Research by America's Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA) looks at the effects of the law.
The No Surprises Act (NSA) successfully protected more than nine million Americans from surprise bills in the first nine months since going into effect, according to new data by AHIP and BCBSA.
However, the unintended results of the law have been a boom in claims to the federal independent resolution process (IDR). The survey found that providers have submitted over 275,000 arbitration claims, nearly 10 times more than originally anticipated.
The IDR process is meant to serve as a last option when providers and insurers cannot reach an agreement on fair reimbursement. Excessive use of the process creates unnecessary costs.
"A health care emergency should not lead to a financial crisis. The No Surprises Act has now protected 9 million Americans from receiving costly surprise medical bills from care providers—a huge win for patients," said David Merritt, senior vice president of policy and advocacy for BCBSA.
"However, the tens of thousands of arbitration claims filed by providers clearly demonstrate that more needs to be done to ensure that they don’t abuse the system for their financial gain. We'll continue to work on behalf of patients to protect everyone from surprise medical bills—and lower health care costs with an effective resolution process."
To collect the data, AHIP and BCBSA fielded a nationwide survey to 84 insurers with group health plans and qualified health plans, with 33 payers, making up 57% of the total commercial market, responding.
Using the insurers' commercial enrollment and number of claims between January and September this year, researchers reached a national estimate on the number of NSA-eligible claims (9,367,031) and claims submitted to IDR (275,245).
While the research suggests the NSA is working as intended, another survey by Morning Consult from June found that one in five patients received a surprise bill in 2022. Those bills have been especially costly in some cases, with 22% of respondents saying their chargers were over $1,000.
Meanwhile, the IDR process has continuously been under the spotlight as providers have been unhappywith the rule, claiming it favors payers by heavily factoring in the insurer-calculated qualifying payment amount.
Seven of the 19 Commonwealth facilities surveyed did not have information on discounted cash prices.
Hospitals nationwide have been slow to get up to speed on price transparency compliance and hospital-dense Massachusetts is faring no better, according to a new report by Pioneer Institute.
The survey analyzes 19 facilities on 35 of the 70 shoppable services required by CMS as part of the price transparency law, which took effect on January 1, 2021.
Researchers found that that compliance rates ranged from 60% at Emerson Hospital to 97% at Mass General, while seven hospitals had no information on discounted cash prices — the price for self-pay patients.
Those seven hospitals were Boston Children's, Falmouth, Holyoke Medical Center, MetroWest Medical Center, Mount Auburn, New England Baptist and St. Vincent's.
"Our earlier work found disappointing compliance with Massachusetts' 2012 healthcare price transparency law," said Pioneer executive director Jim Stergios. "And now we find that compliance with the federal law isn't much better. We are not insensitive to the challenges providers are facing, but it is disappointing that compliance with the law has not budged much since 2017, when Pioneer began monitoring hospital price transparency efforts."
The 12 hospitals that did provide some discounted cash prices had pricing discrepancies. For example, the survey highlighted that an MRI of a leg joint was more than $3,400 at Mass General and Brigham and Women's, but $775 at Carney 10 miles away.
"The disparities we observe strongly suggest a market dominated by the systems that are able to maintain prices above competitive norms," said report author Barbara Anthony. "This is why it's crucial that consumers, employers, benefit managers and insurers have ready access to provider prices."
Where the surveyed hospitals did relatively well in was providing prices in machine-readable formats (MRF), which not necessarily for the benefit of consumers due to its lack of user-friendly readability. Only two of the 19 hospitals had no MRF data.
To improve price transparency compliance, the authors of the survey offer recommendations, including: hospitals appoint a single administrator to be in charge of adherence, the federal government provide guidance to hospitals on how to make pricing information more consumer-friendly, CMS enforce the law more strongly, and the Massachusetts state government come up with incentives for hospitals to comply.
After hospitals got off to a slow start with compliance, an October report by Turquoise Health revealed that 76% of facilities have posted a MRF, 65% have posted an MRF with negotiated rates, and 63% have posted an MRF with cash rates.
Nonetheless, the Office of Inspector General recently said it will be keeping an eye on CMS' enforcement of the law after the agency resisted on issuing fines for violations until June.
In a letter to CMS, lawmakers highlight five steps they want the agency to take to counter deceptive practices.
U.S. senators have asked CMS to take action to protect beneficiaries from harmful Medicare Advantage (MA) marketing tactics through further oversight and regulations.
Thirteen senators penned a letter to the agency outlining five changes CMS can make through notice and comment rulemaking and sub-regulatory guidance as soon as possible.
The letter comes after the Senate Finance Committee's investigation into MA marketing practices, which found a "concerning pattern of misleading advertising materials, aggressive marketing tactics, and in some cases flat-out deception harmful to beneficiary access to care and health outcomes," the senators wrote.
Complaints over MA marketing are not new, with the letter pointing to when Congress addressed abuses in 2008 and CMS issued civil monetary penalties to MA plans. However, the senators state that the Trump administration weakened protections and found workarounds to take advantage of beneficiaries.
The letter commends CMS for implementing the changes it already has, which includes a new policy, effective January 1, 2023, which would require CMS approval before running television advertisements for MA or Part D prescription drug plans.
The following five steps would strengthen protections further, the senators argue:
Reinstate requirements loosened during the Trump administration: This includes banning educational and marketing events from occurring on the same day at the same location.
Monitor MA disenrollment patterns and use enforcement authority to hold bad actors accountable.
Provide clear guidelines and trainings to ensure agents and brokers understand and adhere to best practices: Agents and brokers should be accountable
Implement robust rules around MA marketing materials and close regulatory loopholes that allow cold-calling.
Support unbiased sources of information beneficiaries, including State Health Insurance Assistance Programs and the Senior Medicine Patrol.
"We share the same goal to enable the offering of MA plan choices that are valuable to seniors and people living with disabilities," the senators wrote. "Yet, our first responsibility is to protect beneficiaries and the integrity of the MA program from fraudsters and scam artists who look to take advantage of any opportunity to prioritize profits over beneficiary health and well-being."
Housing and food security programs led the way for spending on social determinants of health (SDOH) by payers between 2017 and 2021.
SDOH have been identified as worthwhile investments by health organizations, but insurers are not putting their money where their mouth is, according to a study published in the Journal of General Internal Medicine.
The research, which examines social spending by the top 20 payers in the nation based on market share rankings by the National Association of Insurance Commissioners, found miniscule investment on SDOH by insurers relative to their net income.
Between January 1, 2017, and December 31, 2021, the total spending for the top 20 insurers was at least $1.87 billion, with the top six payers by market share making up 72%. The top six, on average, spent 0.11% of their net income on SDOH in 2017 and 0.67% in 2021. Spending in 2020 peaked at 1.6%, which the researchers attribute to the COVID-19 pandemic.
To quantify social spending, researchers searched news articles and press releases that included insurer name and terms "social determinants of health" or "community health." Social spending was categorized into housing, food security, employment, education, social and community context, transportation, and "general SDOH" for ambiguous reporting.
The researchers acknowledged their method could have blind spots with missed investments by insurers not publicly posted. They also recognize they may have misclassified investments depending on when they were publicized.
Investments in mental health, substance use, domestic violence, natural disaster relief, technological infrastructure, community health workers, and racial equity initiatives without specifically mentioning SDOH were excluded from the study.
The majority of payers' spending was on housing ($1.2 billion) and food security ($238 million) programs, while $247 million was classified as general SDOH.
The areas that saw the least investment were transportation ($13.4 million), social and community context ($49.7 million), education ($57.2 million), and employment ($58.6 million).
The spike in SDOH spending in 2020 coincided with significant profit for insurers, but the researchers posit that the uptick in investment was due to urgency around the pandemic and not necessarily based on an increase in net income.
Regardless, the study suggests that payers have the capability to put more money into SDOH initiatives, though investing more in other areas may be more of a priority.
"Whether insurers should spend more on these programs is unclear considering that these dollars may be instead used to lower patient premiums and cost-sharing," the authors wrote. "The impact of insurer social spending remains equivocal, though practice patterns, such as considering SDoH in hypertension guidelines, will continue to change as payers and providers make more investments."
Healthcare financial leaders were asked if and when they calculate return on investment (ROI) on revenue cycle management (RCM) automation.
While the use of automation in RCM continues to grow, how its ROI is measured varies heavily depending on the provider, according to a survey from Healthcare Financial Management Association commissioned by revenue cycle firm AKASA.
The survey, which fielded responses from 556 chief financial officers and revenue cycle leaders at hospitals and health systems across the nation between July 8 and August 2, reveals a lack of set standards when it comes to quantifying RCM automation.
Nearly a third of respondents (32.7%) said they calculate ROI on RCM automation in-house, while 7.1% stated ROI is calculated by their RCM automation vendor. More than half (51.9%) answered that instead of calculating ROI, they focus on other key performance indicators, such as accounts receivable days. Finally, a small but not insignificant amount of providers (8%) said they don't measure for ROI at all.
There were also differences among the respondents in how often ROI on RCM automation is measured. More than a third (34.7%) said they measure ROI monthly, followed by quarterly (26.4%), annually (14%), and semi-annually (6.6%). The option of "other – write in", chosen by 18.2% of providers, indicated that ROI measurement will be determined once automation is fully implemented or on an as-needed basis.
"This survey really highlights that healthcare financial leaders are struggling with who or where to turn on ROI measurement," said Amy Raymond, VP of revenue cycle operation at AKASA. "There's a significant gap in the market for guidance and frameworks on how to get ROI right.
"As health systems mature in their automation journey, the current understanding of ROI falls short as a sole measure of success. Part of this is that not all metrics are easy to measure upon implementation — specifically those that examine the impact on the workforce or patient financial experience. There is a clear need for a new form of assessment — one that holistically looks at Total Value."
As ROI becomes more of a focus, revenue cycle leaders are turning their attention to trends and opportunities to develop best practices and evaluate their level of involvement in an array of functions.
The health system and health plan giant saw its bottom line flip in the third quarter compared to the previous year.
Kaiser Permanente experienced a difficult third quarter which included a net loss of $1.54 billion, the company announced.
The operator of hospitals, health plans, and other subsidiaries released its earnings report, revealing a significant fall to the opposite end of the spectrum from last year's third quarter profit of $1.56 billion.
Most of the decline was due to other income and expense totaling a loss of $1.5 billion for the quarter, which the company said was driven by investment market conditions. The operating loss, meanwhile, was $75 million.
Despite the downturn, organization leadership expressed encouragement about the maneuvering through the current financial climate.
"I am proud of our ability to navigate the challenges of the past few years including a global economic crisis, the high cost of goods and services, supply chain issues, labor shortages, and the pandemic while serving our 12.6 million members," Kaiser Permanente chair and CEO Greg A. Adams said in a statement.
"I continue to be inspired by the unwavering commitment and dedication of our Kaiser Permanente teams who through this unprecedented and unpredictable 3-year period continue to provide high-quality, affordable care and service to our members and communities."
The company's membership has experienced modest growth of nearly 40,000 during the calendar year, with the total sitting at 12.6 million at the end of the third quarter.
Kaiser Permanente continues to pour into capital spending, which totaled $820 million for the quarter, compared to $878 million for the third quarter in 2021. Year to date, the company has capital spending of $2.5 billion.
"Kaiser Permanente's integrated model of care and coverage continues to provide long-term stability amid changing market conditions," stated Kathy Lancaster, Kaiser Permanente executive vice president and CFO. "In the third quarter of 2022, we remained committed to our members, patients, and the communities we serve while controlling spending and investing in our capital program."
The American Hospital Association (AHA) finds administrative policies are increasingly overburdening providers.
Some commercial health insurers are using policies that can delay patient care and create burden for providers, causing relationships with hospitals to worsen, according to a survey by AHA.
The association fielded responses from more than 200 hospitals in 2019 and from 772 hospitals between December 2021 and February 2022, creating data that both predates COVID-19 and represents the lasting effects of the pandemic.
With hospitals strained by the challenges of the labor shortage, the survey highlights how insurer tactics are stretching providers even thinner through administrative tasks.
Of the hospitals and health systems surveyed, 95% said there have been increases in staff time spent seeking prior authorization approval, while 84% reported the cost of complying with insurer policies is increasing.
The time and energy spent by providers is unnecessary, however, as 62% of prior authorization denials and 50% of initial claims denials that are appealed are ultimately overturned.
The result is deteriorating relationships with payers, as 78% of hospitals and health systems said their experience with insurers is worsening. Less than 1% said it was getting better.
"These survey results are stark evidence that some commercial health insurers deny care while hospitals and health systems focus on providing care," said AHA president and CEO Rick Pollack. "Patients deserve comprehensive health coverage with the protections they were promised when they signed up. Congress and the Administration need to act now to hold commercial insurers accountable for actions that delay patient care, contribute to clinician burnout and workforce shortages, and increase costs."
Medicare Advantage (MA) has especially come under scrutiny for often unnecessarily denying or delaying care. AHA pointed to a report by the Office of Inspector General from April which found that 13% of MA prior authorization denials met Medicare coverage rules and 18% of MA payment denials met Medicare coverage and Medicare Advantage organization billing rules.
To push for fairer coverage for both patients and providers, AHA wrote a letter to HHS secretary Xavier Becerra and Department of Labor secretary Martin Walsh asking for more oversight of insurers.
A study by the American Medical Association (AMA) highlights the consequences for patients and providers.
Medicare Advantage (MA) markets are largely uncompetitive and deserve scrutiny from regulators and lawmakers, according to a study by the AMA.
In the 2022 edition of Competition in Health Insurance: A Comprehensive Study of U.S. Markets, AMA examined health insurers in 380 metropolitan statistical areas (MSAs) in the U.S., including MA plans for the first time. Researchers captured 2021 data from commercial enrollment in preferred provider organization (PPO), health maintenance organization (HMO), point-of-service (POS), consumer-drive health plans (CDHP), and public health exchanges.
The findings reveal just how little competition is present in MA markets, with 79% of MSAs having markets that were ranked as highly concentrated in 2021.
Market competition is based on the Herfindahl-Hirschman Index (HHIs), a calculation that factors in market size and distribution. Markets with an HHI score of less than 1,500 are considered unconcentrated, while an HHI between 1,500 and 2,500 correlates to a moderately concentrated market. An HHI score above 2,500 means the market is highly concentrated and therefore uncompetitive.
In the AMA study, the average HHI for MA markets was 3,331,down from 3,923 in 2017. The median HHI for 2021, meanwhile, was 3,068.
Thirty-four percent of MA markets had one insurer with a share of 50% or more and 6% had one insurer with a share of 70% or more.
The 10 largest insurers by MA market share were UnitedHealth Group (28%), Humana (19%), CVS Health (11%), Kaiser Permanente (7%), Elevance Health (6%), Centene (4%), Cigna (2%), Blue Cross Blue Shield of Michigan (2%), Highmark (1%), and SCAN Health Plan (1%).
The 10 states with the least competitive MA markets were Vermont, North Dakota, Wyoming, Montana, Rhode Island, South Dakota, West Virginia, District of Columbia, Nebraska, and Louisiana.
"High levels of market concentration can result in diminished competitive constraints on insurers," said AMA president Jack Resneck, Jr. "Unchecked market power among insurers is a formula for higher premiums, lower coverage, and inadequate levels of patient care, concerns of great relevance to Medicare Advantage. Most large Medicare Advantage insurers are accused of fraud and flouting the authority of federal agencies.
"The new AMA study shines a light on the lack of competition in Medicare Advantage markets across the country and will help regulators and lawmakers better scrutinize anticompetitive insurer behavior that harms patients and physicians in an industry where exploitative business practices are already commonplace."
In response, America's Health Insurance Plans (AHIP) strongly disputed the study, labeling AMA's report "simply false and wrong."
AHIP pointed to the average number of MA plans per county increasing by 68% over the past decade, as well as the number of competing MA companies increasing by 15%.
"Here is the bottom-line truth: MA and the Exchange marketplaces are prime examples of the government and free market working together to deliver lower costs, more choices, and better outcomes for the American people."
There's still misunderstanding around the use of technology on the back end of healthcare operations, says University Health's vice president of health information management and revenue cycle.
How to best leverage it is something organizations are learning on the fly. But for healthcare leaders and workers, it's just as important to understand what technology can't and shouldn't do.
Tackling those misconceptions is critical, explains University Health's vice president of health information management and revenue cycle Seth Katz.
Katz spoke with HealthLeaders about implementing technology in revenue cycle, why automation is not a plug-and-play solution, and medical coding as the next strategy to leverage.
This interview has been edited for clarity and brevity.
HealthLeaders: How do you see technology's role in the patient financial experience?
Katz: I think it's growing. Technology has been part of everything for years now, but specifically the automation side of things is definitely growing. I think the last two years have taught a few things. One was with the pandemic, on the negative side, you can say people got sick. You can also say there's a lot of extra work. And then people are just burnt out in general. Not even just from COVID, but from what I call button-mashing. Nobody goes to school to be a cash poster or to be a denials analyst. You find yourself in those roles. It doesn't excite people and I think it shows a lack of creativity on the revenue cycle side. So when we look at automation specifically and we've implemented some, that's what it's about. It prevents us from having people work menial tasks over and over so we can automate those. It's a really big positive. People need to invest in it.
You hear all the time about doctors and nurses and people say we want them to practice at the top of their license, right? But we don't look at that in the back end. I want them to work at the top of their skillset too. I want them spending time on things that matter more, that bring in more cash, that are the problem. So I think it has a huge opportunity. It's still fairly new which is a little surprising that it's taking a little longer to catch on and I think some of it just misunderstanding. People don't understand what automation is. But it's absolutely vital. You have to do it. You're not going to be able to find enough staff, retain them, pay them, all that stuff. So it's huge.
Pictured: Seth Katz, vice president of health information management and revenue cycle, University Health.
HL: How does automation have to be used and deployed? Does there still need to be a balance between automation and the human touch?
Katz: So number one is go back to that point about staff. I use this example a lot. Amazon has more automation than everybody and they keep adding more. They want drone delivery. There's all those robots working in the warehouse, right? But at the same time they're on pace this decade to pass Walmart as the world's largest employer. So that's the way to look at this. Now they might not need as many people in the warehouse. But that doesn't mean you need fewer people just because you've automated. In some ways you need more. You have different new roles that you never would have thought of before.
And the second part, it's still a computer system. It's garbage in, garbage out. If you don't set it up right, if you don't train on it properly, if you don't maintain it, it's not going to work. You have to keep training, you have to keep updating it, you have to keep it in sync, you have to learn about it. If you don't do those things and support it then you're going to fall short of your expectations. It adds efficiency, it adds improvement, but it also comes with other things you have to do. It's not a plug-and-play and it's also not one-size-fits-all. Meaning you might have a couple of different automation companies. The company you choose to help automate prior authorizations, I can tell you will not be the same company that we're looking at to do artificial intelligent medical coding. You might have multiple automation vendors working at the same time too.
HL: What type of technology has University Health implemented on the back end of revenue cycle and how has that affected outcomes?
Katz: We started with prior authorizations. We're expanding into some inpatient notifications, eligibility running, claim status checking, stuff like that. As a whole it's going very well. To go live is probably two-and-a-half months of letting that automation run in the background and learn and see how we do things. But within about two months of kicking off it started GI and started going to payer websites and logging requests for prior authorizations by taking that information out of our EMR. So it's going very well. We're happy. We're looking to continue to expand it. You've to get creative with this. Prior authorization is a big one that a lot of people start with. It's a repetitive task. It's taking discrete data from your EMR and putting it out to a payer portal. So it's very systemic. But I was starting to get to a point of what else can we automate? What are things that are maybe outside the box?
HL: Are there additional strategies you plan to leverage in the future?
Katz: People are trying to leverage more information exchanges. In healthcare, there's still a lot of manual moving of data between hospitals, even though there's health information exchanges. Participation isn't necessarily strong. You're starting to get more and more players trying to automate that. So we're actually part of a pilot project where when a person applies for Social Security assistance, they would of course ask for their records. They'll be able to pull that information via a secure API and so they can get it done faster, they get the information faster, they can approve the request faster. I think it's things like that, trying to get the information to flow faster.
On the revenue cycle site, the biggest one is the medical coding. I think there's a number of players growing in that space doing AI coding. It's very early. It is still a job that there are oftentimes shortages, that it relies on contract coders which are very expensive. So I think this is a really interesting opportunity there in the next couple of years. And what's more interesting is it's all new players who are driving this. We've done a lot of deep dive on that, done a lot of testing, met with a lot of vendors, but it's coming, it's coming quickly and I want us to be at the front end of that. This train is not slowing down anytime soon. I think those who adopt to it quickly are going to see returns quickly.
The company is growing five-star rated Essence Healthcare to Indiana, Kentucky, Arkansas, Georgia, and Ohio.
Lumeris will offer its Medicare Advantage plan, Essence Healthcare, in five new states in 2023, the a value-based care managed services operator announced.
The expansion is due to Essence's customer and provider satisfaction with the plan and its benefits, allowing the MA offering to move beyond Illinois and Missouri.
Beginning January 1, Essence will be available in Indiana, Kentucky, Arkansas, Georgia, and Ohio marketplaces.
"We are passionate about our vision to create the system of care every doctor wants for their own family," said Michael Long, chairman and CEO of Lumeris. "While the health care delivery system in the United States has struggled to balance quality, cost, and patient and physician satisfaction, Lumeris has demonstrated that it is not only possible, but also scalable. We are pleased to expand our provider partnerships to bring Essence Healthcare to a growing number of seniors."
Essence received a five-star rating for the second consecutive year from CMS, which released Medicare Advantage plan ratings based on 38 quality measures.
"Our strategically aligned partnerships with providers are creating a new standard for how healthcare can be delivered and financed," said Umar Farooq, president of Essence Healthcare. "Through these deep-rooted partnerships, Essence Healthcare has demonstrated that when providers are the table in co-designing managed care solutions, we can together achieve highest quality star rating designated by CMS."
