The groups allege the health insurer underpaid claims submitted by patients for services covered through MultiPlan.
The American Medical Association (AMA), as well as the Medical Society of New Jersey and the Washington State Medical Association, have joined a class action lawsuit against Cigna alleging underpayments for claims through the MultiPlan network, the nations' largest third-party network.
Originally filed in June by Cigna members, the lawsuit takes issue with the health insurer's reimbursements at its non-participating providers rate instead of a rate for a MultiPlan contract when services were received from a participating provider. As such, Cigna members were "exposed to the threat of balance billing," the lawsuit states.
The plaintiffs argue that MultiPlan contracts prohibit providers from billing patients for the difference between the original charges and the discounted rates, which Cigna is responsible for.
They claim the payer "also breached its fiduciary duties, including its duty to honor written plan terms and its duty of loyalty, because its conduct serves Cigna's own economic self-interest and elevates Cigna's interests above the interests of plan member patients."
AMA president Jack Resneck Jr. criticized Cigna for prioritizing its "economic self-interest" above its commitment to physicians and patients in the MultiPlan Network.
"The AMA and other physician organizations allege that Cigna's misconduct is riddled with conflicts of interest and manipulations that routinely shortchanged payments to MultiPlan Network physicians and interfered with the patient-physician relationship by ignoring the MultiPlan contracts and making incorrect statements to patients about their liability for the unpaid portion of the billed charges," Resneck said in a statement.
"By joining Stewart v. Cigna as a plaintiff, the AMA hopes to shed light on Cigna's misconduct and create remedies so that patients and physicians can look forward to getting what they are promised."
The physician group responds to the ruling by a Texas judge deeming a piece of the Affordable Care Act (ACA) unconstitutional.
The American Medical Association (AMA) has pushed back on the controversial ruling against a provision of the ACA, strongly stating that preventive care requirements must be upheld.
AMA president Jack Resneck called the elimination of no-cost preventive care "unwise and unthinkable" in a statementfollowing Judge Reed O'Connor's decision to strike down the ACA law mandating employers to cover an HIV prevention drug.
The federal judge ruled in favor of Steven Hotze, owner of Braidwood Management, who argued that being forced to buy health insurance for his employee to cover preexposure prophylaxis (PrEP) violates his religious beliefs.
Resneck stated: "Providing insurance coverage for drugs that prevent the transmission of infectious disease does not violate anyone’s religious freedom—to the contrary. This type of preventive care saves lives."
Preventive care not only saves lives and saves money, it's part of physician' ethical obligation to take care of patients, Resneck argues. He also pointed to research by HHS that found more than 150 million people benefited from preventive care services in 2020 alone.
"The AMA is alarmed by this line of judicial reasoning and we fear it could turn back the clock and limit access—not only to PrEP, but also to a long list of preventive services that physicians and patients depend on," Resneck said.
As the legal process for the preventive provision plays out, Resneck believes empowering, educating, and encouraging patients about their health is necessary.
He said: "In short, we need to build on the gains we've made under ACA, not abandon vital components of the law just as we’re starting to reap their benefits."
A new survey reveals what factors Americans weigh when seeking out healthcare, such as quality and convenience.
Unsurprisingly, patients are more than willing to reach into their pockets if it means receiving higher quality of healthcare, according to a survey by AKASA.
The revenue cycle firm commissioned the survey, which was conducted by YouGov, and fielded responses from 2,026 Americans in March to highlight what factors adults are willing to pay more for when choosing their providers.
Quality of care led the way, with 57% of respondents ranking it first among all factors. The next most important factor was the ability to work with a care team of choice, which was chosen by 47%.
The ability to work with hospitals of choice and location proximity or convenience were each selected by 41% of those surveyed, while 40% said they would pay more for the ability to get an appointment quickly.
The survey also asked how far patients are willing to travel for the best price in healthcare, assuming the quality is the same. Respondents revealed there is a limit, with 51% answering they would travel 10-20 miles for an optimal price, while 31% said they would journey as much as 50 miles. Beyond that, only 13% would travel 100 miles, 2% would go up to 200 miles, and 3% would trek up to 400 miles.
"The findings can help healthcare leaders prioritize what to focus on when thinking about their bottom lines through the lens of what patients are willing to pay for and aligning it with improving the patient experience," Amy Raymond, VP of revenue cycle operations at AKASA, said in a statement. "However, the quality of care is often diminished by the less-than-stellar patient financial experience."
Quality versus quantity has been a longstanding tug of war in healthcare, but the industry is attempting to shift more towards the former.
The transition has been a slow one however, as illustrated in a recent report by the Medical Group Management Association. The findings showed that revenue from value-based contracts in 2021 accounted for 6.74% of revenue in primary care specialties, 5.4% in surgical specialties, and 14.74% in nonsurgical specialties.
As patients prioritize higher quality of care, industry leaders must do the same.
Judge Reed O'Connor deemed the services unconstitutional, drawing heavy criticism from patient advocacy groups.
A key piece of the Affordable Care Act (ACA) requiring employers to cover an HIV prevention drug and other preventive services is in jeopardy after a federal judge ruled against it for violating religious freedom.
Judge Reed O'Connor of the U.S. District Court for the Northern District of Texas ruled in favor of Steven Hotze, owner of Braidwood Management, who claimed the ACA mandate violates the Religious Freedom Restoration Act.
Hotze specifically took issue with being forced to buy health insurance for his employees to cover an HIV prevention drug, preexposure prophylaxis (PrEP), arguing it "facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman," the ruling stated.
O'Connor wrote that "Braidwood has shown that the PrEP mandate substantially burdens its religious exercise."
Additionally, O'Connor found that the U.S. Preventive Services Task Force violates the Constitution's Appointments Clause, which deems how public officials are appointed, because of the scope of the task force's authority.
O'Connor previously ruled that the entire ACA was unconstitutional in 2018, arguing that the law was invalid because Congress zeroed out the penalty tied to its individual mandate. The decision was flipped by the Supreme Court, which upheld the ACA by a 7-2 vote in 2021 in the midst of the COVID-19 pandemic, allowing millions to retain their insurance coverage.
Patient advocacy groups have spoken out against O'Connor's most recent ruling, voicing their displeasure and warning of the dangers of the decision.
"The free preventive care guaranteed by the ACA has become a bedrock of our health care system, benefiting patients with all types of insurance, including those insured by their employer," Protect Our Care chair Leslie Dach said in a statement. "The consequences of this ruling cannot be understated and it is essential that Judge O'Connor stay the effects of his order while this disastrous decision is appealed."
The Medical Group Management Association (MGMA) and the American Hospital Association (AHA) have offered their recommendations on streamlining the administrative process.
Reforming prior authorization to cut down on treatment delays and administrative burden is a necessity for improving Medicare Advantage (MA), according to key medical groups.
MGMA and AHA have submitted their comments to CMS in response to a request for information on the MA program, with both groups offering recommendations on prior authorization policies.
Publish the Interoperability and Prior Authorization for MA Organizations, Medicaid and CHIP Managed Care and State Agencies, FFE QHP Issuers, MIPS Eligible Clinicians, Eligible Hospitals and CAHs proposed rule: This rule would improve the electronic exchange of data and streamline prior authorization processes, but MGMA believes the timeframe for when health plans should respond to medical groups for urgent prior authorizations and for standard prior authorizations should be shorter than the timeframe CMS proposed of 72 hours and seven days, respectively.
Implement recommendations included in the OIG report: The research revealed the MA organizations often unnecessarily delayed or denied members' access to services, even when prior authorization requests met coverage rules. Among its recommendations, OIG urged CMS to update audit protocols to prevent errors.
Reinstate step therapy prohibitions in MA plans for Part B drugs: MGMA notes that step therapy requires patients to try and fail certain treatments before allowing access to usually more expensive treatments, which allows health plans to undercut the provider-patient decision-making process.
Increase CMS oversight over MA plans' use of prior authorization processes.
Require transparency of payer prior authorization policies and establish evidence-based clinical guidelines available at the point of care.
Requires MAOs to follow traditional Medicare coverage rules to prevent unnecessary delays and burdens associated with inappropriate use of prior authorization.
Establish a standard electronic transaction for providers to submit and receive responses for prior authorizations.
Improve the quality and use of MAO data related to prior authorizations, including changes in the frequency of reporting, increased transparency, penalties for non-compliance, more targeted auditing, and suggestions for how these data could be incorporated into Star Ratings.
Reduce administrative waste in the MA program, including requiring plans to comply with standard, electronic process for prior authorization.
While prior authorization requirements can negatively affect patient outcomes, as shown in the OIG report, the administrative process can also hinder providers.
A recent survey by MGMA revealed that 79% of medical groups feel that payer prior authorization requirements increased in the past year. The increase is only putting more stress on providers, with 88% of physicians reporting that the administrative burden associated with prior authorization is high or extremely high, according to a survey conducted by the American Medical Association.
The federal agency is striving to make it easier for eligible people to enroll in and continue their Medicaid coverage.
The Biden administration has proposed a new rule to overhaul the application and renewal process for Medicaid and other government programs like the Children's Health Insurance Program (CHIP), CMS announced.
By simplifying enrollment and verification processes, CMS is aiming to make it easier for children, older adults, and people with lower income to both attain and retain Medicaid and CHIP coverage.
With the COVID-19 public health emergency slated to end on October 13, the proposed rule comes at a time when states are beginning to notify Medicaid beneficiaries about potentially losing coverage.
The proposal includes standardizing eligibility and enrolment policies like limiting renewals to once every 12 months to allow applicants 30 days to respond to information requests.
It would also end lifetime benefit limits in CHIP, allowing children to enroll in coverage immediately by doing away with pre-enrollment waiting periods. Children's eligibility would transfer directly from Medicaid to CHIP when a family's income rises, preventing an unnecessary redetermination process.
For adults aged 65 and older, as well as those with a disability, the proposed rule would remove unnecessary administrative hurdles for individuals who are eligible for the government programs.
"This proposed rule will ensure that these individuals and families, often from underserved communities, can access the health care and coverage to which they are entitled – a foundational principle of health equity," CMS administrator Chiquita Brooks-LaSure said in a statement.
Other changes in the proposal include:
Establish a clear process to prevent termination of eligible beneficiaries who should be transitioned between Medicaid and CHIP when their income changes or when the beneficiary appears to be eligible for the other program, even when the beneficiary fails to respond to a request for information.
Ensure automatic enrollment, with limited exceptions, of Supplemental Security Income recipients into the Qualified Medicare Beneficiary group.
Eliminate the requirement to apply for other benefits as a condition of Medicaid eligibility to ensure eligible individuals to reduce unnecessary administrative hurdles.
Propose specific timelines for states to complete Medicaid and CHIP renewals, including guidelines to ensure beneficiaries who return information late are properly evaluated for other eligibility groups prior to being terminated.
The median revenue amount from value-based contracts across all practices was $30,922 per provider in 2021.
Even with the healthcare industry trending towards more value-based care, the transition away from fee-for-service is happening at a slow rate.
Medical revenue continues to predominantly consist of fee-for-service payments, with value-based care making up just a small slice, according to a report by the Medical Group Management Association(MGMA).
The survey found that revenue from value-based contracts accounted for 6.74% of revenue in primary care specialities, 5.54% in surgical specialities, and 14.74% in nonsurgical specialities. Across all practices, the median revenue amount from value-based contracts was $30,922 per full time equivalent provider.
MGMA examined 2021 data from more than 2,300 organizations from a variety of specialties and practice types to gauge the shift to value-based reimbursement.
The research also revealed that the share of physician compensation tied to quality performance has changed during the pandemic. More than a third (35%) of medical groups report they have increased the share of compensation tied to quality in the past two years, while 62% said they have the same share compared to 2019. Only 2% of respondents said they have decreased the percentage of compensation tied to quality.
The workforce shortage has had an affect on appointments, the survey stated, with appointment availability for new patients increasing by two days, from 6.1 days in 2020 to 8.1 days in 2021.
While no-show rates held steady, appointment cancelations also increased across nonsurgical and surgical specialties, jumping from 8.3% in 2020 to 17.7% in 2021, and from 7.0% to 8.4%, respectively. Primary care experienced a slight decline in cancelations from 8.3% to 8.0%.
Practices reported that it took longer to post charges in 2021 for third-party payment from the time a patient is seen. Primary care saw a dip in charge-positing lag time from 5.2 days in 2020 to five days in 2021, but nonsurgical and surgical specialties jumped significantly, from 6.8 to 11.6, and from 6.8 to 10.4, respectively.
The number of claims denied on first submission also rose in 2021, across all specialty types. Primary care saw an increase from 4% to 8%, nonsurgical went up from 3% to 8.14%, and surgical leapt from 4.16% to 8.14%.
However, percent of copayments collected at the time of service decreased across the board.
With the stress that's placed on the dwindling number of staff, optimizing administrative operations is key to alleviating the challenges practices are facing today.
"The medical workforce is grappling with burnout, staffing declines, decades-high inflation, operational challenges and a dynamic reimbursement environment that affects providers across the board," Halee Fischer-Wright, president and chief executive officer of MGMA, said in a statement.
"This report reveals how addressing scheduling errors and billing denials could help relieve the financial burden on health groups, moving them toward value-based care that promotes the welfare of physicians, staff, and patients."
Nearly one-third of patients with seven or more chronic diseases face medical debt versus 7.6% for individuals with no chronic conditions.
Patients with chronic conditions have a higher likelihood of facing adverse financial outcomes and incurring medical debt, according to study published in JAMA Internal Medicine.
The research used medical claims data from adults enrolled in Blue Cross Blue Shield of Michigan from January 2019 to January 2021 and linked it to commercial credit data in January 2021.
Of the 2.85 million adults studied, the predicted probabilities of having medical debt, nonmedical debt, delinquent debt, a low credit score, or recent bankruptcy were all significantly higher when more chronic conditions were present.
Individuals with seven to 13 chronic diseases had medical debt 32% of the time, compared to 7.6% for those with none. The split between the two groups was also wide and skewed heavily to adults with seven or more chronic conditions when it came to nonmedical debt (24% vs 7.2%), delinquent debt (43% vs 14%), a low credit score (47% to 17%), and recent bankruptcy (1.7% vs 0.4%).
Among those with medical debt, the estimated amount increased with the number of chronic conditions, from $784 for individuals with no chronic conditions to $1,252 for those with seven or more.
The findings featured sizeable variation between each chronic condition and its risk of creating medical debt. The chronic conditions associated with the greatest adjusted increases in medical debt were severe mental illness ($274), substance use disorders ($268), stroke ($235), congestive heart failure ($234), and liver diseases ($228).
The study notes that the variation between conditions could suggest some conditions are more costly to treat with higher out-of-pocket expenses, while others may lead to an individual's inability to work and earn income.
Regardless, the results of the research show that worsened financial health is associated with worse physical and mental health outcomes.
"If poor financial well-being leads to additional chronic disease, policy makers should consider new social safety-net policies to reduce poverty rates and should explicitly incorporate improvements in physical health—and correspondingly reduced health care spending—as a benefit of antipoverty programs," the study concluded.
"If, in contrast, chronic disease diagnoses are directly leading to adverse financial outcomes, then improving commercial insurance benefit design would be warranted to provide additional protection from out-of-pocket medical expenses, particularly for conditions identified as being costly for patients."
The implications of patients accumulating debt puts stress on providers as well.
Accountable Care Organizations (ACOs) are delivering high-quality care while spending less to earn performance payments.
The Medicare Shared Savings Program saved $1.66 billion in 2021 compared to spending targets, CMS announced today.
It marks the fifth consecutive year savings have been generated by the program, which worked with ACOs to incentivize the delivering of high-quality care.
ACOs are made up of various providers who come together to give value-based care to Medicare patients. When an ACO can both deliver high-quality care and spend wisely by avoiding unnecessary services, they can qualify to share in the savings they've created for the program.
As of January 2022, Shared Savings Programs include over 525,000 providers giving care to more than 11 million Medicare beneficiaries, according to CMS. The federal agency is aiming to have 100% of people with traditional Medicare in an accountable care relationship by 2023.
"The Medicare Shared Savings Program demonstrates how a coordinated care approach can improve quality and outcomes for people with Medicare while also reducing costs for the entire health system," CMS administrator Chiquita Brooks-LaSure said in a statement. "Accountable Care Organizations are a true Affordable Care Act success story, and it is inspiring to see the results year after year. The Biden-Harris Administration and CMS are committed to a health care system that delivers high-quality affordable, equitable, person-centered care – and a Medicare program that can deliver just that."
CMS states that approximately 58% of participating ACOs earned payments for their performance in 2021, with low-revenue ACOs leading the way at $237 per capita in net savings, compared to $124 for high-revenue ACOs. The ACOs made up of at least 75% primary care clinicians saw $281 per capita in net savings, compared to $149 for ACOs with fewer primary providers, highlighting the importance of primary care to the success of the Shared Savings Program.
The program is also facing potential changes after CMS outlined its proposed 2023 Physician Fee Schedule, which features expanding access to ACOs.
The proposal includes incorporating advance payments to certain new ACOs in rural and underserved communities, allowing smaller ACOs to progress more slowly from low to high risk, benchmark adjustments to encourage more ACO participation, and more. Public comments on the Physician Fee Schedule are due by September 6.
The National Association of Accountable Care Organizations (NAACOS) has backed the potential changes to the program and lauded ACOs role in creating significant savings last year.
"Today's results again demonstrates that ACOs drive us towards a health care system that delivers affordable, equitable, high-quality, person-centered care" Clif Gaus, NAACOS president and CEO, said in a statement. "Eight years of continued strong performance with the positive proposed changes to the program included in the physician fee schedule sets the stage for significant growth in accountable care."
Medical claims are back on the rise after being supressed during the early stages of the COVID-19 pandemic.
Healthcare costs for employers are set to increase to more than $13,800 per employee in 2023, according to analysis by Aon.
The financial services firm used data of nearly 700 employers representing approximately 5.6 million employees and found that healthcare expenditures will rise significantly from the budgeted $13,020 per employee in 2022.
The projection of a 6.5% increase is more than double the rate employers experienced from 2021 to 2022, but remains well below the 9.1 inflation figure reported through the Consumer Price Index, the research stated.
Naturally, with employees utilizing care more at typical levels following the first year of the COVID-19 pandemic, medical claims have increased and continue to grow.
Inflation will affect costs, as will other factors like new technologies, severity of catastrophic claims, blockbuster drugs, and increasing share of specialty drugs, Aon notes.
When it comes to health plans, the research revealed employer costs shot up by 3.7% in 2022, while employee premiums from paychecks rose by 0.6%.
"In what remains a tight labor market, employers are absorbing most of the health care cost increases," Debbie Ashford, the North America chief actuary for health solutions at Aon, said in a statement. "Employers are budgeting higher due to uncertainty and the anticipation that inflationary pressures will increase the cost of health care services."
One approach to alleviate high costs is to target patients with chronic and complex conditions, the analysis states. Ashford notes it is not uncommon to see 1% of membership making up 40% of spending in a given year.
By identifying and predicting when costs associated with long-term complex conditions can arise, employers can find solutions to spending.
"The effect of chronic conditions has far-reaching implications beyond what we see with health care costs, out to the other areas of the business, like absence and productivity, disability and worker's compensation," said Farheen Dam, Aon's North America health solutions leader. "By focusing on chronic conditions, not only are we improving the health and happiness of employees, but we're helping to improve the way they live and work."
