High volume has created a backlog that federal departments have to sift through to review and process disputes.
The No Surprises Act may be preventing unexpected bills, but the law's independent dispute resolution (IDR) process is being used significantly more than the federal government anticipated, according to a government report.
HHS, the Department of Labor, and the Department of the Treasury released statistics on the IDR process from April 15 to September 30, 2022, detailing how often providers and payers utilized arbitration to resolve disagreements over payment for items and services after an unsuccessful negotiation period.
The IDR portal was opened on April 15, 2022, just over 15 months after the No Surprises Act was signed into law to protect patients from surprises out-of-network bills. The Departments estimated that 17,333 claims would be submitted in the IDR process annually.
In reality, the IDR process saw 90,078 disputes over the aforementioned period in the report, far and away outpacing expectations.
The Departments state that disputes reached 18,163 in the second quarter (April 15 to June 30, 2022), including disputes over items and services that would have been eligible for the Federal IDR process beginning January 1, 2022, when the surprise billing protections became effective.
The third quarter (July 1 to September 30, 2022) saw nearly four times as many disputes as the second quarter, totaling 71,915.
Most of the disputes in the second and third quarters were for emergency or non-emergency items or services and most of those disputes were submitted by out-of-network providers and facilities.
Of the total disputes initiated, 23,107 were closed, 3,576 reached a payment determination, and 15,895 were found ineligible for the IDR process. The remaining closed disputes were either withdrawn by the disputing parties, were closed because the parties reached an outside settlement, or were closed for other reasons, such as incorrect batching, data entry errors, or unpaid fees.
The backlog of disputes is due to the review and processing time needed to determine the eligibility of disputes.
"It is within this context that the Departments are working to enhance the Federal IDR portal's ability to intake and process disputes and associated data," the report stated.
Providers and payers have struggled to get on the same page on how the IDR process should be settled, with medical associations filing multiple lawsuits contending the emphasis on the qualifying payment amount, or the median in-network rate.
According to analysis by the Commonwealth Fund, providers are favored in some states' IDR process compared to the federal system, which could lead to higher payments for providers.
Marketing practices have caused CMS to put rules in place to curb deceptive or inaccurate ads.
Medicare Advantage (MA) marketing has come under scrutiny for unscrupulous tactics, but where exactly is it coming from?
According to a report from the Commonwealth Fund, non-government entities account for one-third of all Medicare-related search records and 87% of all search engine ads, creating confusion for beneficiaries and consumers struggling to select an appropriate health plan.
"Medicare Advantage plans are promoted through direct mailings, telemarketing, and advertising on radio, television, websites, and social media channels," the researchers state. "No organization, including the federal government, directly 'markets' traditional Medicare, although commercial insurers sell supplemental Medigap and Part D plans for people in traditional Medicare. Thus, nearly all beneficiaries are subject to some form of marketing effort."
When users search for information on Medicare, 20% of the records are from agents, brokers, or partners, while 16% are from health plans. CMS is responsible for the largest share of search records at 27%.
When it comes to search engine ads, agents, brokers, and partners make up 55% and health plans an additional 32%. CMS only has 7% of the ads, tied with other for-profit organizations.
While 40% of Medicare beneficiaries do not receive any help with their plan choice, the ones that do most often turn to brokers and agents for guidance – 30% in traditional Medicare and 31% in MA.
As brokers and agents are paid commission by insurers, beneficiaries can be negatively influenced. Researchers for the Commonwealth Fund highlight that CMS has reported more than 41,000 complaints in 2021 about Medicare private plan marketing, which was double the number in 2020 and up from about 6,000 in 2017.
To alleviate complaints and combat misleading marketing practices, CMS has proposed a ruleto prohibit ads that don't mention a specific plan name, as well as ads that use words, imagery, language, or logos that can be confusing and deceptive.
It is unclear, however, if the restrictions put in place will affect outcomes. Researchers believe more needs to be done to better understand what information is accessible for Medicare beneficiaries.
"Additionally, more information about agent and broker compensation — including overrides and payment for other services such as health risk assessments, as well as more transparency around the relationships between health care providers, TPMOs, and insurers — could help CMS ensure a level playing field and assess whether compensation and other financial arrangements are aligned with beneficiaries' interests," the researchers concluded.
A recent survey of uninsured individuals finds that health insurance is considered too expensive or unaffordable for most.
The main reason many people don't have health insurance is the perceived high cost, according to a survey conducted on behalf of Florida Blue.
Hundreds of uninsured Florida residents aged 21 to 64—with more than half uninsured for three or more years or having never had health insurance—were polled online between October 6 and October 31, 2022, to better understand why they have no coverage.
The results revealed that the perceived high cost of insurance is the biggest barrier to the uninsured, with almost 70% of respondents saying they can't afford health insurance or feel it is too expensive.
Sixty five percent of respondents believed it would cost $50 to $500 per month for insurance, while 11% thought the cost could be $10 or less. In reality, however, the study points out that four out of five people with Affordable Care Act (ACA) Marketplace plans are able to find coverage for $10 or less per month after financial assistance and over 90% of Marketplace enrollees receive financial assistance.
"At Florida Blue, we are dedicated to providing our communities with access to affordable, high-quality health care solutions," Pat Geraghty, president and CEO of Florida Blue, said in a statement.
"We realize that people are busy, tired, and everything costs more, but we are here to help them during these challenging times and make it easier than ever to switch plans or sign up for plans, especially during the open enrollment period that closes on January 15."
Aside from believing insurance costs are too high, many of the people surveyed did not know what coverage gets them. Almost three in four respondents (73%) were unaware that most health plans cover preventive care, such as regular checkups, mammograms, colonoscopies, and vaccinations with no out-of-pocket costs.
While health insurance awareness can be improved among the uninsured, the national uninsured rate did reach a record-low of 8% in the first quarter of 2022.
The ACA Marketplace saw 11.5 million people enroll in a health plan last year, which marked an 18% increase from 2021, with the Inflation Reduction Act making plans more affordable and accessible.
The agency recommends the payer refund the estimated overpayments to the federal government and review its compliance procedures.
Cigna-HealthSpring of Tennessee received $5.9 million in Medicare Advantage overpayments for 2016 and 2017, a report by the Office of Inspector General (OIG) found.
The audit sampled 279 unique enrollee-years with the high-risk diagnosis codes for which Cigna received higher payments and revealed that 195 of the enrollee-years did not have medical records that supported the diagnosis codes.
The sample resulted in $509,194 in overpayments, with OIG extrapolating that figure to estimate that the payer owes nearly six million over a two-year span.
"As demonstrated by the errors found in our sample, Cigna's policies and procedures to prevent, detect, and correct noncompliance with CMS's program requirements, as mandated by Federal regulations, could be improved," OIG stated.
OIG recommended that Cigna refund the $5.9 million of estimated overpayments back to the federal government and identify similar instances of noncompliance that happened before and after the audit period to refund any other potential overpayments.
Additionally, OIG asked the health insurer to examine its compliance procedures to find where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with federal requirements and take the necessary steps to update those protocols.
Cigna did not concur with OIG's recommendations or findings and claimed that that intent and design of the investigation was "contrary to Medicare Advantage regulations and the goal of payment accuracy audits."
Following Cigna's comments, OIG revised the number of enrollee-years in error from 201 to 195 and revised the estimated overpayments from $6.3 million to $5.9 million. However, the agency did not alter its recommendations.
The audit of Cigna is one of many OIG has recently conducted of Medicare Advantage plans, including a report on Humana that uncovered $34.4 million in overpayments in 2016 and 2017.
States will have the opportunity to give additional benefits through the use of "in lieu of services and settings."
HHS is offering states greater flexibility to address health-related social needs for people enrolled in Medicaid, the department announced.
As part of the Biden administration's efforts to bolster Medicaid, the initiative gives states an opportunity to provide alternative benefits through the use of "in lieu of services and settings" in Medicaid managed care.
The benefits focus on a range of unmet social needs, such as food insecurity and housing instability, to help beneficiaries maintain their coverage as well as improve their health outcomes.
"We are deeply committed to strengthening Medicaid for the millions of Americans covered by it," HHS secretary Xavier Becerra said. "Today's step ensures people with Medicaid receive the broader care they need to live safe and healthy lives. We call on all states to leverage these innovative options and stand ready to partner with them in providing essential health care services."
CMS administrator Chiquita Brooks-LaSure said: “Today’s announcement is the next step in CMS' effort to use every lever available to protect and expand coverage for all eligible individuals as we work with our state partners to offer whole-person care.”
HHS stated that the initiative also allows states to adopt in lieu of services and settings to provide tailored meals for people with severe, chronic conditions that are worsened by poor diet, living in "food deserts," or not having access to nutritional choices.
The announcement additionally establishes the requirements and guardrails states must meet to ensure the actions are medically appropriate, cost effective, preserve enrollee rights and protections, and fulfill Medicaid objectives.
Most of the new Medicare Advantage enrollment growth can be attributed to members switching over from Medicare.
A higher share of beneficiaries switched from traditional Medicare to Medicare Advantage (MA) than vice versa in 2020, contributing to recent MA growth, according to research published in JAMA Health Forum.
MA share of overall Medicare enrollment skyrocketed from 19% in 2007 to 46% in 2021, the study notes, and is expected to surpass the 50% threshold by 2023. Key to that larger share is enrollees in traditional Medicare migrating to MA.
The study, which used the 2014 to 2020 CMS Master Beneficiary Summary File Limited Data Sets, found that switching rates from MA to traditional Medicare exceeded those from traditional Medicare to MA from 2017 through 2020.
In 2020, traditional Medicare to MA switching rates were nearly four times higher than MA to traditional Medicare for Medicare only and 2.5 times higher than MA to traditional Medicare for Medicare-Medicaid enrollees.
Switching accounted for new MA enrollment growth, increasing from 49% in 2016 to 67% in 2020.
Researchers also found switching rates differed by population group. Rates generally declined with age, while mortality status played a factor as well. Beneficiaries in the last year of their life were more than twice as likely to disenroll from MA than from traditional Medicare in 2016 (5.4% vs 2.6%). By 2020, that flipped the other way to the tune of 3.1% vs 5.1%.
The study discovered that Black and Hispanic beneficiaries generally switched at greater rates than White enrollees. By 2020, Black and Hispanic beneficiaries were more than twice as likely to disenroll from traditional Medicare as White enrollees (13.4% and 13.5%, respectively, vs 5.9%).
"Switching may be associated with changes in health status, inclusion of additional services in MA, cost considerations, and access to specialized health care clinicians," researchers wrote.
"The observed trends may reflect a growing importance of access to non-TM benefits in MA, cost considerations among beneficiaries, and divergence in the enrollment preferences of Black and Hispanic beneficiaries compared with White beneficiaries."
More benefits and out-of-pocket cost limits are at the top of the list for reasons why enrollees are selecting MA plans, a survey by the Commonwealth Fund found.
The survey fielded responses from older adults aged 65 and above who were enrolled in Medicare to better understand why they opt for MA or Medicare.
The Inflation Reduction Act has played a role in making health insurance on the Marketplace more affordable.
The ACA Marketplace has seen 11.5 million people enroll in a health plan this year, marking an 18% increase from 2021, HHS announced.
In total, that increase represents about 1.8 million more people as of December 15, which is the deadline for coverage starting January 1, 2023.
The boost in enrollment signals the Biden administration's commitment to making health insurance more affordable and accessible.
"Unprecedented investments lead to unprecedented results. Under President Biden's leadership, we have strengthened the Affordable Care Act Marketplace with continued record affordability, robust competition, and historic outreach efforts – and today's enrollment numbers reflect that," said HHS secretary Xavier Becerra.
"Thanks to the Inflation Reduction Act, four out of five customers will be able to find a plan for $10 or less. As we head into the new year, there is no greater gift than the peace of mind that comes with having high-quality, affordable health care."
Through the Inflation Reduction Act, individuals will continue to receive enhanced tax credits to purchase health insurance.
Meanwhile, 92% of HealthCare.gov enrollees will have the option to choose from three or more insurance companies they shop for plans, HHS stated.
Marketplace Open Enrollment is still open until January 15, 2023, with coverage options made by that deadline going into effect beginning February 1, 2023.
The second Marketplace snapshot by CMS showed 5.5 million plan selections, an increase from 4.6 million year over year. Those selections included 1.2 million new enrollees and 4.3 million who had renewed coverage from both HealthCare.gov and the state-based Marketplaces.
A survey examines how Americans view their health coverage and other workplace benefits.
Health insurance isn't just a perk, but one of the main draws of employment for nearly all American workers, according to a new poll.
The survey, from Seven Letter Insight for the Protecting Americans Coverage Together campaign, fielded responses from 2,334 workers with employee-sponsored health coverage with from November 14 to November 19, 2022.
Respondents overwhelmingly highlighted the significance of receiving insurance through their employer, with 83% saying it is important that a job offers coverage, while 13% say it is very important.
Americans would rather get their insurance through their employer than on the individual market, as 89% of respondents expressed their preference for employer-sponsored coverage.
Over 75% of workers surveyed said they believe insurance through employers is higher in quality than open market plans, while 95% said employer-sponsored coverage is more convenient, and 83% said it is more affordable.
Overall, 93% of respondents are satisfied with their insurance. More than half (54%) are highly satisfied, more than 70% agree their health insurance is worth what they pay for it, and 87% call their plans affordable.
Speaking of affordable, that topped the provided list of words for respondents when asked to describe their coverage. The other top choices were "high-quality" and "comprehensive." Meanwhile, the least chosen descriptions were "lacking," "confusing," and "low-quality."
Nearly all workers (97%) feel that "quality health coverage is an important way for companies to retain their valued employees," and 80% named health insurance as one of the most important benefits for an employer to offer.
"Employees value their employer-sponsored health coverage, and they believe it is fundamentally important for employers to offer it," said Katie Mahoney, vice president of Health Policy at the U.S. Chamber of Commerce. "ESI is working for the people with access to it, and the goal of policymakers should be to strengthen and bolster the system to help more people."
The payer giant has signed contracts with four health systems in a milestone initiative.
Blue Cross Blue Shield of Massachusetts (BCBSMA) announced value-based contracts with four health systems with the aim of reducing racial and ethnic inequities in care.
The health insurer said the agreements are the first in the state of Massachusetts, as well as among the first in the nation, to create a financial payment model that rewards providers for improving equity measures.
The four Massachusetts health systems to sign on are Steward Healthcare Network, Beth Israel Lahey health, Mass General Brigham, and Boston Accountable Care Organization. In total, the health systems provide care to more than 550,000 Blue Cross members.
"For more than a decade, we've collaborated with physicians and hospitals via our Alternative Quality Contract, which replaced the fee-for-service model and instead rewards clinicians' efforts to improve the quality and value of the care they deliver," Andrew Dreyfus, CEO of Blue Cross, said in a statement.
"We're now building on that model to help health systems in our value-based payment programs improve equity. As a health plan, this is the most important tool we have to work toward a health system that provides affordable, quality and equitable care to all our members."
At the start, the agreements will focus on measuring and rewarding equity in care in multiple clinical areas with inequities, such as colorectal cancer screenings, care for diabetes, and blood pressure control. As the payment model evolves, more categories will be included.
The Center for Healthcare Organization and Innovation Research at the UC Berkeley School of Public Health will conduct an independent external evaluation of the contracts and publish the effects of their effectiveness.
Whopping statistics show how quickly payers responded to the price transparency rule this year, compared to hospitals.
When it comes to price transparency rules, the hospital regulation has been in place four times longer than the payer version, yet the difference in the data available for the two is miles apart.
More specifically, enough miles that it would be the equivalent of traveling from Earth to Neptune and back 14 times, according to Turquoise Health. The price transparency data company put together numbers that illustrate how much payer pricing information is out there in its 2022 year in review.
Since the hospital price transparency rule went into effect on January 1, 2021, Turquoise Health has collected about three terabytes of hospital data. That figure pales in comparison to the 630 terabytes of payer data since the payer rule arrived on the scene July 1, 2022. If you're calculating at home, that's a gargantuan 20,090% increase in size from the hospital data.
Those 630 terabytes consist of 78 billion payer price records, with 163 total number of payers in Turquoise Health's database. If you decided to manually count the rows of data after payers refresh their data monthly, the company says it would take a mind-boggling 76,104 decades.
Despite the size of all that data, payers haven't yet figured out the best way to display it for consumers. Turquoise Health found payer machine-readable files that varied 50-100 times in size.
"The takeaway: payers can drastically reduce their file sizes by taking measures to ensure smart architecture," Turquoise Health said. "For example, using references to provider groups within rates, as opposed to duplicating the provider group data within each rate shrinks the overall file sizes."
