the current climate consisting of labor shortages, inflation, and organizational changes like mergers and acquisitions and leadership turnover.
Software is a top five strategic priority for nearly 80% of provider organizations and a top three priority for almost 40% as providers seek solutions to increase productivity and automate tasks.
More than 95% of providers expect to make new software investments over the next year, with one-third planning significant new investments. Roughly another third indicate they plan to spend more than usual over the next 12 months due to the challenge of the current environment.
Revenue cycle management is at the top of the list for where those investments will go. Half of providers chose revenue cycle as a top-five priority for investment over the next year, followed by security and privacy (44%), patient intake/flow (44%), clinical systems (40%), and telehealth (36%).
Authors of the report highlight that revenue cycle management software is essential for smaller provider organizations that have to navigate complex payer landscapes and catch up to health systems, as well as for larger health systems that need to continue to make investments in outsourcing and adoption of software modules such as complex claims and artificial intelligence.
"Providers of all types cited RCM as a top priority for the next year, pointing to a broad set of specific priorities, including revenue integrity, charge capture, and complex claims, and underscoring a robust set of RCM needs across the provider ecosystem," the report states.
While there is no shortage of software solutions on the market, over 50% of providers say they are struggling with the flood of offerings, while a quarter claim their current tech stacks are keeping them too busy to update to new offerings.
In response, 72% of providers plan to look to existing vendors with proven solutions before considering new vendors. Additionally, around 71% plan to look to their electronic medical records for new solutions before looking to others, and 63% are making plans to streamline the number of third-party software solutions in their tech stacks over the next 12 months.
New research finds payers negotiate different prices for services like CT and MRI scans within the same hospital.
Health insurers are not only negotiating prices for common radiology services less efficiently than their competitors, but across other health plans under their management as well, according to a study on pricing variation.
Published in Radiology, a journal of the Radiological Society of North America, the researchexamined commercial negotiated prices across hospitals for shoppable radiology services such as CT or MRI scans.
The authors found that on average, the maximum negotiated price for shoppable radiology services was 3.8 times the minimum negotiated price in the same hospital and 1.2 times in the same hospital-insurer pair.
"Many commercial plans are leaving money on the table when negotiating price with hospitals, especially for expensive CT and MRI scans," said study co-author Ge Bai, Ph.D., C.P.A., professor of accounting at the Johns Hopkins Carey Business School. "High prices paid by commercial plans eventually come back to bite U.S. employers and workers through high premiums and out-of-pocket costs."
CT and MRI services had the most price variation within a hospital and within a hospital-insurer pair, as well as higher prices relative to Medicare when compared to other radiology services. Brain CT had the most variation, with 25% of hospital-insurer pairs having their maximum negotiated price more than 2.4 times their minimum negotiated price.
Additionally, the study found that higher prices for higher cost services imply higher hospital profitability, which can influence hospitals to opt for high-cost imaging and lead to inefficient spending for payers and patients.
In theory, the hospital price transparency rule should discourage that behavior by hospitals and give payers and patients more information. Hospitals have been slow to adhere to the law, however, as an August report by PatientsRightsAdvocate.org found that only 16% of hospitals were complying with the rule nearly 20 months after it went into effect.
A recent report by Turquoise Health suggests facilities may finally catching up though, with the research revealing that 65% of hospitals have published robust negotiated rates.
"Price transparency took the blindfold off the eyes of commercial payers, forcing them to recognize the fact that they are often paying too much," Dr. Bai said. "Equipped with pricing information, radiologists can change the landscape of care delivery to benefit patients and payers."
The Save Medicare Act argues that Medicare Advantage (MA) plans are deceptive and overcharge seniors for profit.
MA plans are under fire once again, this time with the introduction of new legislation that's aiming to take 'Medicare' out of the name.
The Save Medicare Act, sponsored by representatives Mark Pocan (D-Wis.) and Ro Khanna (D-Calif.), arrives just ahead of the open enrolment period, running from October 15 to December 7.
The bill would prohibit private insurers from using 'Medicare' in plan titles or advertising, and levy fines on payers that use the "deceptive practice."
"'Medicare Advantage' is just private insurance that profits by denying coverage and the name is being used to trick seniors into enrolling. That’s not right," Khanna said in a statement. "This bill will prevent these private insurers from labeling themselves as 'Medicare' and allow us to focus on strengthening and expanding real Medicare instead."
It is unlikely the bill passes through the House, where MA has received bipartisan support. In January, 346 representatives, or 80% of the chamber, signed a letter to CMS backing MA.
Yet the push for the legislation is necessary, according to its sponsors, who pointed to a recent report by The New York Times that showed eight of the 10 largest MA insurers submitted inflated bills. Four of the five largest insurers—United Health, Humana, Elevance, and Kaiser—have faced federal lawsuits alleging fraudulent efforts to overdiagnose patients.
Pocan and Khanna also highlighted a report by the Medicare Payment Advisory Commission from March that found at least $12 billion in overpayments to MA plans in 2020 by the federal government.
"These non-Medicare plans run by private insurers undermine traditional Medicare. They often leave patients without the benefits they need while overcharging the federal government for corporate profit. This bill eliminates any confusion about what is – and what is not – Medicare, and ensures this essential program will continue to serve seniors and other Americans for years to come."
Over 200 CFOs and VPs of revenue cycle were surveyed on top concerns facing health systems and physician groups.
The financial challenges of the COVID-19 pandemic are still being felt across the healthcare industry and revenue cycle management (RCM) departments are no exception.
Between increasing costs and the labor shortage, providers are under pressure to come up with solutions in real-time to reduce the burden of administrative processes for not only their own sake, but for patients as well.
For its Mid-Year Healthcare Financial Trends Report, revenue management company R1 RCM surveyed 205 CFOs and RCM VPs from health systems and physician groups to gauge today's top priorities, concerns, and trends for RCM.
Increasing costs were identified as the top concern for respondents (25%), while finding a strategic RCM partner was chosen as the top solution for the second half of 2022 (28%).
Here are five key takeaways from the report:
Economic pressures from returning patients: 96% strongly agree there is, or will be, additional strain on RCM operations as patient volume increases.
Labor shortage: 90% are currently experiencing a labor shortage in their RCM/billing department, while 50% of their RCM/billing roles are currently vacant.
Need for automation: 45% say patients are experiencing longer hold times for scheduling and customer service calls. Additionally, 48% have witnessed billing errors due to lack of experienced staff for coding, claims, and reimbursement.
Choosing a partner: 44% are partnering with a strategic RCM company that specializes in an outcomes-focused approach to optimizing the entire revenue cycle. More than half (52%) report experiencing positive financial outcomes through their RCM partnerships.
Benefits of global delivery: 82% say their sentiment toward global delivery has become more favorable in the face of today's labor shortage.
To continue overcoming the obstacles at hand, as well as the challenges coming down the road, RCM departments will have to adjust their strategies to be more efficient and effective.
"The financial difficulties the healthcare industry is facing are driving a need for both digital and cultural transformation, which will lead to better outcomes for both staff and patients alike," Todd Craghead, SVP of Commercial Relationships at R1 RCM, said in the report.
"The best way for health systems and physician groups to address these challenges is to focus on optimizing in every way they can: investing in people, processes and technology, and embracing an open mind regarding partnerships, employee reallocation and global delivery."
