Surveyed medical groups reveal burdens have increased in the past 12 months, resulting in delays or denials for necessary care.
Despite scrutiny of prior authorization practices in Medicare Advantage (MA), requirements for the administrative process have only grown over the past year, according to a survey by the Medical Group Management Association (MGMA).
With MA continuing to experience a significant rise in enrollment, MGMA surveyed 601 medical groups to better understand the impact of prior authorization in the program.
More than four out of five respondents (84%) said prior authorization requirements for MA have increased in the past 12 months, with less than 1% reporting requirements had decreased.
Practices ranked MA as the most burdensome program when it comes to obtaining prior authorization (46%), ahead of commercial plans (32%), Medicaid (20%), and traditional Medicare (4%).
Prior authorization in MA is becoming a greater issue due to more and more beneficiaries choosing the program. The survey found that 58% of practices saw 15% or more their patients either switch from traditional Medicare to MA or between MA plans, while 84% of respondents said they had to reauthorize existing Medicare-covered services for those Medicare enrollees who've switched plans.
"With half of all Medicare beneficiaries enrolled in private Medicare Advantage (MA) plans, prior authorization reform has taken on new urgency at the federal level," Anders Gilberg, senior vice president of Government Affairs at MGMA, said in a statement. "Medical groups now identify prior authorization in the MA program as more burdensome than commercial insurance and Medicaid. More needs to be done to protect beneficiaries."
Prior authorization requirements are having unintended consequences such as delaying and denying necessary care, increasing practice costs, and disrupting provider workflows.
Nearly all medical groups surveyed (97%) said their patients experienced delays or denials for necessary care due to the administrative process, with requirements varying widely across payers. More than nine in 10 respondents (91%) agreed that a single standard electronic prior authorization system across all insurers would alleviate burden on their practice, while just 7% said MA plans they're contracted with offer a gold-carding program.
With providers facing significant financial pressure in the wake of COVID-19, prior authorization is only adding to practice costs. Over three-quarter (77%) of respondents said they have hired or redistributed staff to work on prior authorizations due to an increase in requests, and 60% said there are at least three different employees involved in completing a single prior authorization request.
Even when practices have enough of a workforce and adequate resources to devote to prior authorization, requirements often mean spending plenty of time and energy on requests instead of caring for patients. More than a third of practices reported spending upwards of 35 minutes on an average single prior authorization request, with nearly 5% spending 91 minutes or more.
CMS' MA final rule aims to tackle these issues by streamlining prior authorization, including requiring approvals to remain valid for as long as medically necessary and offering coordinated care plan protection for patients. The rule has received widespread support from medical groups like MGMA, along with payer groups.
"MGMA supports commonsense policies that alleviate onerous administrative requirements and improve the timeliness of clinical care delivery," Gilberg said. "Efforts to streamline, standardize, and ultimately reduce the volume of prior authorization demands on medical practices such as CMS' proposed Prior Authorization and Interoperability Rule, and the Improving Seniors' Timely Access to Care Act in Congress, will further strengthen and modernize the MA program."
A survey finds health plans have room for improvement in areas such as having accurate behavioral health directories.
Nearly all employers agree that mental health coverage is a vital component of benefits offered to employees, but few are satisfied with their health plan's services, according to a survey by the National Alliance of Healthcare Purchaser Coalitions.
The organization polled 221 employers that provide health coverage to over 10 million employees and dependents from February to March 2023 to gauge experiences with coverage networks.
Only 31% of respondents said they were satisfied with network access for behavioral health services, with 99% agreeing that offering mental health coverage is important for employees.
"Supporting the mental health and wellbeing of employees and their families is a top priority for major employers," Mark Wilson, vice president of health and employment policy and chief economist for the HR Policy Association, said in a press release.
"We need to work collaboratively with all stakeholders, especially our health plan and vendor partners, if we are going to be able to provide timely access to affordable, high-quality behavioral health providers."
Additionally, 31% of those surveyed said they were dissatisfied with their health plan's efforts to assess and address gaps in network access, while just 34% of employers reported that their behavioral health directories were accurate.
When it came to quality of care, more than half (54%) of employers said they were satisfied with the promotion of standardized measurement for behavioral health services, but only a third (33%) were satisfied with engagement and reporting of outcomes.
Another area health plans fell short was in supporting, promoting, and incentivizing integration of behavioral health into primary care, with just 28% of respondents expressing satisfaction.
Only 39% of respondents said they were satisfied with their workplace mental health support, despite 92% believing high engagement in workplace programs was important.
Finally, payers missed the mark on health equity, according to employers. A little more than a quarter said they were satisfied with their plans evaluating and tailoring behavioral health services to diverse communities, such as LGBTQ+ and people of color.
"Many of the services provided, particularly in managing network access, continue to fall short of employer expectations," Michael Thompson, National Alliance president and CEO, said in a statement. "While there are bright spots, as an industry we still have a long way to go to meet the needs of employees and their families."
Emergency ground ambulance services are one of the blind spots of the regulation that could be improved with federal intervention.
The No Surprises Act (NSA) is protecting patients from most surprise bills as intended, but the law's scope fails to protect certain vulnerable pockets, according to new analysis by the Urban Institute and Georgetown University's Center on Health Insurance Reforms, with funding from the Robert Wood Johnson Foundation.
Researchers conducted 32 interviews with federal and state regulators, as well as organizations representing a spectrum of stakeholders like consumers, employers, payors, physicians, hospitals, air ambulance providers, and medical billing companies.
Informants largely agreed that one year after the NSA went into effect, patients are being "well protected" from surprise bills. In one state, for example, insurance regulators said that of the 1,800 insurance-related consumer complaints received in 2022, only two were NSA-related.
Another state regulator was a "little surprise" by the lack of complaints, but "attributes this to insurers' and providers' cooperative efforts to eliminate balance bills and correct them when they occur."
The analysis also found that patients appear to be protected from services that previously left them exposed to surprise billing, like air ambulance services. Additionally, researchers said the NSA is "getting consumers 'out of the middle' of payment disputes between providers and payors.
However, gaps remains in the law for other services like ground ambulance, which one state regulator noted can result in patients being billed nine out of 10 times.
"Although the limited evidence to date suggests that consumers are being well protected from balance billing in the situations covered by the NSA, some stakeholders remain concerned that gaps in the law can leave consumers with unexpected financial liability," the report stated.
"The failure to include emergency ground ambulance services, in particular, means that many patients will continue to be balance billed for out-of-network services they had no choice but to accept."
Though researchers say it's too early to determine whether the NSA will "constrain the growth in health insurance premiums and encourage broader provider networks," policymakers need to track provider and insurer compliance for potential billing patterns to address vulnerable areas.
In a survey by Morning Consult, 20% of respondents said they or their family had received a surprise bill in 2022, with another one in five billed after being treated by an out-of-network provider at an in-network facility.
Separate data by AHIP and the Blue Cross Blue Shield Association revealed that while the NSA averted over nine million surprise bills in the first nine months of being a law, it also led to providers submitting over 275,000 arbitration claims—nearly 10 times more than originally anticipated.
Research by the American Medical Association (AMA) finds 15 states reported double-digit percentage increases in premiums in 2022.
Physicians are facing higher medical liability insurance costs for the fourth year in a row, according to analysis by the AMA.
The report, based on an annual survey of professional liability insurers conducted by the Medical Liability Monitor (MLM), found that the proportion of premiums with increases in 2022 was 36.2%, the highest rate in any year since 2005. The average premium increase for 2022 was 8.1%.
The prevalence of year-to-year increases in medical liability premiums from 2019 to 2022 has not been observed since the early 2000s, AMA stated.
"There is a growing consensus that a hard medical liability insurance market exists in a considerable number of states and is slowly spreading across the U.S. as more physicians face higher insurance premiums," AMA president Jack Resneck Jr. said in a statement. "For physicians who can still obtain coverage in a hard market, the skyrocketing costs may force physicians to relocate away from certain high-cost states or drop certain critical services that raise their liability risk. These tough choices can lead to reduced access to care for patients."
After medical liability premiums were mostly stable between 2013 and 2018, the upward trend began in 2019 when the proportion of premiums that increased was almost double from the year before, rising from 13.7% to 26.5%. The proportion of premiums that increased went up again in 2020 to 31.1% before taking a slight dip in 2021 to 29.5%.
Double-digit percentage increases in premiums were reported in 15 states in 2022, up from 12 in 2021. Illinois once again had the largest proportion of premiums that increased by double digits (63.6%), followed by New Mexico (33.3%), Oregon (26.7%), Kansas (20%), South Dakota (20%), Kentucky (20%), Massachusetts (16.7%), Montana (16.7%), Maine (6.7%), Virginia (6.4%), Nevada (5.6%), and Georgia (4.8%). Premium increases varied in these states from 10% in Maine and Montana to 40.9% in Kansas.
The analysis also found a wide variation in premiums depending on geography in 2022. For example, OB/GYNs dealt with premiums ranging from $49,804 in Los Angeles County, California, to $226,224 in Miami-Dade County, Florida.
As AMA noted in their analysis last year, the current rise in medical liability premiums is not as severe as the last "hard market" that took place in the early 2000s. The report highlights that two differences compared to the last hard market are that the medical professional liability (MPL) insurance industry is in a much better financial position now and that there is currently a smaller MPL market on the demand side.
"Nonetheless if current trends continue, even if slower and less severe than the last hard market, this medical liability pressure could have detrimental effects on health care markets, such as an increase in defensive medicine, lower physician supply, and thus reduced access to care," the analysis concluded.
New research by Turquoise Health examines the state of price transparency for both hospitals and insurers.
"Price transparency has passed a major inflection point" with there now being no shortage of pricing data by both payers and providers, Turquoise Health CEO Chris Severn said in the company's Q1 impact report.
The analysis finds that as of March 2023, 95% of commercially insured lives are now represented by payer data, while 84% of hospitals have posted pricing data. Additionally, Turquoise scored payers on transparency for all payer machine-readable files based on completeness, size, and parsability.
On the payer side, the report notes that pricing data has come in a lot quicker after the insurer price transparency law went into effect in July 2022 than it did for hospitals following their regulation more than two years ago. And the numbers continue to rise, with Turquoise citing 183 payers publishing data as of March, up from 68 in July 2022, 111 in October 2022, and 170 in January 2023.
However, the report highlights that "healthcare pricing is complex" and that the size of payer data requires refinement and necessary context.
"If the government is aiming to require all insurance companies to publish the rates for all items and services, which we at Turquoise fully support, the output will, by nature, be nuanced and quite large," Turquoise stated.
"Due to this unfortunate truth, the data still requires industry expertise and additional reference data to process and create utility for end users. When left in the hands of the inexperienced, as we’ve seen in some articles from industry outsiders, incorrect and hasty conclusions are drawn."
That is less the case with provider pricing data, which now has 5,383 hospitals out of 6,394 (84%) with machine-readable files and 4,703 (73.6%) with significant negotiated rates. Those figures are up from Turquoise's first impact report released in October 2022, when 4,909 hospitals (76%) had posted a machine-readable file and 4,195 (65%) had negotiated rates.
The rise in compliance will "usher in a transformational era where data will be embedded in revenue cycle workflows, contract negotiations, and become an integral part of running a savvy healthcare organization," Turquoise said.
Severn recently shared some price transparency tips for revenue cycle leaders in an exclusive interview with Healthleaders.
"Make sure that you have a good understanding of the laws and requirements," Severn said. "There are a lot of resources out there that can help you get educated and understand where you and your organization can best focus your time.
"Also, keep an eye on the landscape for information. We’re seeing guidance, training, podcasts, and notice of any changes, such as a recent job aid to assist payers and providers with their Independent Dispute Resolution applications, published nearly weekly."
Severn also gave congressional testimony at the March 28th hearing "Lowering Unaffordable Costs: Examining Transparency and Competition in Healthcare," where he spoke for more government action, including the enforcement of standards.
The payer giant posted $91.9 billion in revenue for the first quarter of 2023, up 15% year-over-year.
The nation's largest Medicare Advantage (MA) insurer doesn't expect its growth in the sector to slow down amid risk adjustment changes.
UnitedHealth Group CEO Andrew Witty affirmed the payer's outlook in an investor callon the same day the company announced significant gains in its first quarter earnings report.
Witty acknowledged CMS' final decision to phase in the risk adjustment changes over the next three years gives UnitedHealth Group time to adjust, both as a business and for its beneficiaries. CMS said MA plans will see an average payment increase of 3..32% due to the phase-in, instead of the 1.03% in the advance notice.
"While we remain concerned about some of the potential unintended consequences of the changes of the risk adjustment model, particularly around adequate diagnosis and support for people with diabetes, complex behavioral needs and more, we do appreciate CMS' decision to phase-in the changes," Witty said.
MA experienced record enrollment for the 2023 plan year and UnitedHealth Group accounted for nearly two in three new enrollees (44%) by for-profit insurers, according to analysis by The Chartis Group.
UnitedHealthcare CEO Brian Thompson said the payer feels good about its market position and intends to grow again in 2024.
"We expect the marketplace to continue to grow in 2024. And we continue to lead with the strong momentum that we have demonstrated for many years now," Thompson said. "So, we are obviously in the middle of our benefit planning, but I can just share with you that we are encouraged and optimistic."
For the first quarter of 2023, UnitedHealth Group raked in $91.9 billion to achieve 15% year-over-year growth over the $80.1 billion from 2022, the company's earnings report stated.
The strong performance was driven by double-digit growth by both its health services business Optum and its insurer arm UnitedHealthcare.
Optum's first quarter revenues shot up 25% to $54.1 billion, while operating earnings climbed 19% to $3.7 billion.
For UnitedHealthcare, revenue increased 13% to $70.5 billion and operating earnings grew 14% to $4.3 billion.
The payer's MA member base, meanwhile, increased from 6.9 million to 7.5 million year over year.
A study reveals an increased interest among executives to work with third-party partners to support their revenue cycle management.
In large part due to the workforce shortage in the wake of the pandemic, most providers plan to outsource revenue cycle functions, according to a study by CWH Advisors.
The consulting firm surveyed 38 hospital and medical group executives in November and December 2022 to gauge interest in the use of third-party partners going forward.
More than six in 10 respondents (61%) said they expect to make greater use of third parties for offering patient financing options in the next two years, with 63% indicating they were dealing with staffing shortages in their revenue cycle departments.
Only 42% of respondents said they are satisfied with their current patient payment solutions. Improving check-in and payment capabilities are high on the list of areas of improvement for providers in order to offer patients a more retail-like experience, the survey stated.
"We designed this study to get providers' point of view on their patient payment needs, to better understand how technology supports payments processes, and to learn more about how the procurement of those services occurs," David Stievater, partner at CWH Advisors, said in a press release.
"Overall, our research found that providers work hard to balance their financial goals of accelerating cash flow and reducing debt with offering excellent service and flexible payment options to patients."
Kaufman Hall's 2022 State of Healthcare Performance Improvement report found that revenue cycle is the most common area for outsourcing among hospital leaders. Of the 86 hospital and health system leaders surveyed for the report, 27% said they've pursed outsourcing revenue cycle functions, which was ahead of other solutions like environmental services (23%) and IT services (21%).
Nearly two-thirds (65%), of medical billing companies have a positive outlook on the sourced billing industry, according to another report by Tebra. Forty three percent of respondents also said they view outsourcing as a significant opportunity, while 42% see significant opportunities to expand services.
Over 35% of surveyed health plans said they used more than 10 outcomes-based contracts (OBCs) in the plan year 2022.
The majority of payers used OBC for prescription drugs in 2022, according to a survey by Avalere.
The healthcare consulting firm surveyed 46 U.S.-based health plans from February 14 to February 20, 2023, to gauge their use and experience with OBCs during the 2022 plan year.
Answers revealed that 58% of plans had at least one OBC, while about 10% had two to five contracts, another 10% had five to 10 contracts, and over 35% had more than 10 contracts. Around 15% of respondents said they had no contracts, but are in negotiations for one or more now.
Usage was modestly higher than in 2021, when Avalere found that 56% of payers had an OBC. That year, 12% of plans reported having more than 10 OBCs, which was double the mark from 2020. With that number almost tripling in 2022, the trend shows payers are becoming more willing to utilize the value-based approach.
When asked why they are currently using OBCs, respondents said they were for new products mostly, as well as some existing products, "reflecting growing interest among stakeholders to align payment with clinical benefit, particularly for new products that have limited real-world clinical benefit."
The top three therapeutic areas in which payers utilized OBCs in 2022 were oncology, cardiology, and endocrinology.
Additionally, 74% of respondents with at least one OBC said they prefer contracts with both claims-based and clinical outcomes. Yet, 53% indicated they do not feel claims-based outcomes are a good proxy for clinical benefit.
"Claims-based measures are typically easier to track because they leverage information that plans and PBMs are already gathering, rather than clinical outcomes that may need to be tracked specifically for an OBC," the researchers wrote.
"Clinical measures can be more difficult to track if they require new data infrastructure and pose an additional administrative burden on providers and other stakeholders. Therefore, while clinical outcomes may better reflect clinical benefit, claims-based outcomes are more practical."
The survey notes that lack of consensus on which metrics of value are meaning measures of clinical benefit is one of the barriers to value-based care.
The changes aim to provide consistent access to medically-necessary care while reducing delays for beneficiaries.
Prior authorization policies in CMS' Medicare Advantage (MA) final rule have garnered widespread support from medical and payer groups for streamlining the administrative process.
As part of the rule, prior authorization approvals are required to remain valid for as long as medically necessary, while denials of coverage based on medical necessity must be reviewed by healthcare professionals with relevant expertise before a denial can be issued. MA plans are also required to annually review utilization management policies.
Additionally, the rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary, according to the fact sheet released by CMS. Coordinated care plans must also provide a minimum 90-day transition period when an enrollee underdoing treatment switches to a new MA plan, during which the new MA plan cannot require prior authorization for the active course of treatment.
Here’s how groups reacted to the prior authorization changes in the rule:
American Hospital Association (AHA)
"Hospitals and health systems have raised the alarm that beneficiaries enrolled in some Medicare Advantage plans are routinely experiencing inappropriate delays and denials for coverage of medically necessary care," said Ashley Thompson, AHA senior vice president of public policy analysis and development. "This rule will go a long way in protecting patients and ensuring timely access to care, as well as reducing inappropriate administrative burden on an already strained health care workforce."
American Medical Association (AMA)
"The AMA applauds CMS Administrator Brooks-LaSure for leading the effort to include provisions in this final rule that will ensure greater continuity of care, improve the clinical validity of coverage criteria, increase transparency of health plans' prior authorization processes, and reduce care disruptions due to prior authorization requirements," said Jack Resneck Jr., AMA president. "The AMA has long advocated for such meaningful prior authorization reforms and Medicare Advantage enrollees will benefit from the important new protections."
Medical Group Management Association (MGMA)
"MGMA supports today's action by CMS to finalize its proposals to reign in detrimental prior authorization practices, thereby strengthening the Medicare Advantage (MA) program," said Anders Gilberg, MGMA senior vice president of government affairs. "We are thankful that the agency heeded our call to finalize the continuity of care provision, limiting dangerous disruptions and delays to necessary patient care."
Better Medicare Alliance
"CMS' final policy rule for 2024 will support Medicare Advantage's efforts in bridging the health equity gap and providing high-quality care," said Mary Beth Donahue, president and CEO of Better Medicare Alliance. "Further, we support provisions to streamline the prior authorization process to ensure timely access to care as well as steps to ensure transparency and accountability within Medicare Advantage."
The legislation aims to reduce overpayments to Medicare Advantage (MA) plans.
A pair of U.S. Senators have put forth a bill to oppose upcoding in MA by eliminating incentives for plans to overcharge.
The No Unreasonable Payments, Coding, or Diagnoses for the Elderly Act, or No UPCODE Act, has been introduced by senators Bill Cassidy (R-La.) and Sen. Jeff Merkley (D-Ore.) in the midst of MA plans taking heat for receiving billions of dollars in overpayments.
CMS has released its Medicare Advantage Risk Adjustment Data Validation final rule to claw back those overpayments, but the rule will only apply to audit findings beginning with the payment year 2018.
"Federal audits have found that taxpayers have been overpaying bad actors running Medicare Advantage plans by billions of dollars every year, threatening the stability of both Medicare Advantage and traditional Medicare," Merkley said in a statement. "This fraud has to end."
The No UPCODE Act strives to fight that fraud by:
Switching to a risk-adjustment model that uses two years of diagnostic data instead of just one.
Restricting the use of old or unrelated medical conditions to determine cost of care.
Ensuring Medicare is only charged for relevant treatment.
Closing the gap between how patients are assessed under MA and traditional Medicare.
With MA growing at record rates, it's vital MA plans are kept in check so beneficiaries and taxpayers aren't negatively affected.
"Medicare is going insolvent in four years," Cassidy said. "The challenge is preserving that which is good while squeezing out waste. This bill is a step in that direction."