The new ruling applies to task force recommendations issued on or after the Affordable Care Act (ACA) was signed into law.
The American Medical Association (AMA) expressed concern and disappointment over the recent ACA ruling on preventive care, while AHIP emphasized coverage won't be immediately affected.
U.S. District Judge Reed O'Connor struck down enforcement of preventive care mandates under the ACA, determining that health insurers are not required to cover services such as cancer and heart screenings.
The decision applies to recommendations made by the U.S. Preventive Services Task Force on or after March 23, 2010, when the ACA became a law.
The Biden administration filed a notice of appeal two days after the ruling was made.
AMA president Jack Resneck Jr. said in a statement that the physician association "is alarmed by today’s deeply flawed court ruling in Texas" and decried the decision.
"Providing insurance coverage for screenings and interventions that prevent disease saves lives—period," Resneck said. "Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients."
Meanwhile, AHIP president Matt Eyles stated that patients will continue to have preventive services covered as the appeal process plays out.
"Every American deserves access to high-quality affordable coverage and health care, including affordable access to preventive care and services that help avoid illnesses and other health problems," Eyles said in a statement. "As we review the decision and its potential impact with regard to the preventive services recommended by the United States Preventive Services Task Force, we want to be clear: Americans should have peace of mind there will be no immediate disruption in care or coverage."
Loss of coverage for preventive care could have serious consequences, according to a recent survey by Morning Consult.
The business intelligence company polled a sample of 2,199 Americans and found that at least two in five respondents are not willing to pay for 11 of the 12 preventive services. Cancer screenings are the service respondents said they would most likely pay out of pocket for.
If O'Connor's ruling holds up, it could result in patients skipping or delaying necessary care.
The payer giant will reduce codes in the summer with the aim of easing the administrative process.
UnitedHealthcare is responding to concerns over prior authorization's potential to delay care and create burden by introducing code reductions this summer, the company announced.
The nation's largest health insurer said it will eliminate nearly 20% of current prior authorizations beginning in the third quarter for most commercial, Medicare Advantage, and Medicaid businesses.
The move is "part of a comprehensive effort to simplify the health care experience for consumers and providers."
Additionally, the insurer stated that it will also implement a national Gold Card program for provider groups in early 2024, which will get rid of prior authorization requirements for most procedures.
"Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members," Dr. Anne Docimo, chief medical officer of UnitedHealthcare, said in the press release.
"We need to continue to make sure the system works better for everyone, and we will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure. We hope other health plans will make similar changes."
UnitedHealthcare's efforts to scale back on prior authorization are a step in the right direction, but more still needs to be done to ensure the process isn't harming patients and overwhelming providers.
In a recent poll of practicing physicians by the American Medical Association, 89% of respondents said prior authorization has had a negative impact on patient clinical outcomes, with 94% saying it delayed access to necessary care.
Furthermore, 86% of physicians reported that prior authorization requirements sometimes, often, or always led to higher overall utilization.
Regulations are on the way for insurers that are expected to streamline the process by requiring certain payers to implement electronic prior authorization.
Medicare Advantage (MA) growth was led by United and Humana, while nonprofit insurers lagged behind.
MA experienced record enrollment for the 2023 plan year as for-profit payers continued to grab a greater market share, according to analysis by The Chartis Group.
The healthcare consulting firm examined MA and Medicare data from CMS between January 2019 and January 2023 and found that MA grew 9.5% this year. The addition of 2.7 million beneficiaries brings MA enrollment to 30.7 million in total.
When Chartis originally released the report in February, the findings showed MA growth of 1.5 million members for 2023, representing a slowdown from previous years. However, after accounting for new CMS MA enrollment data, the updated research illustrates that MA is growing faster than ever.
While MA enrollment continues to rise, traditional Medicare remains on the downslope. The report revealed traditional Medicare lost 1.3 million members this year and has contracted by four million since 2019, all while Medicare as a whole has grown by 5.1 million beneficiaries.
"This shift has meaningful implications for health plans and organizations that serve seniors," the authors wrote. "The 'where' and the 'how' of generating enrollment by aligning with growth markets become increasingly important and nuanced."
Much of the MA growth this year was spurred by for-profit insurers, which accounted for 84% of the rise in enrollment. Nearly two in three enrollees came from United (44%) and Humana (21%).
Collectively, the 10 largest for-profit insurers make up 70.6% of MA enrollment nationally, with the top five payers accounting for 67.1%, the analysis found.
While nonprofit Blues plans earned a market share gain of 0.1 percentage point, the remaining nonprofit plans experienced a 1.1 percentage point share decline to continue a pattern from previous years.
"The competitive shift here is stark and will have implications for health plans looking to both enter and grow in this space, for organizations that partner with Medicare Advantage plans, and for healthcare providers that participate in their networks," the authors stated.
As MA commands more and more attention and eventually surges past traditional Medicare in terms of market share, the industry will follow to support its needs.
The insurtech is shaking up its leadership group, with co-founder and current CEO Mario Schlosser transitioning to President of Technology.
Oscar Health is handing the CEO reins to veteran healthcare leader Mark Bertolini as it continues to shore up its strategy for profitability, the company announced today.
Bertolini, who was formerly CEO of Aetna, will take over the role on April 3, with co-founder and current CEO Mark Schlosser moving to President of Technology, where he will lead product and engineering, focusing on Oscar's tech platform +Oscar.
Schlosser will continue as a member of the board, which will expand to include Bertolini.
"Oscar Health is an established challenger brand in the healthcare industry, pushing the boundaries of how insurance operates and delivers for members," Bertolini said in the press release. "I am proud to join the company at this pivotal time, and excited to cement Oscar's future as a leader in the industry."
During his tenure at Aetna, Bertolini established a reputation as a healthcare thought leader and led the payer from 2011 through its sale to CVS for $69 billion in 2018.
Most recently, Bertolini served as co-CEO of asset management firm Bridgewater Associates and in an advisory role to Oscar.
"I have worked closely with Mark in his role as a strategic advisor to Oscar for the past 18 months and it's become clear that we share a vision for the future of healthcare," Schlosser said. "By pairing my passion in tech with Mark's extensive expertise in building and scaling companies, we are well-positioned to continue to execute our strategy for profitability, set Oscar up for continued growth, and deliver enhanced value for our members and shareholders."
Oscar is hoping the hiring of Bertolini will accelerate it towards profitability, which has so far eluded the insurtech.
The company announced it suffered a net loss of $610 million for 2022 in its recent fourth quarter and full year earnings report, with revenue being offset by operating expenses.
Last year also saw Oscar lose a significant customer for +Oscar and the payer saying it will pause any new +Oscar deals through early 2024.
Insurtechs as a whole have struggled to achieve financial stability and 2023 could be telling for the future of several companies in the space.
Research reveals the financial discrepancies between Medicare Advantage (MA) and Medicare Supplement beneficiaries.
Most MA enrollees are satisfied with their plan coverage, but are more financially challenged than Medicare Supplement (Medigap) beneficiaries, according to an eHealth report.
The research surveyed 3,880 Medicare enrollees who purchased their coverage through eHealth in February 2023 to highlight how MA and Medicare Supplement beneficiaries differ in financial profile.
While both MA and Medicare Supplement enrollees are largely satisfied with their coverage, to the tune of 89% and 87%, respectively, MA beneficiaries are more vulnerable to higher premiums and other costs.
Of those surveyed, 73% of MA enrollees live on less than $50,000 per year, with 39% living on less than $25,000. In comparison, 50% of those on Medicare Supplement live on more than $50,000, with 31% living on $75,000 or more.
Income level contributes to 52% of MA beneficiaries saying they cannot afford any monthly premiums, with an additional 18% saying they cannot afford one of more than $25.
When it comes to out-of-pocket costs, only 37% of MA enrollees say they have enough savings to pay for hospitalization, versus 61% for Medicare Supplement beneficiaries.
Respondents have different worries for the future, depending on what plan they're on. For MA members, the biggest worry is not being able to afford their medical care in the future (chosen by 39%), while Medicare Supplement enrollees are most concerned with seeing their Medicare benefits reduced (selected by 32%).
"The challenges that lie ahead for Medicare Advantage underscore the importance of highlighting the financial vulnerabilities of millions of beneficiaries who depend on the program," said eHealth CEO Fran Soistman.
"We'll continue to advocate on their behalf with our carrier partners to ensure that enrollees' need for both affordable premiums and affordable out-of-pocket costs are given the attention they deserve."
As MA continues to grow exponentially, it will be important for benefits of an expanding membership group to be protected.
A survey reveals patients' experiences with challenging a bill with their physician, hospital, or insurance company.
Patients don't usually contend medical bills, but when they do their chances of getting charges removed or reduced are high, according to a YouGov survey commissioned by revenue cycle firm AKASA.
Over 2,000 Americans were polled between March 9-14, 2022, including 179 adults with employer-sponsored high-deductible health plans, to gauge patient experience with disputed medical bills.
Nearly two-thirds of respondents (64%) reported having never challenged the validity or accuracy of a bill with their physician, hospital, or health insurance company. That figure shot up to 78% for uninsured individuals, while those with high-deductible health plans (45%) and Medicare Advantage (43%) were more likely to contend bills.
"Despite all the negative experiences many patients have with getting surprise bills, we've been conditioned not to question or challenge medical bills we receive," said Amy Raymond, VP of revenue cycle operations at AKASA.
"While providers need to take a close look at their revenue cycle department to prevent those billing mistakes in the first place, we also need to drive awareness among consumers that they can indeed push back on a bill that is simply incorrect."
Of the respondents who had challenged a bill, 78% reported getting charges reduced or removed.
However, the time it took to resolve the disputed bill varied, sometimes taking longer than half a year. More than a quarter of respondents (27%) said it took one to three months, while 18% said it took three to six months and 16% said it took more than six months.
For providers and revenue cycle departments, ensuring the billing experience is as smooth as possible for patients can pay dividends.
According to a recent survey of 1,000 patients by RevSpring, 56% of respondents said they would likely switch providers if they had a poor billing experiencing, which was especially true for patients aged 18 to 26 (74%).
Patients value personalization and consistency, which means getting the bill right the first time.
Research into directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana uncovers inaccuracies that can lead to surprise billing and delays in care.
Five of the largest health insurers have inconsistencies in 81% of their physician directory entries, according to a study published in JAMA Open Network.
Researchers from the University of Colorado School of Medicine and HiLabs searched physician information in the Medicare Provider Enrollment, Chain, and Ownership System database in online physician directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana, based on physician name and zip code in September 2022.
The analysis considered a physician's information as consistent if it was the same among all locations or specialties across all directories in which the physician was found. Physician information was deemed inconsistent if the physician address or specialty was different across directories or if a physician was found in a directory without an address or specialty that was found in another directory.
Of the 634,914 unique physicians in the database, 449,282 were found in multiple directories, with just 19.4% of those having consistent address and specialty information across all directories they were found in.
Over a quarter (27.9%) of physicians had consistent practice location addresses, while over a third (67.8%) had consistent specialty information.
Among physicians who had only one practice location listed, consistency was 58.6% for address and specialty information, 84.8% for practice address, and 68.6% for specialty information.
"These results were driven by inconsistencies in addresses among physicians listed as practicing at multiple locations, which is concordant with prior research suggesting that most address errors stem from group practices reporting all physicians at all practice locations to insurers, irrespective of each individual physician's practice locations," researchers wrote.
The study highlights the unintended consequences of inaccurate physician directories, which includes but is not limited to surprise billing.
"Beyond surprise billing, inaccurate physician directories can lead to delays in care due to difficulty finding the correct physician, challenges in regulators assessing health insurer network adequacy, and misrepresentation of network depth and breadth as consumers select health plans," researchers stated.
The No Surprise Act requires health plans to maintain accurate provider directories, but the report notes how lack of standardization is making that a challenge.
When the administrative burden to inform and send updates to insurers falls on providers, the collective cost is $2.76 billion annually, according to a report by CAQH.
"This study's findings highlight the need for unified technology-enabled solutions, such as that proposed by the Centers for Medicare & Medicaid Services, which is seeking to create a single, centralized physician directory using modern interoperable formats," the authors concluded.
Six health insurer leaders made CEOWORLD's annual list of the world's top CEOs and business executives.
CVS Health's Karen Lynch leads the presence of health insurance leaders on CEOWORLD's list of the most influential CEOs and business executives of 2023.
The annual list features six payer CEOs among the top 200: Lynch, UnitedHealth Group's Andrew Witty, Cigna Group's David Cordani, Elevance Health's Gail Boudreaux, Centene's Sarah London, and Humana's Bruce Broussard.
Only four executives are ranked ahead of Lynch, who comes in on the list at number five, followed closely by Witty at seven.
The magazine's list measures more than 1,200 CEOs across 96 countries. The ranking is primarily based on the financial returns for the CEO's entire tenure (60%), with the remaining 40% comprising of the company's track record on environmental, governance, and social issues, as well as market shares, change of market capitalization, and brand's newsworthiness and impact.
Claims across physician offices, urgent care centers, and emergency departments have trended towards higher level codes.
Providers are increasingly billing outpatient visits at higher intensity levels which has led to a rise in healthcare spending, according to a report by Kaiser Family Foundation and the Peterson Center on Healthcare's Health System Tracker.
Researchers examined private, large-employer based insurance claims from the Merative MarketScan Commercial Claims and Encounters database from 2004 to 2021 to analyze trends in complexity coding across physician offices, urgent care centers, and emergency departments.
The study found that the share of moderate intensity (level 3) claims across all three sites of care decreased from the majority (60%) in 2004 to less than half (45%) in 2021. Higher intensity level 4 claims, meanwhile, nearly doubled from 19% in 2004 to 37% in 2021. Bills at the highest complexity (level 5) did double from 3% in 2004 to 6% in 2021.
Even for specific diagnoses that are less likely to be worsening over time, the study found claims trended toward higher levels. Urinary tract infections were level 3 claims over half the time (54%) for emergency department visits and 67% for outpatient office visits in 2004. By 2021, level 3 claims accounted for only 31% of emergency department claims and 57% of outpatient office claims. Level 3 claims were the most common for headaches in 2004 in both physician (58%) and emergency departments (41%), but level 4 claims were the majority in both settings by 2021.
The result of outpatient bills trending towards higher levels was 4% higher outpatient evaluation and management spending in both physician offices and emergency departments in 2021, compared to visits being coded at the same levels in 2011.
"Overall, our findings demonstrate that regardless of the driving factors, increasing billing at higher levels for outpatient care has led to substantial increases in outpatient visit spending at the health system level," the researchers wrote. "For consumers who bear the marginal costs of more expensive services—those with co-insurance or deductibles—this trend impacts out-of-pocket costs in addition to overall health system costs."
The report suggest that upcoding isn't all to blame for the trend, which was also highlighted in a recent study published in Health Affairs that found high-intensity billing for treat-and-release emergency department visits had significantly increased over the past 14 years.
However, upcoding is a practice that can be all too common, which is why the Office of Inspector General recently recommended that CMS takes aim at the issue to ensure hospitals bill appropriately moving forward.
A survey finds many will not pay for preventive services if they are no longer covered by health insurers.
Americans won't be quick to reach into their own pockets for preventive care services if courts uphold a ruling that they shouldn't be covered as part of the Affordable Care Act (ACA), according to a survey by Morning Consult.
The business intelligence company polled a sample of 2,199 U.S. adults in January 2023 to gauge the potential ramifications a ruling by a Texas federal judge in September 2022 could have on preventive service utilization.
Judge Reed O'Connor, after previously ruling that the entire ACA was unconstitutional, struck down a key piece of the ACA requiring health insurers to cover 12 preventive services with no cost sharing for members. The ruling on the ACA was ultimately overturned by the Supreme Court, but it could take some time for the recent decision to go through the appeals process and be settled.
If coverage for preventive services are stripped, however, it may result in millions of patients missing out on life-saving care.
The Morning Consult survey found that at least two in five Americans say they are not willing to pay for 11 of the 12 preventive services, with at least half saying they would not pay for services such as tobacco cessation or screenings for HIV, depression, and unhealthy drug use.
Cancer screenings are the preventive service respondents say they would most likely pay out of pocket for, chosen by 46%.
The survey also found that one in three Americans say emergency care is the most important service for insurers to cover. Preventive services were ranked as the most important service for insurers to cover by 23% of respondents, while breastfeeding was chosen as the least important by 35%.
Finally, the survey revealed that half of respondents delayed or skipped care due to cost, with three in 10 saying they did so in the past year. Income was a significant factor, as 32% of respondents living in households making under $50,000 delaying care in the past year, compared to 22% of those who make $100,000 or more.
Adding to patients' healthcare costs by eliminating coverage of preventive services will likely lead to even more patients skipping or delaying necessary care.
American Medical Association Jack Resneck Jr. called the decision by O'Connor "unwise and unthinkable" and strongly stated preventive care requirements must be upheld.
"Providing insurance coverage for drugs that prevent the transmission of infectious disease does not violate anyone’s religious freedom—to the contrary," Resneck said. "This type of preventive care saves lives."
