The impending renewal process could mean enrollees are left without coverage.
Most adults in a Medicaid-enrolled family lack awareness of the upcoming Medicaid eligibility redetermination, according to analysis from the Urban Institute, funded by the Robert Wood Johnson Foundation.
April 1 is the deadline for states to start redetermining eligibility of Medicaid beneficiaries and the survey by the Urban Institute finds 64.3% of enrollees have heard nothing about the return to regular Medicaid renewal processes as of December 2022.
That's virtually no change when compared to survey results from June 2022, when 62% of beneficiaries reported being unaware of redeterminations.
The most recent survey uncovers that 16% of adults have heard only a little about the return to regular renewal processes, while 13.9% have heard some, and 5.1% have heard a lot.
Regardless of geographical location, awareness remains low. Lack of awareness was 66.5% in the Northeast, 67.6% in the Midwest, 63.4% in the South, and 61.3% in the West.
Whether respondents were in a state that has expanded Medicaid eligibility made no difference either. Lack of awareness was 64.5% in Medicaid expansion states and 63.7% in non-expansion states.
"The end of the public health emergency's continuous coverage requirement means millions of people are at risk of losing continuous coverage in Medicaid, which they have relied upon for nearly three years," Gina R. Hijjawi, senior program officer at the Robert Wood Johnson Foundation, said in a statement.
"States and the federal government must quickly raise awareness that many families will soon need to take steps to maintain or find new health coverage."
As many as 18 million people could lose Medicaid coverage with the COVID-19 public health emergency ending, the Urban Institute states.
States and the federal government can do their part to offset coverage loss by raising awareness that families will have to take steps to maintain or find new coverage on the Affordable Care Act marketplace.
A new report analyses the state of outsourced medical billing and uncovers areas of opportunity.
Nearly two-thirds (65%) of medical billing companies have a positive outlook on the outsourced billing industry, according to a report by digital health operating system company Tebra.
In its 2023 State of the U.S. Medical Billing Industry Report, Tebra surveyed 277 medical billing companies serving independent practices from September 2022 to October 2022 to gauge billing outlooks and trends.
In addition to most respondents saying they have a positive outlook, compared to 9% with a negative outlook, almost half of companies (43%) see outsourcing as a significant opportunity, while 42% see significant opportunities to expand services.
"Even amidst the recent tumult of Covid-19, physician burnout, and consolidation in the medical industry, medical billing companies are still a trusted choice for front-office support to independent practices, and make it easier for physicians to focus on delivering better care to patients," Kevin Marasco, chief marketing officer at Tebra, said in a statement.
"Our new 2023 U.S. Medical Billing Industry report highlights that medical billing companies will continue to thrive in this period of economic uncertainty."
Outsourcing medical billing is a strategy many providers have identified as a way to help cut costs and improve efficiency. A report by Kaufman Hall from October 2022 found that outsourcing revenue cycle functions was the most common area of outsourcing solutions for hospital and health system leaders, pursued by 27% of surveyed respondents.
Automation is part of the appeal for providers outsourcing billing, but many billing companies are still manually handling administrative tasks. According to Tebra's report, only 29% of billing companies use automation, robotic process automation (RPA), HL7 integrations, and outsourcing to manage workflows, leaving plenty of room for improvement to streamline processes.
The companies that have embraced automation have experienced growth, the report states, with more than half (52%) of "high-growth" companies using RPA and 39% using patient collections automation.
Utilizing technology to improve services will be essential in an industry that 46% of companies say has become either more competitive or presents more challenges to finding new customers over the past three years.
The medical billing outsourcing market is expected to keep growing, however, with a study published by Future Market Insights last summer anticipating a compound annual growth rate of 16% from 2022-2032 and a valuation of $55.6 billion by the end of 2032.
Research finds lack of prior authorization as one of the foremost reasons for denials by non-group qualified health plans (QHPSs).
Health insurers on the Affordable Care Act (ACA) marketplace denied an average of 16.6% of in-network claims in 2021, according to a brief by Kaiser Family Foundation (KFF).
Researchers analyzed data released by CMS on claims denials and appeals for QHPs offered on HealthCare.gov for the 2021 plan year and found that denial rates ranged significantly from 2% to 49%. The dataset included 162 QHPs that reported receiving at least 1,000 in-network claims and showed data on claims received and denied.
Of the 291.6 million in-network claims received between the insurers, 48.3 million were denied (16.6%) while 243.3 million (83.4%) were paid. In 2021, 41 insurers had a denial rate of less than 10%, 65 insurers denied between 10% and 19%, 39 insurers denied between 20% and 29%, and 17 insurers denied 30% or more.
Health plans that reported denying one-third or more of claims were Meridian Health Plan of Michigan, Absolute Total Care in South Carolina, Optimum Choice in Virginia, UnitedHealthcare of Arizona, Health Net of Arizona, Buckeye Community Health Plan in Ohio, Celtic Insurance in seven states, and Ambetter Insurance in three states.
Researchers also examined the 44.7 million reasons health plans reported for denying the claims. Lack of prior authorization or referral accounted for 3.6 million (8%), excluded services made up six million (13.5%), medical necessity reasons were 920,000 (2%), and all other reasons accounted for the remaining 34.2 million (76.5%).
Many prior authorization denials occur due to insufficient documentation and an inability to match information that is spread across different systems. Automating the administrative process has become a strategy for revenue cycle leaders, with 78% of respondents in a report by KLAS saying they saw improved financial performance after implementation.
When it comes to ACA data, the KFF brief highlights that CMS does not collect out-of-network claims submitted and out-network enrollee cost sharing and payments.
The researchers state that the lack of required transparency in coverage data reporting by other non-group plans or employer-sponsored plans contributes to hindering improvement with denials.
"The federal government has not expanded or revised transparency data reporting requirements in years and does not appear to conduct any oversight using data that are reported by marketplace plans. As a result, consumers are not provided any information about how reliably marketplace plan options pay claims and plans reporting high claims denial rates do not appear to face any consequences."
The initiative, which changes the holding company's name to The Cigna Group, reflects the corporation's growing portfolio.
Cigna is evolving its brands to be more in line with the company's businesses, the major payer announced.
The rebrand sees the holding company's name change to The Cigna Group, while Cigna Healthcare will be the health benefits provider, and Evernorth Health Services will provide pharmacy, care, and benefits solutions.
"Over the last several years, we’ve built a diverse portfolio of leading capabilities to serve more people across our businesses," Lou Aversano, Cigna's chief brand and marketing officer, said in a statement. "Now, we are evolving our brand architecture to reflect how we are serving the breadth of our relationships today and into the future."
Cigna has maneuvered strategically to better serve its customers and clients, which includes expanding its reach in the Affordable Care Act marketplace. Last summer, the company announced it would branch out to three new states—Indiana, South Carolina, and Texas—as well as 50 new counties in Georgia, Mississippi, and North Carolina.
The payer also announced Medicare Advantage expansion for the fourth consecutive year, growing its offerings to 106 new counties in 2023.
Meanwhile, Cigna's rebranding efforts follow similar initiatives by other payers recently.
In March 2022, Anthem announced it would change its name to Elevance Health to reflect its commitment "to elevating whole health and advancing health beyond healthcare."
Humana also restructured last year, breaking down into two business units: Insurance Services and health services, CenterWell.
Payer giant UnitedHealth Group has operated health benefits under UnitedHealthcare and other services by Optum.
Rebranding is one of the ways companies can get a facelift to grow their presence and appeal.
Organizations will add, enhance, or end services to address employee experiences and benefits.
Almost nine in 10 employers plan to change health and wellbeing vendor partnerships in the next two years, according to a survey from Willis Towers Watson (WTW).
The survey fielded responses from 232 U.S. employers—with three million workers—in November 2022 and found that organizations will adjust their offerings in the near future to address employee needs.
Most respondents (88%) said they are planning to make changes to their vendors either this year or next, which includes adding, enhancing, or ending certain services. Changes may also include working with a different vendor.
"High-performing health and wellbeing vendors are now vital to employers," Courtney Stubblefield, senior director of WTW, stated. "They have become a critical component of competitive benefit and wellbeing programs and strategic to their portfolio."
"However, in an effort to meet the needs of their employees and improve worker health, employers are taking a close look at the value and cost savings their vendors promise. What’s more, they are ready to make changes as needed."
Respondents ranked their top areas of focus for vendor solutions over the next two years, with mental health finishing first, general wellbeing coming in second, and financial wellbeing slotting fifth.
Of those surveyed that provide mental health solutions, 37% said they are planning to make changes to their mental health services in the next two years, including employee assistance programs and other clinical and pharmacy solutions. Nearly a quarter (24%) made changes in 2022.
More than half of the respondents (55%) that offer wellbeing services said they are planning to make changes in the next two years, while 12% already made changes last year.
Just over four in 10 employers (42%) are planning to make changes to their point solutions for clinical conditions like diabetes and musculoskeletal disease over the next two years, with 24% having made changes in 2022.
When it comes to navigation and advocacy programs, 40% of employers are set to make changes to areas such as clinical guidance and expert medical opinion. More than one in 10 respondents made changes in 2022.
Finally, 43% of employers are aiming to change their digital platforms, including digital hubs and health information portals, building on the 7% that already did last year.
"Companies prioritize ROI but need a broader definition of ROI that includes choices based on driving quality, filling the gap in core offerings and lowering cost," said Regina Ihrke, WTW senior director."
"At the same time, they should evaluate if the solution is working, how to optimize current partners and whether they need to embrace innovation in the market. This balanced approach will offer a better experience for their employees."
Plans have experienced exponential growth, but researchers caution that the outdated payment policy has ramifications.
Medicare Advantage (MA) payment policy hasn't kept up with its rapid growth of 337% from 2006 to 2022, according to a study published in Health Affairs.
Researchers from the USC Schaeffer Center analyzed Medicare enrollment data over that time period and found MA added 22.2 million beneficiaries while enrollment in traditional Medicare declined by one million (-2.9%).
MA penetration increased from 16.9% in 2006 to 49.9% nationally in 2022, and 24% of Medicare beneficiaries with Parts A and B lived in a county with adjusted MA penetration equal to greater than 60%.
"The dramatic growth in MA penetration during the past two decades indicates that beneficiaries are reforming Medicare with their feet," the study stated. "Policy discussions about the future of the Medicare program would be well served by recognizing these trends and accounting for the dramatic shifts in the preferences exercised by Medicare beneficiaries in recent years."
With MA enrollment booming, the study highlights that the way plans are paid hasn't evolved to reflect the growth.
Payment to MA plans is based on the average cost per beneficiary in traditional Medicare in each county, but researchers ask what that will mean if only a minority of Medicare enrollees are in traditional Medicare.
"We know that MA plans are getting overpaid relative to the costs of providing care to comparable beneficiaries in traditional Medicare, and this has contributed to the magnitude of extra benefits offered to MA enrollees," study co-author Paul Ginsburg said in a press release. "While this is appealing to consumers, this is increasing federal spending and accelerating the rate at which the Medicare trust fund is being exhausted."
MA plans have come under scrutiny for receiving billions in overpayments, which they will likely have to pay back from 2018 onwards after CMS released its Risk Adjustment Data Validation final rule.
For policymakers wanting to balance the scales and adjust the payment to MA plans, the study suggests not tying payment policy to costs in traditional Medicare, but rather competitive-bidding benchmarks.
"We can't continue to think of Medicare Advantage as an appendage of the traditional Medicare program," Ginsburg said. "We are at a point where the tail is wagging the dog."
New analysis further supports the need for stronger policies to streamline the administrative process.
More than two million prior authorization requests, accounting for six percent of the 35 million total requests, were denied by Medicare Advantage (MA) plans in 2021, according to a report by Kaiser Family Foundation (KFF).
While beneficiaries of traditional Medicare are rarely required to receive prior authorization, nearly all MA members were enrolled in a plan that required prior authorization for some services in 2022, the analysis found.
KFF looked at the data plans must send to CMS for each MA contract that includes the number of prior authorization determinations made during a year and whether the request was approved, and then examined the use of prior authorization in MA during 2021.
The findings reveal that MA plans made over 35 million prior authorization determinations for the year, which equates to 1.5 requests per enrollee on average. Of those, over two million were denied in full or in part, with adverse determinations making up the majority of the denied requests.
The denial rate varied among insurers, ranging from 3% for Anthem and Humana to 12% for CVS (Aetna) and Kaiser Permanente. Insurers that had more prior authorization requests were generally found to deny a lower share of those requests.
While just 11% of denied prior authorization requests were appealed, 82% of appeals resulted in the initial denial being either fully or partially overturned. Only Kaiser Permanente overturned less than half (30%) of appeals of the insurers analyzed.
Researchers stated that the "medical care that was ordered by a health care provider and ultimately deemed necessary was potentially delayed because of the additional step of appealing the initial prior authorization decision, which may have negative effects on beneficiaries' health."
CMS has recognized the problem and proposed a rule in December 2022 to streamline the administrative process by requiring MA plans to implement electronic prior authorization.
Building on that proposed rule, CMS released another proposal to strengthen prior authorization protections for patients, requiring: a granted prior authorization approval remain valid for an enrollee's entire course of treatment; MA plans to annually review utilization management policies; and coverage determinations to be reviewed by professionals with relevant expertise.
KFF's report concluded by highlighting the importance of observing prior authorization practices in MA plans.
Researchers stated: "As the number of Medicare beneficiaries enrolled in Medicare Advantage continues to grow, a better understanding of prior authorization and other processes and programs to contain spending and manage utilization will be important in evaluating the implications of these policies on utilization and quality, including variation across Medicare Advantage plans and compared to traditional Medicare."
Hospitals are slowly becoming better at adhering to the regulation, but too many facilities are still lagging.
Nearly three out of every four hospitals remain noncompliant with the hospital price transparency rule more than two years after the law was implemented, according to a report by PatientRightsAdvocate.org.
The latest Semi-Annual Hospital Price Transparency Compliance Report analyzed 2,000 of the nation's largest hospitals from December 10, 2022 through January 26, 2023 to determine compliance, based on the inclusion of machine-readable files for all items and services, as well as price display of the 300 most common shoppable services.
The findings reveal a modest increase in compliance percentage since the previous report in August 2022, with 24.5% of hospitals (489) now compliant, compared to 16% last year.
Meanwhile 116 hospitals (5.8%) did not post any standard charges files and were found to be completely noncompliant.
More than half (1,025 or 51.3%) posted negotiated prices clearly associated with payers and plans, but 536 of those still failed compliance because most of their pricing data was incomplete.
"Though the majority of hospitals have posted files, the widescale noncompliance of 75.5% of hospitals is due to most hospitals' files being incomplete, illegible, or not having prices clearly associated with both payer and plan," the report stated. "This noncompliance obstructs the ability of patients, employer and union purchasers, and technology developers to comparatively analyze prices, make informed decisions, and have evidence to remedy errors, overcharges, and fraud."
Some of the largest health systems in the country continue to be some of the biggest perpetrators of the law. None of the hospitals owned by HCA Healthcare, Tenet Healthcare, Christus Health, Providence, Bon Secours Mercy Health, UPMC, Mercy Health, UnityPoint Health, and Average Health were found to be compliant.
On the other end of the spectrum, 58% of CommonSpirit hospitals and 73% of LifePoint Health hospitals were deemed compliant.
Not only did the report find a wide range in pricing information available between hospitals, it also observed variation in data size. There was a significant increase in the number of files that were one to seven gigabytes or larger, although many large hospitals did have files less than 200 megabytes. Making pricing information available is only one aspect of creating more price transparency, made relatively useless without accessibility and user-friendliness.
Payers have also had the same problem displaying data as part of their price transparency rule, but in terms of sheer quantity, hospitals are well behind their counterparts despite a head start. According to Turquoise Health, payer data accounts for 630 terabytes, significantly outpacing the three terabytes of hospital data.
The hospital compliance report also highlights that the lack of enforcement of the law by HHS has given hospitals the leeway to continue disregarding the rule. The two hospitals which HHS has penalized to date—Northside Hospital Atlanta and Northside Hospital Cherokee—were found in the report to now have exemplary and complete pricing files, proving that enforcement is necessary.
Timely enforcement by HHS was one of the recommendations put forward by the authors, along with elimination of price estimates in favor of real prices, clear pricing data file standards, and accountability of hospital executives to attest to the completeness and accuracy of their prices.
The report concluded: "When full compliance with the transparency regulations is achieved, the widespread availability of pricing data systemwide in healthcare will unleash the benefits of competition and consumer choice, lowering the costs of care and coverage to patients, employers, and workers."
A report investigates the information the federal agency has on enrollees' utilization of Medicare Advantage (MA) supplemental benefits.
While almost all MA plans offer supplemental benefits, data on their usage is lacking for CMS, according to a report from the Government Accountability Office (GAO).
The research analyzed plan benefit data for 3,893 MA plans in the 50 states and District of Columbia, reviewed CMS regulations and guidance, and interviewed officials from CMS and six MA plans to better understand how much information on beneficiaries' utilization was available in 2022.
GAO found that all but one plan offered at least one supplemental benefit not covered under traditional Medicare, with vision and hearing being the most common at 98% and 94%, respectively.
The report states that MA plans could offer benefits to reduce avoidable healthcare use beginning 2019 and could offer benefits to improve or maintain the health of chronically ill enrollees beginning 2020. Only one-third of plans offered at least one of the new benefits in 2022—most commonly in-home support services (17%) and food and produce (15%).
MA plans are required to submit data of utilization of these services, known as encounter data, to CMS, but GAO found that information to be limited for two reasons.
Firstly, CMS guidance on encounter data does not specifically mention supplemental benefits, although CMS officials told GAO that the guidance does not differentiate between supplemental and traditional Medicare benefits. However, three officials from MA organizations told the researchers that encounter data for supplemental benefits is not required and that they do not submit it.
Secondly, collecting and submitting encounter data for certain supplemental benefits can be a challenge, according to officials from CMS and two MA organizations. Newer supplemental benefits like food and produce have no procedure code, for example.
"As of October 2022, CMS was in the early stages of assessing the completeness of the encounter data for supplemental benefits and identifying options for collecting enrollee utilization data for the newer benefits but did not have a workplan or timeline for next steps," GAO stated.
"More complete information on enrollees' use of supplemental benefits would put CMS in a stronger position to ensure the benefits effectively support the health and social needs of enrollees."
The report recommended two steps for CMS: clarifying guidance on which encounter data submissions require data on supplemental benefits and addressing circumstances where submitting encounter data for benefits is challenging. HHS concurred with GAO's recommendations.
Highmark Health's new executive vice president and market president for Western Pennsylvania discusses his unique role bridging two sides that don't always see eye-to-eye.
Editor's note: This conversation is a transcript from an episode of the HealthLeaders podcast. Audio of the full interview can be found here and below.
That proverb should be on the minds of payers and providers alike as both sides continue to battle economic challenges in the wake of the COVID-19 pandemic from their respective positions.
Putting aside differences and working together is the best path forward, says Dr. Bruce Meyer, Highmark Health's new executive vice president and market president for Western Pennsylvania.
In his new role, Meyer is bridging the payer side of Highmark Health and the provider side of subsidiary Allegheny Health Network, giving him a unique perspective on the issues facing the two groups.
Meyer recently sat down with HealthLeaders for a podcast interview to talk about the opportunity at Highmark Health, what specific challenges payers and providers are grappling with, and why the "adversarial relationship" between the sides needs to be left in the past.
This transcript has been edited for clarity and brevity.
HealthLeaders: What is your new role affording you and how are you finding it so far?
Meyer: It gives me the opportunity to really think about how we have to redesign the economics of healthcare from the payer and provider perspective to create a sustainable model. Because right now, we are pretty much in a semi crisis mode, particularly for hospitals and healthcare systems in terms of the economic dynamics of the significant increases in expenses and a flattening of the revenue stream over the last 18 months or so as we've been through the pandemic. We've seen these dramatic changes in economics for hospitals and health systems that is an unsustainable situation. So I feel like I'm in a unique opportunity to try to find a much better future that gives us an opportunity to create more sustainability.
HL: You mentioned that hospitals and health systems right now are in a semi crisis mode and the economic challenges are plenty. What specifically have you found to be of the most concern?
Meyer: I think the biggest concern is really workforce. Between burnout issues and the rise of the nursing workforce shortage, that's profound. And what that has led us to is to have a significant increase in travelers and even foreign nurses coming in just to be able to provide the appropriate care at healthcare sites, particularly in hospitals and health systems. And that's led to very significant increases in costs in patient settings and facility-based settings, but also in doctors' offices because you just have to pay a premium in order to get the staff to be able to take care of patients.
I think second to that is supply chain. Inflationary costs in the supply chain are no different and actually at some level worse than what we've seen in food and housing and other kinds of pricing in this country. In terms of inflation, we've had double-digit inflation in those arenas over the last three years. In healthcare, the same kind of thing with pharmacy costs having had double-digit inflation over the last three years. And those three things combined have just led to a dramatic rise in the expense equation for the facility-based side of the healthcare world.
Pictured: Bruce Meyer, executive vice president and market president for Western Pennsylvania, Highmark Health.
HL: On the payer side, how do you see these problems trickling over?
Meyer: On the payer side, we face a similar dramatic issue, which is that employers and the federal government pay for the vast majority of care in this country. And we've been shifting costs of care onto employers in one way or another, whether they're self-insured or commercial. Employers have reached a point where that continuing inflationary cost of healthcare has simply become unsustainable for them. Employers have said 'I can't sustain this continued increase' and so there is incredible pressure on plans to find ways to plateau the inflationary increase or just cap off increased costs in terms of healthcare.
That's why we've seen a dramatic shift from commercial insurance to self-insured insurance because that's a way for people to help control their costs a little more. Then the onus entirely becomes on the individual and health literacy in this country has not reached a point where individuals really understand cost of care and can make good decisions on their own. Yet that's obviously a goal for us.
HL: What strategies do you feel payers can utilize right now to deal with these challenges?
Meyer: Without tooting the horn of Highmark and what Highmark is trying to do in our catchment area, I think there's got to be a much better partnership between payers and providers. We, for the most part in this country, have had relatively adversarial relationships between payers and providers in which payers kind of view providers as folks who are just spending money unnecessarily and providers look at payers as folks who have a giant pool of money sitting somewhere in a vault somewhere that they're simply not giving to providers for the work that they are doing. And although that's simplistic, it's very real. And that adversarial relationship has been going on for 40 years in this country. It's just accelerated significantly through the pandemic because with significantly less spending for healthcare, payers were able to do well because they still received the payments from the government and from the businesses, but providers struggled mightily because they weren't seeing volumes and getting revenues in.
I think that the solution is that we've got to find a way to partner. We've got to find a way to work together to find a better future for the economics of healthcare in this country. Because our current economic trajectory is truly unsustainable. And what we cannot do is say that there's a winner and a loser in that economic equation. Because ultimately, the loser is the public who need healthcare, and particularly the disadvantaged among us who have poor access or poor health literacy in terms of being able to live their best lives.
