Multiple payers are the target of concern in a letter to CMS urging for an investigation into program participants.
A group of House and Senate Democrats are asking CMS to boot organizations that have committed fraud out of the ACO REACH program before they "further encroach on the Medicare system."
In a letter to CMS administrator Chiquita Brooks-LaSure, the lawmakers, led by Senator Elizabeth Warren (D-Mass.) and Representative Pramila Jayapal (D-Wash.), express their concern that payers will continue "ripping off taxpayers" with their participation in the new payment model, which will start on January 1, 2023.
The ACO REACHprogram is replacing the Global and Professional Direct Contracting (GPDC) model, with participants of GDPC allowed to enroll as ACOs if they maintain a strong compliance record and agree to meet the requirement of the model. However, the lawmakers point out that participants have troubling records, including notable health insurers Centene, Humana, Cigna, Clover Health, and Bright Health.
A preliminary review of the direct contracting entities (DCEs) by Physicians for a National health Program (PNHP) found that at least 10 current GPDC participants had documented cases of fraud and abuse.
Centene, for example, paid $97 million in 2021 to settle allegations of "duplicated and inflated claims" to the Department of Veterans Affairs. The payer giant's pharmacy benefit managers also allegedly overcharged state Medicaid programs on prescription drugs last year, resulting in settlements that totaled more than $260 million.
"The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries, and raises concerns that CMS screening procedures for participants are inadequate, putting taxpayer dollars at risk" the lawmakers write.
The letter calls on CMS to address these issues and protect patients before the ACO REACH program begins by stopping the participation of the organizations with histories of fraud and removing DCEs that do not meet the new standards for the program.
In addition, the lawmakers want written answers to multiple questions by January 16, 2023, such as how organizations that have been accepted into GPDC been screened for acceptance into ACO REACH, and what methods CMS will use to screen ACO REACH participants.
Blue Cross Blue Shield of Massachusetts is expanding its mental health provider network to keep up with the rise in demand.
The use of in-person and virtual visits for mental health have doubled since 2019, according to new data by Blue Cross Blue Shield of Massachusetts (BCBSMA).
The payer's numbers are reflective of a nationwide trend that sees a greater demand for mental health treatment since the beginning of the COVID-19 pandemic.
In response to that demand, BCBSMA announced it will further expand its mental health provider network, which includes partnering with national mental health provider groups to have more clinicians available and a greater variety of services.
BCBSMA highlighted that its mental health provider network has expanded by 46% over the past five years and now features almost 18,000 clinicians.
"As the need for mental health services continues to grow, access to convenient and affordable care is critical," Andrew Dreyfus, Blue Cross president and CEO, said in a statement. "By expanding and diversifying our mental health network, we're ensuring that our members are able to find and receive the high-quality care they need, when they need it."
One of the partnerships is with Talkiatry, a telehealth psychiatric therapy provider, which joins the four other in-person and virtual mental health providers BCBSMA partnered with earlier this year.
The health insurer also said it is adding two specialty mental health providers: And Still We Rise, which offers culturally affirming practices, and DynamiCare, focused on substance abuse.
"It's not enough to simply expand our network with more clinicians," Greg Harris, a psychiatrist and senior medical director for mental health at Blue Cross, stated.
"We want to ensure we have the right clinicians to treat members' specific needs – and that includes specialized treatment and approaches. When it comes to mental health treatment, one size does not fit all. We're committed to building a network of practitioners to serve a diverse array of needs for children, adolescents and adults."
The rule aims to streamline the administrative process by requiring certain payers to implement electronic prior authorization.
Medical associations and payer groups are reacting approvingly to CMS' proposed rule which would require Medicare Advantage (MA) plans and other payers to implement electronic prior authorization.
The rule is part of the Biden administration's initiative to increase health data exchange and investing in interoperability, CMS announced. It would apply to MA organizations, state Medicaid and Children's Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan Issuers on the Federally-facilitated Exchanges.
"The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers – helping us to address avoidable delays in patient care and achieve better health outcomes for all," said CMS administrator Chiquita Brooks-LaSure.
The proposed rule would require the implementation of a Health Level 7 Fast Healthcare Interoperability Resources standard Application Programming Interface to support electronic prior authorization, payers to give a reason when denying requests, publicly reporting certain prior authorization metrics, and sending decisions within 72 hours for expedited requests and seven calendar days for standard requests—twice as fast as the existing MA response time limit.
CMS stated that the rule would save providers more than $15 billion over a 10-year period.
The response to the rule from both provider and payer groups has been positive, ranging from the American Hospital Association (AHA) to MA advocacy group Better Medicare Alliance (BMA).
AHA: "The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans. Hospitals and health systems especially appreciate that CMS included Medicare Advantage plans in these requirements, as the AHA has urged. Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens health care providers and adds unnecessary costs to the health care system."
Medical Group Management Association: "MGMA is encouraged to see that CMS heeded our call to include Medicare Advantage plans in the scope of this proposed rule. An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals. The onerous methods of completing these requests, coupled with the increasing volume is unsustainable. An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care. This is a positive step forward for both medical groups and the patients they treat."
America's Health Insurance Plans: "AHIP's Fast PATH demonstration showed that electronic processes for prior authorization are essential for ensuring that patients receive swift, evidence-based care that improves value and reduces administrative burdens for everyone. This proposed rule would require clinicians and hospitals to adopt electronic prior authorization to meet certain quality measures, ensuring that we are all incentivized to work together for a better patient and clinician experience that improves satisfaction, efficiency, and affordability for everyone."
BMA: "Better Medicare Alliance thanks CMS for their leadership in modernizing the prior authorization process for beneficiaries. While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization's essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community's work streamlining this clinical tool to better serve its 30 million diverse enrollees. We additionally welcome the proposed rule's data exchange provisions, which will further improve communication between health plans, providers, and beneficiaries."
A survey of providers highlights their experiences and satisfaction with patient payment solutions.
While most providers have seen an implementation of new patient payment solutions in the past five years, the platforms still have room for improvement for both providers and patients, according to a survey by Bank of America and The Strawhecker Group.
Over 650 providers in the U.S. were surveyed, sharing their experiences with patient payment solutions and what more they want out of the platforms.
Only 58% of respondents reported high satisfaction with their current patient payment systems, with 30% saying the implementations were not successful.
Providers know that patients expect payment methods that are both convenient and efficient, and if they can't get that with their current provider, they may find a new one.
That is why the surveyed providers pointed to improvements to patient payment solutions that would make it easier for patients to use, such as better integrations of software and patient collections workflow, better payment terminal functionality, and the addition of other digital payment forms like Apple Pay.
According to the respondents, 72% of patients used credit or debit cards for their last payment, with 54% interested in email or text payment notifications and 43% interested in automated digital payments.
Providers also want to make their own lives easier, which includes fully integrating patient payment solutions with their electronic health records or revenue cycle software—something only 33% of respondents reported having. More than half (58%) said the seamlessness of their current systems could be improved.
Other improvements on providers' wish list were patient privacy and HIPAA-compliance—the most frequently mentioned crucial platform feature—data safety, improved efficiencies and cost reductions, and confidence from a patient payment solutions partner they can trust.
The majority of providers (78%) said they would feel more confident in a solution provided by a bank, while 66% said they would feel more confident with a solution provided by a "sizeable financial brand."
Software investment and particularly cycle management is a priority for providers going forward, research from Bain & Company and KLAS found.
The report revealed that 45% of providers accelerated software investment over the past year, while more than 95% expect to make new software investments over the next year. Revenue cycle management was at the top of the list for where those investments will go.
The Senate Finance Committee is calling for MA plans to get their provider directories in order with the aim of improving mental health parity in Medicare and Medicaid.
Senators released a discussion draft with policiesto put access to mental health and substance use disorder services on the same level with physical healthcare — the fifth and final legislative draft the committee has released focusing on its bipartisan initiative of advancing mental health.
"Too often the notion of mental health parity falls short of reality," Senate Finance Committee chair Ron Wyden said in a statement. "These policies represent the first step towards addressing the mental health parity and ghost network challenges that I intend to build on in the coming months -- especially the challenges I hear about consistently from families at home who aren't able to find available mental health professionals covered in their insurance networks."
The policies include codifying existing requirements for MA plans to maintain updated provider contact information, whether a provider is accepting new patients, and in-network status changes within two days.
The discussion draft also calls for a Government Accountability Office study on the differences in enrollee cost-sharing and utilization management between behavioral and non-behavioral health services in MA and compared to free-for-service Medicare.
"These proposals will help us gather additional data and increase transparency to ensure Medicare beneficiaries have access to affordable mental health services, on par with their access to physical health services," committee ranking member Mike Crapo said.
A survey of health plans finds prior authorization processes need improvement to become fully electronic.
While the healthcare industry is moving towards automation as a whole, prior authorization (PA) still has plenty of room for growth.
An industry-wide survey conducted by America's Health Insurance Plans (AHIP) fielded responses from 26 health plans covering 122 million commercial enrollees from February to April to better understand PA practices from the perspective of payers.
The survey revealed the top barriers to prior authorization automation for insurers, which were led by providers not using electronic health records (EHR) enabled for electronic PA and the high costs to upgrade EHR.
The top five reasons were:
Provider does not use EHR enabled for electronic PA (71%)
Costly/burdensome for providers to buy/upgrade HER for electronic PA (71%)
Lack of interoperability between EHR vendors (62%)
Costly/burdensome for payers to enable PA rules and information to be delivered electronically (43%)
Lack of electronic PA solutions on market (19%)
Payers reported that a significant percentage of PA requests continue to be submitted manually by providers. The breakdown for prescription medications was 61% electronic and 39% manual, while medical services were 60% manual and 40% electronic.
The use of electronic PA was the most chosen method of streamlining PA for respondents, with 88% automating medical services and 75% automating prescription medications.
On the other side, many providers feel the burden of prior authorization still falls on them.
A survey by the American Medical Association (AMA) revealed that physicians feel payers are not upholding a 2018 voluntary agreement on PA reforms between them, the AMA and other national organizations.
Only 26% of the responding physicians reported that their electronic health record system offers electronic prior authorization for prescriptions.
A study finds variation between rates for insured and uninsured at the same hospital and differences in cash prices across hospitals.
Insured patients have an expectation that their health plan allows them to pay less for hospital services, but that may not necessarily be the case.
According to a study by a Trinity College economist, payer-negotiated rates for insured patients are often higher than self-pay cash prices for the same services.
Ruiz Sánchez examined data on 14 shoppable hospital services that can be scheduled by patients in advance, including office visits, MRIs, and CT scans. Hospitals have had to disclose prices under the price transparency law, which went into effect on January 1, 2021. Data made available through the federal rule was compiled within the Turquoise Health dataset, consisting of records on about 2,200 hospitals.
The research was focused on the payer-specific negotiated rates charged to major insurers Aetna, Blue Cross Blue Shield, Cigna, Humana, and United Health, as well as government-related payer plans like Medicaid, Medicare, Tricare, Veterans Affairs and state agencies insuring state employees.
The findings revealed that 60% of negotiated rates were higher than the cash prices for the same services.
Additionally, there was also significant variation between cash prices across hospitals, with costs for the same service being as much as eight times more expensive depending on the hospital.
"Individuals purchasing private health insurance are paying monthly premiums … under the promise that their insurer is also negotiating the lowest possible rates for services," Sánchez said.
"This raises the question whether it is evidence of poor bargaining by insurers, who are representing consumers, in their negotiations with hospitals."
A recent study also found that some insurers negotiate prices for common radiology services less efficiently than their competitors, as well as across other health plans under their management.
The research, published in Radiology, found that on average, the maximum negotiated price for shoppable radiology services was 3.8 times the minimum negotiated price in the same hospital and 1.2 times in the same hospital-insurer pair.
Another study published in The American Journal of Manage Care found that payers generally negotiate lower amounts for health insurance exchange plans than their commercial group rates and significantly more than their Medicare Advantage contracts at the same hospital.
The health insurer is focused on advancing health equity to address the health needs of all communities.
Twenty-one of Elevance Health's affiliated Medicaid plans have earned accreditation for health equity from the National Committee for Quality Assurance (NCQA), the health insurer announced.
The plans, which serve more than eight million beneficiaries and span 20 states, are the first to receive a full three-year accreditation, according to Elevance. The NCQA health equity accreditation gives organizations, health systems, and health plans an actionable framework for evaluating and elevating the health of the populations they serve.
”Advancing health equity is a priority for everyone at Elevance Health, and we hold ourselves accountable for addressing the root causes that drive poor health outcomes,” said Aimée Dailey, president of Medicaid at Elevance Health.
”Ninety-three percent of our Medicaid members are now served by a health plan that has earned this health equity accreditation, a scale unmatched in the industry. It's an opportunity to continue to address the unique needs and improve the health of the diverse communities we serve.”
Elevance Health, formerly Anthem, states that it has a "health equity by design" philosophy, which allows the insurer to address inequalities and whole health through a personalized approach.
One example of that philosophy in action was when the insurer enrolled 20 Medicaid leaders in a course on advancing health equity through the Harvard T.H. Chan School of Public Health earlier this month.
”While our ongoing work to advance health equity, specifically with this accreditation, is something to celebrate, it is just the beginning," said Dr. Darrell Gray, II, chief health equity officer at Elevance Health. "It's the foundation from which we will continue to innovate in our partnerships and journey towards designing an ecosystem in which all people, regardless of race or ethnicity, age, sexual orientation, gender identity, disability, and geographic or financial access can receive individualized care that optimizes their health and well-being."
The NCQA announced in September that nine organizations had earned the first accreditation as part of its Health Equity Accreditation (HEA) Plus advanced evaluation program.
Those nine entities were part of NCQA's HEA Accreditation Plus Pilot, with the Plus designation building on the NCQA's existing Health Equity Accreditation program by highlighting organizations "further along on their health equity journey."
New customers are flocking to Affordable Care Act (ACA) Marketplace health plans in the early stages of the open enrollment period.
Nearly 3.4 million Americans have chosen an ACA Marketplace plan through the first three weeks of the OEP, the Biden administration announced.
The total number of enrollees represents a 17% increase over last year, with HealthCare.gov experiencing 40% more sign-ups compared to 2021.
"We are off to a strong start – and we will not rest until we can connect everyone possible to health care coverage this enrollment season," said HHS Secretary Xavier Becerra. "The Biden-Harris Administration has taken historic action to expand access to health care, and ensure everyone can have the peace of mind that comes with being insured."
Becerra also highlighted that every four out of five people are eligible for coverage at $10 or less and potential enrollees can explore affordable plans at HealthCare.gov.
The website had 493,216 new enrollees, compared to 354,137 on the same date last year.
Meanwhile, total Marketplace plan selections include 655,000 people (19%) new enrollees and 2.7 million people (81%) who renewed or chose a new plan for 2023.
The early numbers are encouraging for the administration as the OEP continues to run until January 15, 2023.
"Providing quality, affordable health care options remains a top priority," said CMS administrator Chiquita Brooks-LaSure. "The numbers prove that our focus is in the right place. In the first weeks of Open Enrollment, we have seen an increase in plan selections and a significant increase in the number of new enrollees over the previous year."
Earlier this year, on its 12th anniversary, ACA enrollment hit a record-high of 14.5 million people signing up, a 21% increase from the previous year.
The administration is prioritizing ACA growth and the results in 2022 are indicative of that.
Lawmakers take issue with the importance of the qualifying payment amount (QPA) in the independent dispute resolution (IDR) process.
The House Ways and Means Committee is the latest group to call for changes to the No Surprises Act final rule, arguing that the QPA remains too big of a factor in the IDR process.
In a letter to HHS, the Department of Labor, and the Department of the Treasury, the leaders state they are "severely disappointed to find that the August 2022 final rule violates the No Surprises Act in the same ways as before."
The IDR process allows providers and insurers to enter into arbitration when they cannot agree on fair reimbursement. After the government released the interim final rule in 2021, the Texas Medical Association filed a lawsuit alleging the rule required arbitrators to heavily weigh the insurer-calculated QPA in deciding the rate. A federal judge ruled in favor of TMA in February before CMS released a revised final rule in August, which TMA once again challenged and other major medical associations criticized.
Specifically, the committee highlights in the letter the departments' creation of a 'double counting' test, which directs IDR entities to "consider whether the additional information is already accounted for in the QPA."
Lawmakers argue that while the No Surprises Act requires IDR entities to separately consider all of the statutory factors, the final rule prevents entities from considering factors like patient acuity and the item or service unless providers meet the burden of disproving double-counting within the QPA.
"As written, this perpetuates the flaws of the interim final rules and continues to unfaithfully implement the statutory text and intent of the law by skewing the determination of the IDR process toward the QPA," the committee writes.
To stay true to the "Congressional intent" of the No Surprises Act, the lawmakers ask the departments to swiftly adjust portions of the final rule by taking immediate steps.
