/ en Mon, 28 Apr 2025 04:08:46 -0500 Mon, 09 Sep 24 16:01:09 -0500 /news/headline/2024-09-09-agencies-release-final-rule-requiring-mental-health-coverage-parity <p>The departments of Labor, Health and Human Services and the Treasury Sept. 9 released a <a href="https://www.dol.gov/sites/dolgov/files/ebsa/temporary-postings/requirements-related-to-mhpaea-final-rules.pdf">final rule</a> ensuring commercial health plans comply with the Mental Health Parity and Addiction Equity Act of 2008 and require mental health and substance use disorder benefits at the same level as medical and surgical benefits. The rule finalizes standards for determining network composition and out-of-network reimbursement rates; adds protections against more restrictive, Non-Quantitative Treatment Limitations in coverage; and prohibits plans from using biased or non-objective information and sources that may negatively impact access to MH/SUD care when designing and applying an NQTL.</p><p>“The AHA is pleased that the Biden-Harris Administration has taken decisive action to remove barriers to vital mental health and substance use disorder services,” said Ashley Thompson, AHA senior vice president of public policy. “We are pleased the Administration is providing clear guidance on how health plans may and may not apply administrative restrictions to behavioral health services. Thus, patients are more likely to get the care they need and to which they are entitled under the law, and providers can spend less time on burdensome and unnecessary paperwork. We recognize the challenges that exist to establish networks of behavioral health providers considering the dire shortages but encourage the Administration to work with AHA and other stakeholders to alleviate those challenges without compromising on the goals of parity and access.” </p> Mon, 09 Sep 2024 16:01:09 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) /lettercomment/2023-11-06-aha-comments-better-mental-health-care-lower-cost-drugs-and-extenders-act <p>November 6, 2023</p> <table border="0" cellpadding="1" cellspacing="1"> <tbody> <tr> <td>The Honorable Ron Wyden <br /> Chairman<br /> Committee on Finance<br /> United States Senate<br /> 219 Dirksen Senate Office Building<br /> Washington, DC 20510</td> <td>The Honorable Mike Crapo <br /> Ranking Member<br /> Committee on Finance<br /> United States Senate<br /> 219 Dirksen Senate Office Building<br /> Washington, DC 20510</td> </tr> </tbody> </table> <p>Dear Chairman Wyden and Ranking Member Crapo:</p> <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act.</p> <p>The bill reflects the thoughtful, bipartisan work of the Committee over the past year to address numerous issues of importance to the hospital field. The AHA is pleased to support several provisions in the bill to improve access to behavioral health care and delay Medicaid disproportionate share hospital (DSH) reductions. Our comments on specific sections of the bill follow.</p> <h2>Section 104. Medicare incentives for behavioral health integration with primary care.</h2> <p>The integration of behavioral health services into team-based care models is proven to improve patient outcomes for both mental and physical ailments. Although payment systems for these models have existed for some time, their uptake has been limited due to a lack of clarity in their application and continued low reimbursement for all behavioral health services. The AHA supports the committee’s efforts to encourage providers to offer integrated behavioral health care by increasing payment rates for specific codes representing these services in a non-budget neutral manner. We also support the extension of technical assistance in applying the codes and offer to be of assistance in this endeavor.</p> <h2>Section 107. Ensuring timely communication regarding telehealth and interstate licensure requirements.</h2> <p>A key tool for supporting and expanding the behavioral health workforce is revising policies that make it harder for existing providers to treat patients. Reducing barriers to licensure can help maximize provider capacity, particularly in areas that are experiencing shortages. The AHA supports efforts to ensure that licensure processes are streamlined for providers employed by hospitals and health systems operating across state lines, and we urge Congress to fund additional research on the feasibility, infrastructure, cost and secondary effects of licensure requirements.</p> <h2>Section 301. Delaying certain disproportionate share hospital payment reductions under the Medicaid program.</h2> <p>The AHA supports this provision to delay for two years the Medicaid DSH reductions. Congress established the Medicaid DSH program to provide financial assistance to hospitals serving a disproportionate number of low-income patients to ensure Medicaid and uninsured patients have access to health care services. These hospitals also provide critical community services, such as trauma and burn care, maternal and child health care, high-risk neonatal care and disaster preparedness resources. The patients they serve are among those who need care the most and who often experience challenges accessing it, including children, individuals with lower incomes, people with disabilities and older Americans.</p> <p>Reductions to the Medicaid DSH program were enacted as part of the Affordable Care Act, with the reasoning that hospitals would have less uncompensated care as health insurance coverage increased. Unfortunately, the projected coverage levels have not been realized, and hospitals continue to care for patients for whom they are not receiving adequate payment. Consequently, the need for Medicaid DSH payments is still vital for the hospitals that rely on the program.</p> <h2>Section 302. Extension of State option to provide medical assistance for certain individuals who are patients in certain institutions for mental diseases.</h2> <p>Arbitrary and outdated payment policies continue to reflect the undervaluing of behavioral health services. Since 1965, the institutions for mental diseases (IMD) exclusion has prohibited federal payments to states for services for adult Medicaid beneficiaries between the ages of 21 and 64 who are treated in facilities that have more than 16 beds and provide inpatient or residential behavioral health — substance use disorder (SUD) and mental illness — treatment. The discriminatory IMD policy was established at a time when SUDs were not considered medical conditions on the same level as physical health conditions. The AHA supports this provision, which would ease this prohibition by permanently granting state Medicaid programs the option to receive federal matching payments for SUD treatment provided in certain IMDs. Medicaid waivers initially enacted as part of the 2018 SUPPORT Act have allowed our member hospitals to provide behavioral health care through IMDs as well as other parts of the care continuum, and we have heard from these hospitals how impactful this flexibility has been — in many cases reducing the need for long-term hospitalizations.</p> <h2>Section 403. Extension of the work geographic index floor under the Medicare program.</h2> <p>The AHA supports this provision to extend the physician payment work GPCI floor for calendar year 2024. This one-year extension will be helpful for physicians, particularly those in rural hospitals.</p> <h2>Section 404. Extending incentive payments for participation in eligible alternative payment models.</h2> <p>The AHA supports extending the Advanced APM incentive payment for calendar year 2026 period for qualifying APM participants. However, we would prefer that the committee extend the payment amount to the original 5% level instead of the 1.75% payment amount for 2026 that is included in the bill.</p> <h2>Section 407. Increase in support for physicians and other professionals in adjusting to Medicare payment changes.</h2> <p>The AHA supports this section and the committee’s efforts to further mitigate scheduled physician payment cuts by changing the conversion factor increase adjustment from 1.25% to 2.5% for 2024. As CMS charges ahead with a 3.34% decrease to the conversion factor in the 2024 Medicare Physician Fee Schedule rule, it is imperative that physicians in our hospitals and health systems are given all the funding and tools necessary so that patients’ access to care is not negatively impacted.</p> <h2>Section 408. Revised phase-in of Medicare clinical laboratory test payment changes.</h2> <p>The AHA supports this provision, which would delay harmful cuts to the Clinical Laboratory Fee Schedule, as well as the next round of reporting of private payer rates, which are both scheduled to take effect on Jan. 1, 2024 under the Protecting Access to Medicare Act. Without congressional action, hospital laboratories would face cuts as large as 15% on some of the most common tests, reducing access to clinical laboratory services.</p> <h2>Conclusion</h2> <p>Thank you for considering the AHA’s comments on this bill. We look forward to working with the Committee to address these important issues on behalf of the patients and communities we serve.</p> <p>Sincerely,</p> <p>/s/</p> <p>Stacey Hughes<br /> Executive Vice President</p> <p>cc: Members of the Committee on Finance</p> Mon, 06 Nov 2023 14:05:43 -0600 Mental Health Parity and Addiction Equity Act (MHPAEA) /lettercomment/2023-10-13-aha-letter-responding-agencies-mental-health-parity-and-addiction-equity-act-proposed-rule <p>October 13, 2023</p> <p>Lisa M. Gomez<br /> Assistant Secretary for Employee Benefits<br /> Office of Health Plan Standards and Compliance Assistance<br /> Employee Benefits Security Administration<br /> U.S. Department of Labor<br /> 200 Constitution Avenue, NW, Room N-5653<br /> Washington, DC 20210</p> <p>Attention: 1210-AC11</p> <p>Dear Assistant Secretary Gomez:</p> <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to provide comment on the proposed rule regarding Requirements Related to the Mental Health Parity and Addiction Equity Act (MHPAEA) issued by the Department of the Treasury, Department of Labor, and the Department of Health and Human Services (“the departments”).</p> <p><strong>The AHA applauds the Administration for proposing these clear and specific provisions to improve oversight and enforcement of MHPAEA.</strong> While the law has stood in place since 2008, its enforcement has been challenged by the difficulty in defining and identifying instances of noncompliance in coverage of mental health and substance use disorder (SUD) services as well as the efforts of some health plan issuers to avoid covering this vital and lifesaving care. We appreciate the efforts of the joint departments over the past few years to establish distinct guidelines for what health plan issuers may and may not do in terms of designing and administering benefits and believe that the provisions proposed in this rule will further close coverage loopholes and help ensure that patients can access the care they need.</p> <p>We agree with the departments that the next wave of enforcement of MHPAEA must focus on network adequacy, which is the inclusion of sufficient numbers and types of behavioral health providers to meet the needs of beneficiaries enrolled in the plan in a reasonable amount of time. While many health plan issuers construct narrow networks of clinicians to negotiate lower prices, there is also a significant shortage of behavioral health clinicians in the nation. As of March 31, 2023, the Health Resources and Services Administration (HRSA) designated more than 6,635 health professional shortage areas for mental health, with more than one-third of Americans living in these areas.<sup>1</sup> Although HRSA projects shortages of health professionals in other disciplines as well, those of behavioral health are especially dire — likely due to high turnover rates placing enormous demands on the workforce. Research indicates that the behavioral health workforce in particular experiences high levels of work-related stress and full caseloads coupled with low payments relative to comparable professionals. No doubt these insufficient reimbursements are in part driven by unfavorable contracting strategies that offer unfairly low rates and routine payment denials by some plans. The provisions proposed in this rule are likely to help address some of the underlying causes of behavioral health professional shortages, but <strong>we also urge the Administration to work with Congress to invest in the behavioral health workforce in tandem with provisions related to network adequacy in this rule.</strong></p> <h2>Design and Application of Non-quantitative Treatment Limitations (NQTLs)</h2> <p>Insurance issuers continue to flout the requirements of MHPAEA by pointing to the difficulty of identifying uneven application of NQTLs between behavioral health and medical/surgical benefits. These barriers to coverage are not obvious instances of non-compliance; for example, a plan would clearly violate the parity law if it offered behavioral health services but only covered them at 50% cost-sharing as a policy while covering other medical and surgical benefits at 80% cost-sharing. NQTLs, on the other hand, involve restraints on coverage based on qualitative characteristics of the services — like requiring demonstrable improvement in the treated diagnosis as a condition of continued coverage, which is more difficult to discern for many behavioral health disorders than for physical ailments — or administrative barriers that are more stringent or applied more frequently to behavioral health services — like requiring blanket precertification of all outpatient behavioral health services but for only select medical or surgical procedures.</p> <p>Historically, these parameters have been challenging to identify without comprehensive plan information (that is, a direct comparison between how a behavioral health service is covered and how a comparable medical/surgical service is covered). Providers and patients are often unaware that behavioral health benefits are held to different qualitative standards than those for medical and surgical services because these NQTLs are not enumerated in benefits information.</p> <p>To shine a light on these practices, the Consolidated Appropriations Act of 2021 amended MHPAEA to require plans and issuers to provide comparative analyses of their NQTLs upon request. In its 2022 report to Congress on the first year of enforcement of this provision, the joint departments found that not a single plan provided sufficient information in their comparative analyses. In its 2023 report to Congress released contemporaneously with this proposed rule, the departments found that many comparative analyses remained deficient, even after multiple insufficiency letters; they also issued numerous initial and final determinations of non-compliance with MHPAEA.</p> <p>Plans and issuers have had ample time to build the internal structures necessary to analyze their benefits to ensure compliance with MHPAEA. While plans once were able to claim the definition of compliance with NQTLs was too nebulous to understand or apply to their benefit designs, the provisions regarding precisely what must be included in a comparative analysis as proposed in this rule will provide clarity about the appropriate application of these coverage limits.</p> <p>One criterion to determine compliance with MHPAEA is that the NQTL is no more restrictive when it is applied to mental health and SUD benefits than it is when applied to medical/surgical benefits. The proposed rule provides an explanation of how to determine compliance with these requirements; in essence, plans and issuers would be required to follow similar steps to those used when analyzing parity with respect to quantitative (or financial) treatment limitations. <strong>We support this approach and appreciate the clear example provided in the rule that demonstrates each of the steps in the analysis.</strong></p> <p>Another criterion of determining compliance with the law is that the plan or issuer must satisfy a requirement related to how the NQTL is designed and used. As proposed, this would include a prohibition on plans relying upon any factor or evidentiary standard that discriminates against mental health or SUD benefits as compared to medical/surgical benefits. Specifically, the departments cite the example of plans using their own historical data from a time when the coverage was not subject to the parity law; that is, a plan would not be permitted to calculate reimbursement rates for behavioral health services based on spending on those services in 2007, before MHPAEA was passed. <strong>We support this proposal and value the departments’ acknowledgment that many plans have relied upon factors that are discriminatory against behavioral health benefits and have benefited from historical inequities in rate structures that MHPAEA sought to prohibit.</strong></p> <h2>Network Composition</h2> <p>Parity does not only entail covering behavioral health services in the same way as medical and surgical benefits financially; plans also must ensure parity in terms of available services to ensure that consumers have access to needed care without unreasonable delay. This means that plans are obligated to deliver the benefits promised by providing access to enough in-network providers and services included under the terms of the contract. Plans and issuers have been able to meet network adequacy requirements on paper while failing to provide their beneficiaries meaningful access to care. For example, plans may establish standards for provider and facility admission to participate in a network or to continue to participate in a network that result in unfavorable reimbursement rates; in addition, they may use restrictive credentialing procedures that result in an inadequate number of certain categories of providers and facilities to provide services under the plan.</p> <p>One pervasive method employed by some plans involves the growing disparity between in-network reimbursement rates for mental health and SUD providers and those for medical/surgical providers, as well as a significant disparity between how often beneficiaries are forced to utilize out-of-network mental health and SUD providers and facilities as compared to medical/surgical providers and facilities. Therefore, the departments propose that a plan would be considered noncompliant if relevant outcomes data (such as beneficiary utilization) shows material differences in access to in-network mental health or SUD benefits as compared to in-network medical/surgical benefits in a classification as a result of the design or application of one or more NQTLs related to network composition standards. In other words, the rule proposes to treat network composition as an NQTL<strong> for the purposes of the regulation as opposed to merely an outcome of other NQTLs. We support this approach and have encouraged Congress and the Administration in the past to use quantitative information on beneficiary utilization to determine appropriate network composition standards.</strong></p> <p>We acknowledge that developing a robust, highly specialized network of providers is a daunting task considering the severe shortages of behavioral health providers across the country; however, these shortages and gaps in coverage will persist without further action. Further, in the rule, the departments note that if despite taking appropriate action the relevant data continues to reveal material differences in access — that is, the plan is unable to improve network composition because of provider shortages, as opposed to plan business or operational decisions — then the plans would not be cited for noncompliance as long as they are able to document the actions they have taken to attempt to address the differences in access. <strong>We agree with this approach and appreciate that the departments will allow for good-faith efforts to meet network adequacy standards in the face of ongoing provider shortages.</strong></p> <h2>Impact Analyses</h2> <p>The departments propose that a plan or issuer would be required to collect, evaluate and consider the impact of relevant data on access to mental health and SUD benefits relative to access to medical/surgical benefits and subsequently take reasonable action as necessary to address any material differences in access. <strong>The AHA supports this proposal</strong>; it aligns with the November 2021 report from the Office of the Assistant Secretary for Planning and Evaluation (ASPE)’s Office of Behavioral Health, Disability and Aging Policy, which suggested using data on enrollee characteristics — such as information gleaned from claims on utilization and diagnostic patterns as well as qualitative information similar to that found on hospital community health needs assessments — to determine, generally, how, when, where and with whom enrollees seek care. In the rule, the departments cite examples of relevant data including data related to NQTLs as required by state law or private accreditation standards as sources of information to determine access to care.</p> <p>We suggest that, in addition to retrospectively evaluating whether aspects of care episodes were covered, this process could also identify general gaps in access to inform more adequate network and benefit design. For example, the aforementioned ASPE report suggested a comparison of utilization of covered behavioral health services with emergency department visits for behavioral health crises, use of crisis services and jail volumes as indicators of insufficient access to routine behavioral health care.</p> <p>In addition to collecting and analyzing relevant data related to access and network composition (including in- and out-of-network utilization rates, time and distance to available appointments, and provider reimbursement rates), the departments also propose to require plans to document any action that has been or is being taken by the plan to mitigate any material differences in access to services between mental health/SUD and medical/surgical care. The disparity in access would only be considered a “strong indicator” that the plan or issuer is violating the law and would not alone result in a finding of noncompliance. <strong>We believe that this is a reasonable approach to identifying likely instances of noncompliance while allowing for instances where disparities in access are due to factors beyond the plan or issuer’s control, such as workforce shortages.</strong></p> <p>The departments solicit comments on other relevant data points that could be used in an impact analysis to determine material differences in access to care, such as the number and percentage of relevant claims denials. We encourage the departments to also consider the following relevant data:</p> <ul> <li>Variation in authorization request submission processes (including means —verbal, electronic, fax — as well as criteria, necessary documentation and involvement of third-party vendors);</li> <li>Application of prior authorization for services for which the clinical standards of care are well established;</li> <li>Variation in and plan modification of clinical guidelines used to determine medical necessity;</li> <li>Unreasonable requests for documentation;</li> <li>Turnaround time for approval of a request for prior authorization of a behavioral health service compared to a medical/surgical service including those submitted for expedited review;</li> <li>Time to appeal response and resolution for denied claims for behavioral health services compared to medical/surgical services;</li> <li>Variation in the appeal overturn rate between behavioral health denials and medical/surgical denials;</li> <li> Inappropriate delays in decisions, such as returning requests multiple times claiming insufficient information or not responding outside of traditional office hours; and</li> <li>Volume and nature of patient grievances against plans related to behavioral health services.</li> </ul> <p>For too long, benefit management techniques have created dangerous delays in care delivery; due to the nature of behavioral health care — that is, it is more time-based with less clear or quantitative ways to improve efficiency or definitively measure outcomes — these processes take a disproportionate toll on these services. We look forward to working with the Administration to help identify practices that restrict access to mental health and SUD care and continue improving access to these services as Congress intended under MHPAEA.</p> <h2>Parity Opt-out for Self-funded Non-federal Governmental Plans</h2> <p>Under the Health Insurance Portability and Accountability Act of 1996, sponsors of self-funded, non-federal governmental health plans may elect to exempt those plans from parity in the application of certain limits to mental health and SUD benefits (including requirements of MHPAEA). However, the Consolidated Appropriations Act of 2023 eliminated this opt-out. In this proposed rule, the Department of Health and Human Services proposes to amend regulations to implement this change as of the date of enactment of the Consolidated Appropriations Act. <strong>The AHA supports this proposal and the efforts to continue to close loopholes that have impeded progress towards broader compliance with MHPAEA.</strong></p> <p>Again, we thank you for your consideration of our comments. Please contact me if you have questions, or feel free to have a member of your team contact Caitlin Gillooley, AHA’s director of policy, at <a href="http://cgillooley@aha.org" target="_blank">cgillooley@aha.org</a> or (202) 626-2267.</p> <p>Sincerely,</p> <p>/s/</p> <p>Stacey Hughes<br /> Executive Vice President</p> Fri, 13 Oct 2023 14:39:03 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) /news/perspective/2023-08-04-strong-step-enhanced-mental-health-parity-regulations <p>For years, many commercial health insurers treated coverage for mental health or substance use disorders (SUD) very differently than for medical and surgical benefits.</p> <p>Congress’ passage of the Mental Health Parity and Addiction Equity Act of 2008 was intended to level the playing field by prohibiting burdensome prior authorization requirements and other management techniques that made mental health claims much more difficult to get approved and paid. But compliance with the 15-year-old law has not been uniform as some insurers found ways around its provisions.</p> <p>Last week, we were pleased that the Administration released a new <a href="https://www.federalregister.gov/documents/2023/08/03/2023-15945/requirements-related-to-the-mental-health-parity-and-addiction-equity-act" target="_blank">proposed rule</a> that would put some teeth back into the 2008 act by further clarifying what insurers may or may not do in terms of prior authorization, in-network coverage and payments.</p> <p>Improved compliance in these areas spells good news for patients. The proposed rule would:</p> <ul> <li>Crack down on certain administrative practices that continue to produce unequal coverage of mental health and SUD services;</li> <li>Set standards for determining network composition and out-of-network reimbursement rates; and</li> <li>Require plans to collect outcomes data and take action to address differences in access to mental health/SUD and medical/surgical services.</li> </ul> <p>The proposed rule also would end the ability of non-federal government plans to opt out of federal parity requirements; and it requests <a href="https://www.dol.gov/agencies/ebsa/employers-and-advisers/guidance/technical-releases/23-01" target="_blank">feedback</a> on proposed new data requirements related to a health plan’s network composition.</p> <p><strong>This decisive action to limit barriers to access vital mental health and SUD services means patients are more likely to get the care to which they are entitled under the law. It also means that providers can spend less time on burdensome and unnecessary insurance barriers and more time on patient care.</strong></p> <p>While improved monitoring of how commercial insurers treat coverage of mental health and SUD services is important, the proposed rule does not address the larger problem of dire shortages in the behavioral health clinical workforce. We urgently need more trained providers to meet demand, and strengthening the health care workforce remains a top priority for the AHA.</p> <p>Among other priorities in our Advocacy Agenda are:</p> <ul> <li>Addressing physician shortages, including shortages of behavioral health providers, by increasing the number of residency slots eligible for Medicare funding while rejecting cuts to Medicare graduate medical education;</li> <li>Increasing targeted funding for facilities that provide pediatric mental health services and investing in the pediatric behavioral health workforce; and</li> <li>Supporting workforce development programs to enhance recruitment, retention and advanced education for health care professionals.</li> </ul> <p>We’ll continue to lead efforts to strengthen the workforce and spotlight commercial insurance practices that limit or deny patient access to necessary care.</p> <p>Dr. Brock Chisholm, who was the first Director-General of the World Health Organization, famously stated that “without mental health there can be no true physical health.” This proposed rule is a welcome step in the right direction.</p> Fri, 04 Aug 2023 08:23:58 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) <div class="container"> <div class="row"> <div class="col-md-8"> <p>The departments of the Treasury, Labor and Health and Human Services July 25 issued a <a href="https://www.dol.gov/sites/dolgov/files/ebsa/temporary-postings/requirements-related-to-mhpaea-proposed-rules.pdf" target="_blank">proposed rule</a> related to the enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. The proposed rules would amend existing standards regarding the application of non-quantitative treatment limitations (NQTLs) to prevent insurance plans and issuers from placing greater limits on access to mental health and substance use disorder (SUD) benefits as compared to medical/surgical benefits. Comments on the rule are due 60 days after its official publication in the Federal Register.</p> <div class="panel module-typeC"> <div class="panel-heading"> <h3>Key Highlights</h3> <p>The proposed rule would:</p> <ul> <li>Provide more specific examples of what plans and issuers may not do regarding prior authorization and medical management techniques for mental health and SUD benefits</li> <li>Set standards for network composition of mental health and SUD providers</li> <li>Provide factors to determine out-of-network reimbursement rates for mental health and SUD services</li> <li>Require plans to collect and evaluate outcomes data and take action to address disparities in access between mental health/SUD services and medical/surgical services</li> <li>Codify standards for comparative analyses of the use of NQTLs</li> <li>Sunset the ability of self-funded, non-federal government plans to opt-out of providing mental health/SUD benefits at parity</li> </ul> </div> </div> <h2>AHA TAKE</h2> <p>The AHA is pleased that the Administration is proposing clear and decisive action to limit barriers to access vital mental health and SUD services. By providing clear guidance on how health plans may and may not apply administrative restrictions to behavioral health services, patients are more likely to get the care to which they are entitled to under the law, and providers can spend less time on burdensome and unnecessary insurance barriers and more time on patient care. We recognize the challenges to building robust networks of behavioral health providers considering the dire shortages in the behavioral health clinical workforce and hope that the Administration and others can work to alleviate those challenges in tandem with its ongoing enforcement of the Parity Law.</p> <h2>BACKGROUND</h2> <p>Despite the passage of MHPAEA 15 years ago, plan participants continue to face barriers to accessing care for mental health and SUDs; many of these barriers are due to group health plans and health insurance issuers offering group or individual health insurance coverage that is not operating in compliance with the law. The departments of the Treasury, Labor and Health and Human Services have conducted investigations — both independently and because of complaints — that have demonstrated that nearly all plans or issuers audited for MHPAEA compliance could not demonstrate compliance with the law’s obligations, specifically with the prohibition of setting NQTLs discriminatorily on benefits for mental health/SUD services. NQTLs are generally nonnumerical requirements that limit the scope or duration of benefits, such as prior authorization requirements, step therapy and standards for provider admission to participate in a network, including methodologies for determining reimbursement rates.</p> <p>In their 2022 MHPAEA Report to Congress, the departments found that plans were unable to comply with requirements to provide comparative analyses of their application of NQTLs as directed by the Consolidated Appropriations Act of 2021. In their 2023 MHPAEA <a href="https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/report-to-congress-2023-mhpaea-comparative-analysis.pdf" target="_blank">Report to Congress</a>, released contemporaneously with these proposed rules, the departments found once again that nearly all of the comparative analyses reviewed contained insufficient information, lacking specific supporting evidence, detailed explanations, or sufficient detail to draw meaningful comparisons. These failures occurred despite a large volume of guidance documents and other resources provided by the departments to plans to assist them with their statutory duties. In the last two years, the departments have made oversight and enforcement of MHPAE a top priority.</p> <p>The proposed rules would amend certain provisions of existing MHPAEA regulations to incorporate new and revised definitions of key terms, as well as to specify additional steps that plans and issuers must take to meet their obligations under MHPAEA. The rules would also add a new regulation establishing minimum standards for developing NQTL comparative analyses to demonstrate compliance with the law, as well as content elements of the analyses and the timeframe for plans and issuers to respond to a request from the departments to submit them. If finalized, the rules would apply on the first day of the first plan year beginning on or after Jan. 1, 2025.</p> <h2>SUMMARY OF PROPOSED PROVISIONS</h2> <p>The departments are proposing changes that would add requirements for plans and issuers that apply NQTLs to prevent the imposition of a greater burden on beneficiaries accessing mental health and SUD benefits while preserving plans ability to impose NQTLs to the extent they are consistent with generally recognized independent professional medical or clinical standards or standards related to fraud, waste and abuse. Specifically, plans and issuers would not be permitted to impose an NQTL unless specific conditions, elaborated upon below, are met.</p> <p><strong>“No More Restrictive” Requirement.</strong> One criterion to determine compliance is that the NQTL is no more restrictive as applied to mental health and SUD benefits than it is when applied to medical/surgical benefits. The proposed rules provide an explanation of how to determine compliance with these requirements. In essence, plans and issuers would be required to follow similar steps to those that apply when analyzing parity with respect to quantitative (or financial) treatment limitations. The departments also provide an example showing each of the steps in the analysis.</p> <p><strong>Design and Application.</strong> Another criterion of determining compliance is that the plan or issuer satisfies requirements related to the design and application of the NQTL. This includes a prohibition on plans relying upon any factor or evidentiary standard that discriminates against mental health or SUD benefits as compared to medical/surgical benefits (such as historical plan data from a time when the coverage was not subject to MHPAEA).</p> <p><strong>Impact Analysis. </strong>The plan or issuer would also be required to collect, evaluate and consider the impact of relevant data on access to mental health and SUD benefits relative to access to medical/surgical benefits and subsequently take reasonable action as necessary to address any material differences in access. Relevant data includes — but is not limited to — the number and percentage of relevant claims denials as well as any other data related to the NQTLs as required by state law or private accreditation standards.</p> <p>In addition, the departments propose to require plans and issuers to collect and evaluate data specifically related to network composition, including in-network and outof-network utilization rates (including data related to provider claim submissions), network adequacy metrics (including time and distance data and data on providers accepting new patients) and provider reimbursement rates (including as compared to billed charges). The plan would also be required to document any such action that has been or is being taken by the plan to mitigate any material differences in access to services between mental health/SUD and medical/surgical services. This provision would allow plans to explain why these differences should not result in a violation of the rules for NQTLs.</p> <p><strong>Network Composition.</strong> Some NQTLs involve standards for provider and facility admission to participate in a network or for continued network participation, including methods for determining reimbursement rates, credentialing standards and procedures for ensuring the network includes an adequate number of each category of provider and facility to provide services under the plan. The departments explain that there is a growing disparity between in-network reimbursement rates for mental health/SUD providers and those for medical/surgical providers as well as a significant disparity between how often beneficiaries are forced to utilize out-of-network mental health/SUD providers and facilities as compared to medical/surgical providers and facilities.</p> <p>Therefore, the departments propose that, if the relevant outcomes data described above show material differences in access to in-network mental health or SUD benefits as compared to in-network medical/surgical benefits in a classification as a result of the design or application of one or more NQTLs related to network composition standards, the plan would be considered noncompliant. In other words, the departments propose to treat network composition as an NQTL for the purposes of the regulation, as opposed to merely an outcome of other NQTLs.</p> <p>The departments note that they recognize that shortages of mental health and SUD providers could make this a challenge, and thus if despite taking appropriate action, the relevant data continues to reveal material differences in access (that is, the plan cannot improve network composition because of provider shortages and not due to plan business or operational decisions), the departments would not cite the plan for noncompliance. Plans would have to be prepared to document the actions they have taken to attempt to address differences in access.</p> <p><strong>Examples.</strong> The proposed rule would revise some existing examples, remove other existing examples and add several new examples to demonstrate how to interpret both existing provisions and those added or amended in these rules. Examples would show how an NQTL would be analyzed under these provisions and instances in which a plan would be determined to be in violation of one or more provisions.</p> <p><strong>Content of Comparative Analyses.</strong> The departments propose specific information and data that plans and issuers would be required to incorporate in each comparative analysis of the application of an NQTL as well as the factors and evidentiary standards used to design or apply it. Specifically, a comparative analysis would have to include, at a minimum, with respect to each NQTL on mental health or SUD benefits, six elements:</p> <ol> <li>A description of the NQTL;</li> <li>The identification of the factors used to design or apply it;</li> <li>A description of how factors are used in the design or application of it;</li> <li>A demonstration of comparability of the NQTL and stringency with which it is applied between mental health/SUD benefits and medical/surgical benefits, as written;</li> <li>A demonstration of comparability and stringency in operation; and</li> <li>Findings and conclusions.</li> </ol> <p>The departments propose that the analyses would have to include the date of the analysis, the title and credentials of all persons who participated in the documentation, and a certification by one or more named fiduciaries who have reviewed it. The proposed rules also set forth details with respect to when and how plans would be required to make those comparative analyses available upon request, either to the departments or to a beneficiary.</p> <p><strong>Regulatory Text.</strong> The departments propose to add and revise several sections and terms in existing regulations. Proposed provisions include:</p> <ul> <li>Adding a new purpose section to the implementing regulations specifying the underlying intent of MHPAEA and requirements for plans and issuers regarding the law.</li> <li>Amend the definitions of medical/surgical benefits and mental health and SUD benefits to more clearly delineate these categories for the purpose of complying with MHPAEA and to ensure that the use of state laws does not prevent the application of MHPAEA’s protections with respect to conditions that are recognized as mental health conditions and SUDs under generally recognized independent standards of current medical practice.</li> <li>Add several new definitions related to the application of NQTLs to provide clarity to plans and issuers, regulators and beneficiaries with regard to compliance — terms with new definitions include “processes,” “strategies,” “evidentiary standards” and “factors.”</li> </ul> <h2>PARITY OPT-OUT FOR SELF-FUNDED NON-FEDERAL GOVERNMENTAL PLANS</h2> <p>Under the Health Insurance Portability and Accountability Act of 1996, sponsors of selffunded, non-federal governmental health plans may elect to exempt those plans from parity in the application of certain limits to mental health and SUD benefits (including requirements of MHPAEA). However, the Consolidated Appropriations Act of 2023 eliminated this opt-out.</p> <p>In this proposed rule, the Department of Health and Human Services proposes to amend regulations to specify that a sponsor of a self-funded, non-federal governmental plan may not elect to exempt its plan(s) from any of the MHPAEA requirements on or after Dec.29, 2022 (the date of enactment of the Consolidated Appropriations Act).</p> <h2>REQUEST FOR INFORMATION</h2> <p>In addition to the various proposed provisions, the departments also seek feedback on ways to improve mental health and SUD benefits through other consumer protection laws, including the Affordable Care Act. Specific areas for comment include provider directory requirements, the application of parity requirements to telehealth services and the behavioral health crisis services landscape.</p> <h2>FURTHER QUESTIONS</h2> <p>Please contact Caitlin Gillooley, AHA’s director of behavioral health and quality policy, at <a href="mailto:mailto:cgillooley@aha.org" target="_blank">cgillooley@aha.org</a> or (202) 626-2267 with any questions.</p> <p>__________</p> </div> <div class="col-md-4"><a href="/system/files/media/file/2023/07/2023-07-26_SB_EBSA-Parity-Rule-final.pdf" target="_blank"><img alt="Cover Administration Proposes Enhanced Mental Health Parity Regulations" data-entity-type="file" data-entity-uuid="9551377b-9ad6-46b8-a4c6-d74b178e8a7d" src="/sites/default/files/inline-images/cover-cms-issues-updated-guidance-on-ligature-risk-and-assessment-in-hospitals-bulletin-7-18-2023.png" width="510" height="659"></a></div> </div> </div> Wed, 26 Jul 2023 11:54:17 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) /lettercomment/2023-01-30-aha-comments-cms-request-information-essential-health-benefits-ehb <p>January 30, 2023</p> <p>The Honorable Chiquita Brooks-LaSure<br /> Administrator Centers for Medicare & Medicaid Services<br /> Hubert H. Humphrey Building<br /> 200 Independence Avenue, S.W., Room 445-G<br /> Washington, DC 20201</p> <p><em><strong>RE: Request for Information; Essential Health Benefits (CMS-9898-NC)</strong></em></p> <p>Dear Administrator Brooks-LaSure:</p> <p>On behalf of the ���������� Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 90 that offer health plans, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, we thank you for the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) request for information on Essential Health Benefits (EHB) under the Patient Protection and Affordable Care Act (ACA).</p> <p>Patients must be able to rely on their health care coverage to facilitate access to needed care. As such, the ACA required that qualified health plans (QHPs) sold on the Health Insurance Marketplaces (Marketplaces) and certain other health plans offer their enrollees sufficient access to a comprehensive set of services and providers. In addition, these plans’ benefit structure — the services they cover and at what cost-sharing — must not discriminate against enrollees based on age, health conditions or sociodemographic factors. The ACA codified these requirements under the EHB and network adequacy provisions.</p> <p>Since the ACA’s inception, AHA has supported the intent of the EHB requirements and subsequent efforts to strengthen them. We commend CMS for seeking stakeholder input on potential modifications to these requirements, and we specifically focus our comments on the following issues: behavioral health; maternity, infant and pediatric care; health equity and access; and health plan policies that may restrict patient access to EHBs. While we do not provide detailed comments on prescription drug access, we recognize that such benefits are vital for patients. As CMS considers potential changes to the current EHB drug classification system, we urge the agency to ensure that any updates to the current drug classification system, including adoption of USP Drug Classification (USP DC), revolve around a transparent and comprehensive process that is focused on the best interest of patients.</p> <h2>BEHAVIORAL HEALTH</h2> <p>Behavioral health services are generally one of the areas of care that patients struggle most to access. While there are multiple causes, including a dearth in the supply of providers, coverage rules certainly play an important role. While plans subject to the EHB requirements must cover mental health and substance use disorder services, specific benefits vary by state and plan. This variation presents a particular challenge to individuals seeking coverage because covered mental health and substance use disorder services are generally listed on plan benefit summaries only as “outpatient” or “inpatient” with little further specificity. Certain plans may explicitly limit or include exceptions for services such as partial hospitalization, group therapy or intensive outpatient treatment; others may not. Some plans may apply prior authorization for certain services; others may not. Not all plans are clear about cost-sharing requirements, with some benefit summaries merely listing “additional charges may apply” for inpatient or outpatient services. There are no filters in the health plan search tools to account for these differences.</p> <p>The lack of specificity in coverage allowances not only makes it difficult to discern whether certain services are covered, it makes it difficult to determine if they are adequately covered. A particularly striking example is emergency behavioral health services, including mobile crisis care and stabilization services. The availability and reliability of crisis stabilization services vary widely by jurisdiction, challenging patients’ ability to determine what services are actually available to them through the various coverage options sold in their communities.</p> <p>AHA recommends CMS improve the specificity of what mental and behavioral health services are included in the EHBs and explicitly list services of most interest to patients: individual psychotherapy, group therapy, partial hospitalization services, intensive outpatient services, crisis transport and stabilization services, and peer support and recovery. Plans should include this list of covered services as they do prescription drugs in their plan benefit summaries. For reference, plans could review the list of HCPCS H-codes representing a standardized set of behavioral health services. In addition, plans should be required to identify when a service is subject to a utilization management requirement, such as prior authorization.</p> <h2>MATERNITY, INFANT AND PEDIATRIC CARE</h2> <p>Improving the health of mothers and children is a top priority for the AHA and our member hospitals and health systems. Eliminating maternal mortality, reducing severe morbidity and reducing disparities in care and outcomes for mothers and babies are of particular concern. <strong>As CMS and HHS look to update and improve the policies pertaining to EHBs for maternal and infant care, the AHA recommends that maternal and infant benefits cover services provided by non-physician clinicians and other non-clinical practitioners in maternal and postpartum care for mothers and infants</strong>. Examples include non-physician clinicians such as midwives, nurse practitioners (NPs), and non-clinical practitioners such as doulas, to assist in maternal and postpartum care. Studies have shown that using doulas, for example, can improve outcomes for mothers and infants, especially for women at risk of adverse outcomes, including Black and Latina women. Doulas have demonstrated a reduction in labor time, a reduction of a mother’s anxiety, improvements in mother-baby bonding post-birth and improved breastfeeding success.<sup>1</sup></p> <p>In addition to expanded benefits to include non-physician clinicians and other practitioners, telehealth has proven essential in providing maternal care. During the COVID-19 pandemic, telehealth visits allowed supported care throughout the perinatal period, kept patients safe during their pregnancy, and allowed consultations with specialists when needed. Access to telehealth services was particularly beneficial for patients in both urban and rural areas with no or limited access to obstetric providers. Telehealth visits also allow in-home monitoring of the physical conditions of mothers and babies and monitoring of depression or other mental health conditions the mother could be facing. <strong>The AHA recommends that reimbursable telehealth visits be included in the EHBs for maternity and infant care</strong>.</p> <p>Regarding pediatric EHBs, such benefits must allow children and adolescents access to timely and age-appropriate care. Timely access is particularly the case for pediatric behavioral health providers, as discussed in the previous section on improvements to behavioral health essential benefits.</p> <h2>HEALTH EQUITY AND ACCESS</h2> <p>The agency asks for feedback on how EHB policy could advance health equity. The basic concept of EHB — that is, to provide a minimum set of health care items and services that QHPs must cover for all enrollees — is intrinsically linked to health equity. However, the full promise of EHB in advancing health equity can only be realized if enrollees are empowered to know and understand the specific ways their plans are implementing their benefits, as well as to ensure that plans are not placing inappropriate restrictions on EHBs. Limited English-language proficiency and low health insurance literacy can serve as major barriers to patients selecting the coverage that best meets their needs. As administrators of a public benefit, QHPs have a core responsibility to ensure their plans and benefit designs are easily accessible and understandable to all enrollees.</p> <p>We urge CMS to prioritize the development of policies and programs that ensure plans are delivering their services in linguistically and culturally appropriate ways, as well as on a non-discriminatory basis. For example, CMS has recently proposed several changes to the requirements for its Medicare Advantage plans that are intended to advance health equity; the agency could consider adopting similar requirements for plans on the Marketplaces. Among other policies, CMS could expand the list of populations to which plans must provide culturally appropriate services and ensure plans offer digital health education to access telehealth benefits.</p> <h2>BARRIERS TO ACCESSING COVERED SERVICES</h2> <p>Certain health plans are erecting unnecessary barriers to care that have direct negative impacts on patient health and the health care workforce. This includes improper use of utilization management programs, inappropriate denials of medically necessary covered services, overly restrictive medical necessity criteria that are not transparent to patients or providers, unnecessary and unreasonable documentation requirements, and mid-contract year changes to patients’ coverage (such as where patients may access certain services, like surgeries or diagnostics). The AHA is increasingly concerned these plan policies are inappropriately restricting or delaying patient access to EHBs, while adding cost and burden to the health care system. In short, such plan policies may have the effect of curtailing the benefits of the EHB requirements.</p> <p>Patients should be able to rely on their coverage to facilitate access to medically necessary health care services, especially EHBs, when they need them, without delays or inappropriate denials, and clinicians should be able to focus on caring for patients without burdensome obstacles. Hospitals and health systems report that prior authorization and other utilization management tolls are increasingly applied to a wide range of services, including those for which the treatment protocol is long-established and clear and there is no evidence of abuse. The resulting denials can cause delays in necessary treatment for patients and require doctors and nurses to go through onerous and duplicative appeal processes to rectify inappropriate coverage denials. Similarly, health plans also often force patients to suffer through periods of ineffective treatment before permitting access to the most appropriate therapy. Use of step therapy or fail-first policies is increasing, and the inappropriate application of these policies often puts quality of care at risk.</p> <p>Overall, there is mounting evidence that these problematic health plan practices are growing. Government agencies, as well as courts and arbitrators, have continued to uncover concerning findings with respect to certain commercial insurer conduct.<sup>2</sup> It is increasingly clear that some health plans are pursuing a strategy of denying appropriate care to avoid legitimate payment obligations, and greater oversight and accountability is needed to prevent unfair insurer practices and ensure appropriate patient access to EHBs and other covered health services.</p> <p>The AHA commends CMS for recent proposals<sup>3 </sup>that would streamline prior authorization rules in many forms of coverage. <strong>We urge the agency to ensure adequate oversight of health plans to address instances of inappropriate prior authorization and payment denials and ensure fair coverage of EHBs for patients and providers</strong>. This includes conducting routine oversight and evaluating plan-level performance metrics to ensure that patients have timely access to covered EHBs, that plans do not place excessive burdens on providers to comply with such utilization management techniques, and that critical health system resources are not squandered by costly administrative requirements that do not add value.</p> <p>We thank you for your consideration of our comments. Please contact me if you have questions or feel free to have a member of your team contact Molly Smith, AHA’s group vice president of public policy, at <a href="mailto:mailto:mollysmith@aha.org">mollysmith@aha.org</a> or 202-626-4639.</p> <p>Sincerely,</p> <p>/s/</p> <p>Ashley B. Thompson<br /> Senior Vice President<br /> Public Policy Analysis and Development<br /> __________</p> <p><small><sup>1</sup> “Impact of Doulas on Healthy Birth Outcomes,” accessed at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647727/" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647727/</a><br /> <sup>2<a href="https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp" target="_blank"> </a></sup><a href="https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp" target="_blank">https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp</a><br /> <a href="https://www.beckerspayer.com/payer/5m-fine-against-bcbs-largest-in-georgia-regulator-s-history.html" target="_blank">https://www.beckerspayer.com/payer/5m-fine-against-bcbs-largest-in-georgia-regulator-s-history.html</a><br /> <sup>3<a href="https://www.federalregister.gov/documents/2022/12/13/2022-26479/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability" target="_blank"> </a></sup><a href="https://www.federalregister.gov/documents/2022/12/13/2022-26479/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability" target="_blank">https://www.federalregister.gov/documents/2022/12/13/2022-26479/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability</a> and <a href="https://www.federalregister.gov/documents/2022/12/27/2022-26956/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program" target="_blank">https://www.federalregister.gov/documents/2022/12/27/2022-26956/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program</a></small></p> Mon, 30 Jan 2023 12:20:16 -0600 Mental Health Parity and Addiction Equity Act (MHPAEA) /guidesreports/2022-11-01-addressing-commercial-health-plan-challenges-ensure-fair-coverage-patients-and-providers <div class="container"> <div class="row"> <div class="col-md-8"> <h2><span>Table of Contents</span></h2> <ol> <li><a href="#executivesummary">Executive Summary</a></li> <li><a href="#introduction">Introduction</a></li> <li><a href="#prior">Prior Authorization</a></li> <li><a href="#reimbursement">Reimbursement Delays and Denials</a></li> <li><a href="#policy">Policy Solutions</a></li> <li><a href="#conclusion">Conclusion</a></li> <li><a href="#endnotes">Endnotes</a></li> </ol> </div> <div class="col-md-4"> <div><a class="btn btn-wide btn-primary" href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf" target="_blank" title="Click here to download the Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers PDF.">Download the PDF</a></div> <div><a class="btn btn-wide btn-primary" href="/system/files/media/file/2022/10/Survey-Commercial-Health-Insurance-Practices-that-Delay-Care-Increase-Costs.pdf" target="_blank" title="Click here to download the Survey: Commercial Health Insurance Practices that Delay Care, Increase Costs Infographic PDF.">Infographic with Survey Results</a></div> <div><a class="btn btn-wide btn-primary" href="/lettercomment/2022-11-01-letter-hhs-and-dol-addressing-commercial-health-plan-challenges-ensure-fair-coverage" target="_blank" title="Click here to view the AHA Letter to HHS and DOL Secretaries.">AHA Letter to HHS and DOL Secretaries</a></div> <div><a class="btn btn-wide btn-primary" href="/press-releases/2022-11-01-aha-survey-some-commercial-health-insurers-apply-policies-delay-patient-care-burden-clinicians-and" target="_blank" title="Click here to view the Press Release.">Press Release</a></div> <div><a class="btn btn-wide btn-primary" href="/special-bulletin/2022-11-02-aha-releases-new-resources-urging-oversight-challenges-certain-commercial-health-plan-practices" target="_blank" title="Click here to view the Special Bulletin.">Special Bulletin</a></div> </div> </div> <div class="row"> <div class="col-md-8"> <hr> <div class="row"> <div class="col-md-10"> <h2 id="executivesummary"><span>Executive Summary</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=3" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <p>Hospitals and health systems are committed to ensuring timely patient access to medically necessary health care services. Comprehensive health care coverage is a critical tool to help individuals and patients access and finance their care. This is why hospitals and health systems have long advocated for a robust system for universal coverage rooted in our long-standing public-private model that relies on a strong commercial health insurance market alongside the Medicare and Medicaid programs.</p> <p>However, while some health insurers provide value thorough collaboration with providers and their enrollees, many others are increasingly adopting policies and practices that contribute to delays in patient care and place undue burdens on both enrollees and health care providers. Many of these practices also add unnecessary costs to the health care system. In a recent survey of members, the AHA learned that <span><strong>78% of hospitals and health systems’ experience working with commercial insurers is getting worse, not better.</strong></span></p> <p>Patients should be able to rely on their health insurance plan to facilitate covered, medically necessary health care services when they need it without delays or inappropriate denials, and clinicians should be able to focus on caring without burdensome obstacles. This report explores why more oversight is needed to ensure appropriate patient access to care and reduce unnecessary cost and burden.</p> <h3><span>Report Highlights</span></h3> <p>Certain commercial insurers that serve the individual and group markets, as well as the Medicare Advantage and Medicaid managed care programs, are erecting unnecessary barriers to care that have a human cost. This includes improper use of utilization management programs, inappropriate denial of medically necessary covered services, overly restrictive medical necessity criteria that are not transparent to patients or providers, unnecessary and unreasonable documentation requirements, and mid-contract changes to patients’ coverage.</p> <p><span><strong>Some commercial insurer policies and practices appear designed to simply create barriers to appropriate payment. They also contribute to clinician burnout and significantly drive up administrative costs for the health care system.</strong></span> And much of this effort and cost is unnecessary. For example, among some insurers, most appealed prior authorization denials are ultimately overturned. Of course, this appeal process comes with significant cost.</p> <p><span><strong>There is mounting evidence that these practices are growing.</strong></span> Government agencies, as well as courts and arbitrators, have continued to uncover concerning findings with respect to certain commercial insurer conduct. It is increasingly clear that some insurers are pursuing a strategy of denying appropriate care to avoid legitimate payment obligations.</p> <p><span><strong>In addition to the financial and emotional stress placed on enrollees, inappropriate payment delays and denials for appropriate care have serious implications for the financial stability of health care providers and compound fiscal challenges plaguing our health care system.</strong></span> More than $6 billion in delayed or potentially unpaid claims over six months old was reported among the 772 surveyed hospitals alone.</p> <h3><span>Recommendations At-a-Glance</span></h3> <p>Actions are needed to ensure patients get the care they are entitled to, providers do not face unnecessary burdens, and the health care system is appropriately resourced, including:</p> <ul class="ulblue"> <li class="ulblue"><span><strong>Standardize prior authorization requirements and processes.</strong></span> This includes increasing transparency on services that require prior authorization, standardizing the format and process to transmit requests and responses, improving the timeliness of responses, requiring more detailed and complete denial notices, and streamlining appeals processes.</li> <li class="ulblue"><span><strong>Ensure necessary oversight to stop inappropriate prior authorization and payment delays and denials.</strong></span> This includes improving collection of key performance metrics, applying financial penalties for inappropriate delays and denials, and ensuring adequate provider networks.</li> </ul> <hr> <div class="row"> <div class="col-md-10"> <h2 id="introduction"><span>Introduction</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=4" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <p>Most Americans receive their health care coverage through commercial health insurance; yet in recent years, it has become apparent that certain commercial health plan practices restrict patient access to care and increase cost and burden to the health care system. The following report documents the ���������� Association’s (AHA) findings related specifically to prior authorization and payment delays and denials. This work is informed by two large surveys of hospitals, as well as interviews and group discussions with hundreds of hospital and health system leaders. AHA fielded these surveys in 2019 (more than 200 hospitals responding) and again between December 2021 and February 2022 (772 hospitals responding from 47 states).</p> <p>While some of these findings predate the COVID-19 public health emergency, the more recent data results reinforce that certian insurer practices have remained a persistent problem for health care providers and patients during and after a global public health crisis, and that action is needed to address these issues. <span><strong>In fact, our most recent survey found that 78% of hospitals and health systems reported that their experience working with commercial insurers is getting worse. Less than 1% said it was getting better.</strong></span></p> <p>The report concludes by offering policymakers solutions to reduce the risk and burden of these programs while still enabling health insurance plans to compete on quality, benefit package design, provider networks and other important aspects of coverage.</p> <h3><span>Background</span></h3> <p>Commercial health insurers are the dominant source of health care coverage for most Americans. Most employers, as well as the Medicare and Medicaid programs, rely on commercial insurers to provide or administer their health benefits. Nearly half of Medicare beneficiaries are enrolled in a private Medicare Advantage (MA) plan, and enrollment in MA plans is growing at a rate of nearly 10% per year. Nearly all states enroll some or all of their beneficiaries into Medicaid managed care plans.</p> <p>Patient access to the health care system is eroding as some commercial health plans restrict access to health care services by inappropriately denying covered services that are medically necessary, requiring unreasonable levels of documentation to demonstrate clinical appropriateness, and changing health plan rules in the middle of a contract year. For example, prior authorization — one of the most widely used utilization management tools — is designed to help patients obtain the right care in the right place. Its use is intended to ensure that providers order care that is consistent with clinical guidelines and protocols, as well as to confirm that such care is covered by the patient’s plan. However, some commercial health plans are applying prior authorization to a wide range of services, including those for which the treatment protocol has remained the same for decades and there is no evidence of abuse.</p> <p>Misuse of utilization management tools like prior authorization has several negative implications for patients and the health care system. Prior authorization denials can result in delays of necessary treatment for patients and ultimately lead to unexpected medical bills. The extensive approval process that doctors and nurses must go through adds wasted dollars to the health care system through overuse of prior authorization, inefficient submission processes, excessive requests for unnecessary documentation and the need to reprocess inappropriate payment and coverage denials. These practices also are a major burden to the health care workforce and contribute to clinician burnout.<sup><a href="#fniii">ii</a></sup> A May 2022 advisory issued by Surgeon General Vivek Murthy, M.D., notes that burdensome documentation and prior authorization requirements are key drivers of health care worker burnout, which exacerbate health care workforce shortages.<sup><a href="#fniii">iii</a></sup></p> <div class="row"> <div class="col-md-6"> <p>Further evidence of the negative impact of these practices is mounting. The Department of Health & Human Services Office of Inspector General (OIG) issued an alarming report in April 2022 highlighting that inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program.<sup><a href="#fniv">iv</a></sup> Using a random sample of denials from the one-week period of June 1−7, 2019, <strong>the report found that 13% of prior authorization denials and 18% of payment denials actually met Medicare coverage rules and should have been approved.</strong> In a program the size of MA, this rate of improper denials is deeply concerning.</p> </div> <div class="col-md-6"> <h3><span>Prior authorization denials can result in:</span></h3> <div class="row"> <div class="col-md-2"> <p><img alt="Delays of Necessary and Timely Treatment icon. An arrow turning in a circle counter-clockwise." data-entity-type="file" data-entity-uuid="7d94e95b-c9c0-4f6f-99db-0f9602f430a3" src="/sites/default/files/inline-images/Icon-delayed.png" width="602" height="631" class="align-right"></p> </div> <div class="col-md-10"> <p><span>delays of necessary and timely treatment</span></p> </div> </div> <div class="row"> <div class="col-md-2"> <p><img alt="Unexpected Medical Bills icon. A bill with medical charges on it." data-entity-type="file" data-entity-uuid="76e37517-e683-4ffc-8a60-e9c77b86c699" src="/sites/default/files/inline-images/Icon-medicalbill.png" width="492" height="639" class="align-right"></p> </div> <div class="col-md-10"> <p><span>unexpected medical bills</span></p> </div> </div> <div class="row"> <div class="col-md-2"> <p><img alt="Billions of Wasted Dollars icon. A horizontal stack of dollar bills." data-entity-type="file" data-entity-uuid="67a068b3-c82c-45dc-b96b-f2188f363f02" src="/sites/default/files/inline-images/Icon-billions.png" width="739" height="467" class="align-right"></p> </div> <div class="col-md-10"> <p><span>billions of wasted dollars</span></p> </div> </div> <div class="row"> <div class="col-md-2"> <p><img alt="Clinician Burnout Due to Administrative Requirements icon. A human head with a circle where the brain is with electric bolts shooting into it." data-entity-type="file" data-entity-uuid="38e8671d-4ed4-4814-b044-5a70b92605a9" src="/sites/default/files/inline-images/Icon-burnout.png" width="698" height="812" class="align-right"></p> </div> <div class="col-md-10"> <p><span>clinician burnout due to administrative requirements</span></p> </div> </div> </div> </div> <div> <p><span>While the numbers alone tell a distressing story, the report also describes the human impact of these delays and denials on patients. Just consider the following examples described in the report:</span></p> <ul> <li>A 72-year-old woman presented with a cancerous breast tumor. <strong>The MA plan denied her breast reconstruction surgery,</strong> stating “that the service was not covered.”<sup><a href="#fnvii"><span>vii</span></a></sup> That decision was reversed after the OIG requested data from the insurer.</li> <li><strong>An MA plan denied authorization for a 67-year-old patient to move to an inpatient rehabilitation facility, even though he presented with an “acute right-sided ischemic stroke and [was] seen at the emergency department with new onset slurred speech.”</strong><sup><a href="#fnviii"><span>viii</span></a></sup><span> </span>“The beneficiary had difficulty swallowing, was at significant risk of aspiration and fluid penetration, at high risk for pneumonia, and, therefore should have been under the frequent supervision of a rehabilitation physician.”</li> <li><strong>An MA plan refused to pay $150 a month for a hospital bed with rails,</strong> even though a 93-year-old patient had a history of epilepsy, early-onset Alzheimer’s, rheumatoid arthritis, chronic back pain, knee and joint stiffness, and limited range of motion.<sup><a href="#fnix"><span>ix</span></a></sup> OIG’s medical experts determined that this bed request was medically necessary “due to the beneficiary’s chronic conditions and movement limitations.<sup><a href="#fnx"><span>x</span></a></sup></li> </ul> </div> <p>These findings reiterate a similar OIG report published in September 2018 that warned that high rates of MA health plan payment denials and prior authorization delays could negatively impact patients’ access to care.<sup><a href="#fnxi">xi</a></sup></p> <p>Government agencies, as well as courts and arbitrators, have uncovered other troubling findings. Last year, a Nevada jury ordered UnitedHealthcare to pay a group of emergency room physicians $60 million in punitive damages for intentionally underpaying them by millions of dollars.<sup><a href="#fnxii">xii</a></sup> Earlier this year, Georgia’s Insurance Commissioner fined an Anthem (now Elevance) plan $5 million for improper claims settlement practices and violation of other state standards.<sup><a href="#fnxiii">xiii</a></sup> Notably, transparency data reported to CMS by Elevance (formerly Anthem) show consistently higher-than-average denial rates for in-network claims compared to peer plans offered on the Health Insurance Marketplaces in all but one year between 2015-2020.<sup><a title=" The Affordable Care Act (ACA) requires insurers to report certain transparency-in-coverage data to CMS and other regulators; however, these requirements do not apply to all types of coverage, including non-group plans, employer-sponsored plans, or MA plans.">1</a></sup> More recently, in May 2022, an arbitrator ordered the same insurer to pay a group of 11 acute care hospitals in Indiana $4.5 million as compensation for processing claims for emergency services that the arbitrator found to be a clear violation of federal and state law.<sup><a href="#fnxiv">xiv</a></sup></p> <p>It also is noteworthy that in response to COVID-19, many health insurers were urged by government agencies to scale back the use of many of these tactics precisely because they can create barriers to care. State governments, as the primary regulators of insurance, also have acted. For example, New York State passed several insurer accountability measures at the beginning of the COVID-19 pandemic to help ensure patient access to care and to remove unnecessary burdens on providers on the front lines.<sup><a href="#fnxv">xv</a></sup></p> <div> <h3>Integrated Health Systems with Insurance Offerings</h3> <p>Not all health insurers adopt the same policies and practices. Hospitals and health systems routinely report that certain large, national commercial insurers more frequently adopt the problematic practices described in this report. In contrast, hospitals and health systems frequently note more positive working relationships with smaller, communitybased plans, including those that are part of integrated health systems.</p> <p>Integrated health systems that offer insurance plans have shown to be beacons of innovation. As a result of being more readily able to coordinate across and align the delivery system and health insurance benefits, these organizations have been able to develop and test new approaches to things like prior authorization. For example, one integrated delivery system with a health plan recently eliminated a substantial number of prior authorizations for patients cared for in their system to help achieve their care coordination and efficiency objectives. We see considerable opportunity for solutions development within integrated health systems that offer insurance plans, as well as between other health insurers that are willing to work collaboratively with their network providers.</p> </div> <hr> <div class="row"> <div class="col-md-10"> <h2 id="prior"><span>Prior Authorization</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=7" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <p>Prior authorization is a process whereby a provider, on behalf of a patient, requests approval from the health plan before delivering a treatment or service to qualify for coverage and payment by the health plan. According to AHIP, prior authorization is implemented by health plans “to help ensure patients receive optimal care based on well-established evidence of efficacy and safety, while providing benefit to the individual patient.”<sup><a href="#fnxvi">xvi</a></sup> Philosophically, we agree with these laudable goals; indeed, some health plans use prior authorization in ways that accomplish them. <span><strong>However, many health plans apply prior authorization requirements in ways that can create dangerous delays in care, contribute to clinician burnout and drive up health system costs.</strong></span></p> <div class="row"> <div class="col-md-6"> <p>Inappropriate use of prior authorization can negatively impact the quality of care. <strong><span>A 2021 survey of more than 1,000 physicians found that more than 90% of respondents said prior authorization “had a significant or somewhat negative clinical impact, with 34% reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.”</span><sup><a href="#fnxvii"><span>xvii</span></a>, <a href="#fnxviii"><span>xviii</span></a></sup><span> In addition, 93% of the physicians surveyed reported that prior authorizations result in delays in accessing necessary care.</span></strong> The federal government also has acknowledged the risk of delays in care caused by prior authorization requirements, which is why CMS urged health plans to ease such requirements during the COVID-19 public health emergency. Specifically, CMS stated that “new guidance for individual and small group health plans encourages issuers to utilize flexibilities related to utilization management processes, as permitted by state law, to ensure that staff at hospitals, clinics, and pharmacies can focus on care delivery and ensure that patients do not experience care delays.”<sup><a href="#fnxix">xix</a></sup></p> </div> <div class="col-md-6"> <blockquote> <h3><span>“</span> Some commercial health plans are applying prior authorization to services for which the treatment protocol has remained the same for decades and there is no evidence of abuse.</h3> </blockquote> </div> </div> <p>Prior authorization also puts a heavy burden on clinicians and contributes to workforce burnout. According to the National Academies of Medicine, “among clinicians, burnout is associated with job demands related to workload, time pressure, and work inefficiencies, such as burdensome administrative processes which divert clinicians’ attention away from patients and detract from patient care.”<sup><a href="#fnxx">xx</a></sup> Prior authorization is one of the administrative processes most frequently cited by clinicians as a contributing factor to burnout. A few real-world examples of the burden associated with prior authorization include:<sup><a title="These examples were reported to AHA by member hospitals separate from the 2021-2022 survey data collection process.">2</a></sup></p> <div class="row"> <div class="col-md-6"> <ul> <li>One 20-hospital system spends $17.5 million annually complying with prior authorization requirements.</li> <li>A single 355-bed psychiatric facility needs 24 full-time equivalents (FTEs) to deal with authorizations.</li> <li>A large, national system spends $10 million per month in administrative costs associated with managing health plan contracts, including two to three full-time staff that do nothing but monitor plan bulletins for changes to the rules.</li> <li>A large health system conservatively estimates that the negative financial impact of managing prior authorizations for all services (excluding transplant procedures and prior authorizations secured in decentralized clinic locations) was about $18.2 million in 2019, roughly $3.6 million of which was lost revenue due to cancellations and rescheduling because of prior authorization delays. This system requires 65 FTEs to handle prior authorizations; eight additional FTEs to notify insurance companies of unplanned, urgent and emergency admissions; another team in utilization management to handle concurrent reviews with insurers and handle disputes over inpatient or outpatient status when the patient is admitted; and two denial management staff who advocate for patients experiencing denials.<sup><a herf="#fnxxi" href="#fnxxi">xxi</a></sup></li> <li>Physicians report that their offices spend, on average, two business days of the week dealing with prior authorization requests, with 88% rating the burden level as high or extremely high.<sup><a herf="#fnxxii" href="#fnxxii">xxii</a> </sup></li> </ul> </div> <div class="col-md-6"> <blockquote> <h3><span>“</span> . . . the negative financial impact of managing prior authorizations for all services (excluding transplant procedures and prior authorizations secured in decentralized clinic locations) was about $18.2 million in 2019, roughly $3.6 million of which was lost revenue due to cancellations and rescheduling because of prior authorization delays.</h3> </blockquote> </div> </div> <p>The costs associated with prior authorization go beyond workforce burnout. These processes require significant technological infrastructure and staff time, and delays often mean that a patient consumes more health care resources than required, e.g., by remaining in an inpatient bed when they should have already been discharged to another site of care. Health insurers rarely pay for those additional days of inpatient care, forcing the health care system to absorb those costs.<a href="#fnxxiii"><sup>xxiii</sup></a> This is especially common for patients experiencing a behavioral health crisis or for those who require post-acute care. These patients are often kept in an emergency department or an inpatient hospital setting awaiting authorization to transfer to another facility.</p> <p>Why is the administrative burden so cumbersome? Reasons include:</p> ul.red { list-style: none; /* Remove default bullets */ } ul.red li.red::before { content: "\2022"; /* Add content: \2022 is the CSS Code/unicode for a bullet */ color: #9d2235; /* Change the color */ font-weight: bold; /* If you want it to be bold */ display: inline-block; /* Needed to add space between the bullet and the text */ width: 1em; /* Also needed for space (tweak if needed) */ margin-left: -1em; /* Also needed for space (tweak if needed) */ } ul.ulblue { list-style: none; /* Remove default bullets */ } ul.ulblue li.ulblue::before { content: "\2022"; /* Add content: \2022 is the CSS Code/unicode for a bullet */ color: #003087; /* Change the color */ font-weight: bold; /* If you want it to be bold */ display: inline-block; /* Needed to add space between the bullet and the text */ width: 1em; /* Also needed for space (tweak if needed) */ margin-left: -1em; /* Also needed for space (tweak if needed) */ } ol.blue { counter-reset: item; } ol.blue li.blue { display: block; } ol.blue li.blue:before { content: counter(item) ". "; counter-increment: item; color: #003087; font-weight: bold; /* If you want it to be bold */ margin-left: -1em; /* Also needed for space (tweak if needed) */ } <ul class="red"> <li class="red"><span><strong>Variation in Submission Processes.</strong></span> Insurers vary widely on accepted methods of prior authorization requests and supporting documentation submission. While some insurers accept electronic means, may continue to rely on fax machines and call centers, with regular hold times of 20 to 30 minutes. Additionally, insurers offering electronic methods of submission most commonly use proprietary plan portals, which require a significant amount of time spent logging into a system, extracting data from the provider’s clinical system and completing idiosyncratic insurer-specific requirements. Providers and their staff must ensure they are following the right rules and processes for each individual plan, which may change from one request to the next. The tremendous amount of variation in the requirements and processes means that, inevitably, providers commit inadvertent errors that result in denials that must be reprocessed or appealed.</li> <li class="red"><span><strong>Inappropriate Application of Prior Authorization.</strong></span> Health insurers increase administrative burden when they broadly apply prior authorization even to services or treatment protocols that are neither new nor have a history of unwarranted variation. For example, one respondent to the 2019 AHA survey indicated that they had cared for a patient newly diagnosed with diabetes who presented with a fasting blood glucose level of 520 mg/dL. Despite this level being at a critically dangerous five times the acceptable range, the patient’s health plan informed the treating clinician that insulin, a standard lifesaving medication that has been widely used for nearly 100 years, was subject to prior authorization and review would take up to 24 hours. The clinician was forced to provide the patient with samples to immediately start treatment while awaiting the insurer’s decision.</li> <li class="red"><span><strong>Unreasonable or Unrelated Requests for Documentation.</strong></span> As part of their review of medical necessity, insurers will often request voluminous amounts of documentation, which is often duplicative to previous requests, or in some cases entirely unnecessary for determining whether a service is appropriate. This frequently occurs for long stays, high-dollar accounts, and higher acuity care, and can result in diminished access to and payment for covered services. In fact, the 2022 OIG report concluded that “Medicare Advantage Organizations (MAOs) indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the existing beneficiary medical records were sufficient to support the medical necessity of the services.”<sup><a href="#fnxxiv">xxiv</a></sup> In other cases, the OIG reported that MA plan reviewers asked for copies of documentation already contained in the patient case file. <div> <p>For example, according to OIG reviewers, a MA plan denied a request for Botox medication for a beneficiary with a diagnosis of urge incontinence (estimated cost $3,674). The MA plan incorrectly stated that there was a lack of clinical information about the beneficiary’s previous use of the medication and asked for additional records. However, the MA plan had already received records documenting the beneficiary’s previous use of Botox as part of the prior authorization request, making the request for the documentation unnecessary.<sup><a href="#fnxxv"><span>xxv</span></a></sup> (The MA plan reversed the denial after receiving OIG’s data request.)</p> </div> </li> <li class="red"> <p><span><strong>Insufficient Personnel or Network Gaps.</strong></span> Some insurers do not have the personnel to process the growing number of prior authorization requests. A limited sample of 98 hospitals and health systems from our 2019 survey reported approximately 865,000 prior authorization requests in 2018 to which insurers did not respond at all and which required follow-up by the provider. This most frequently occurs when the patient comes in overnight or on the weekend when the insurer does not have staff available to review routine requests. In fact, 92% of respondents to the survey reported having contracts with insurers that do not have prior authorization review available around the clock, seven days a week.</p> <p>In other instances, prior authorization delays may be caused by inadequate provider networks. Although plans participating in government programs (i.e., Medicare Advantage, Medicaid managed care) are required to meet network adequacy standards, referring providers who have had trouble finding placements for patients have cited inadequate in-network options as a contributing factor for delays. In some cases, inadequate networks may be a result of provider shortages in a community; however, in others, they appear to be the result of insufficient contracts between the plan and providers. Hospitals report the greatest challenges in obtaining patient access to inpatient mental health/substance use disorder recovery services, medication assisted therapy, long-term acute care hospital services, and home health service. These shortcomings impede timely access to care and require patients to stay in general acute care hospital beds longer than medically necessary.<sup><a href="#fnxxvii">xxvii</a></sup></p> <p>Under most reimbursement structures, <strong>insurers do not compensate hospitals for the care provided during these delays.</strong> Specifically, under episode- based payments, like MS-DRGs, hospitals receive a fixed payment for each hospital stay, regardless of the number of days the patient is in the hospital. The insurer does not pay more for any additional days the patient spends in the hospital unnecessarily. In fact, insurers may save money as a result of delaying or denying discharge to the next appropriate setting to the extent the hospital continues providing services and the patient’s condition improves to the point of no longer requiring the same next level of post-acute care.</p> <div> <p>A patient with traumatic brain injury was medically ready for discharge but sat for four additional days in the hospital without access to essential post-acute care because the insurer had not responded to the provider’s request to move the patient into a rehabilitation facility.<sup><a href="#fnxxvi">xxvi</a></sup> Another AHA member that operates inpatient rehabilitation facilities reports that 11% of their MA referrals take 10 days or longer to resolve. These delays in moving patients has resulted in tremendous strain on general acute care hospital capacity, which has been particularly critical during the COVID-19 pandemic when hospitals have been in desperate need of inpatient beds to care for COVID-19 patients.</p> </div> </li> <li class="red"><span><strong>Denials of Unanticipated but Medically Necessary Care.</strong></span> It is not always possible to know in advance everything a patient may need during a procedure. Providers will obtain authorization for the primary procedure and what they expect to be any ancillary items and services. However, it is not uncommon once a treatment or procedure is underway for the clinician to discover new information that necessitates other items and services to deliver the best patient care. A common reason that this may occur is when a patient’s condition changes quickly during a procedure, perhaps necessitating an emergent response or intervention. It is not uncommon for an insurer to deny coverage for an item or service not pre-authorized, even if the overall procedure was approved. For example, a provider may have received authorization from the patient’s insurer for a colonoscopy, but a bleed or lesion discovered during the procedure may require additional intervention, such as removal of the lesion, which could not have been known or authorized in advance. This approach is inconsistent with the nature of medical procedures and treatments and may narrow necessary treatment options or result in providers being unpaid for medically necessary care they appropriately provided.</li> <li class="red"> <p><span><strong>Appeals of Inappropriate Denials.</strong> </span>Medical necessity is one of the most common reasons that prior authorization requests are denied.<sup><a href="#fnxxviii">xxviii</a></sup> However, hospitals and health systems frequently experience situations where certain insurers routinely deny medically necessary care, which then requires additional staff time and resources to appeal. For example, one hospital reported through our 2019 survey that an insurer denied prior authorization for the hospitalization of a young adult experiencing their first psychotic episode because there was no prior history of psychosis for that patient.<sup><a href="#fnxxx">xxx</a></sup></p> <p>The denial of medically necessary care was highlighted by the 2018 OIG report, which found that MA plans overturned 75% of denials that were appealed between 2014 and 2016.<sup><a href="#fnxxix">xxix</a></sup> The 2022 OIG report identified several factors contributing to inappropriate denials, which include the use of proprietary clinical criteria and health insurer staff without suitable clinical knowledge. Health insurers frequently modify broadly available clinical guidelines, and these modifications are not always shared with providers. In addition, hospitals and health systems report that some insurers’ clinical reviewers often do not have the requisite expertise. For example, an insurer may assign a urologist to assess whether a cancer patient should receive the type of chemotherapy referred by the treating oncologist.<sup><a href="#fnxxxii">xxxii</a></sup> These issues are further compounded by processing errors, according to the OIG report, which highlights a variety of human errors and systemic plan processing issues that result in inappropriate denials of care or payment.</p> <p>Consistent with the 2018 OIG report findings, AHA survey data from 2021-2022 reflects that most prior authorization and claim denials that are appealed are ultimately overturned in the providers’ favor (Table 2). However, health plans continue to deny a substantial portion of prior authorizations (Table 1).</p> <div class="row"> <div class="col-md-7"> table, th, td { border: 1px solid black; } tr:nth-child(even){ background-color: #f2f2f2; } th { background-color: #003087; color: white; } <p><span><strong>Table 1:</strong></span> <span>Inpatient Prior Authorization Initial Denial Rates</span></p> <table> <tbody> <tr> <th>Product Type</th> <th>Inpatient Prior Authorization Denial Rate</th> </tr> <tr> <td>Medicaid Managed Care</td> <td>15.5%</td> </tr> <tr> <td>FFS Medicaid</td> <td>7.6%</td> </tr> <tr> <td>Medicare Advantage<sup><a title="Traditional Medicare is not included in this table because it does not typically apply prior authorization on the same scale as commercial insurers and MA plans. However, these differences underscore the disparity in access to care between Medicare beneficiaries enrolled in traditional Medicare and those enrolled in MA, whose care is subject to a variety of other barriers and utilization management protocols that are not applied to traditional Medicare enrollees.">3</a></sup></td> <td>19.1%</td> </tr> <tr> <td>Commercial</td> <td>11.4%</td> </tr> </tbody> </table> <p><span><strong>Table 2:</strong> </span><span>Overturn Rate for Inpatient Prior Authorization Denials</span></p> <table> <tbody> <tr> <th>Product Type</th> <th>Overturn Rate</th> </tr> <tr> <td>Medicaid Managed Care</td> <td>61%</td> </tr> <tr> <td>FFS Medicaid</td> <td>69%</td> </tr> <tr> <td>Medicare Advantage</td> <td>69%</td> </tr> <tr> <td>Traditional Medicare</td> <td>51%</td> </tr> <tr> <td>Commercial</td> <td>68%</td> </tr> </tbody> </table> </div> <div class="row"> <div class="col-md-5"> <h3><span>35%</span></h3> <p><span>of hospitals and health<br> systems report</span></p> <h3><span>$50 Million</span></h3> <p><span>or more in foregone<br> revenue as a result of<br> denied claims once appeals<br> have been exhausted</span></p> </div> </div> <p>Table 1 reflects that the rate of prior authorization delays and denials is not uniform across all insurer health plan products. Our most recent survey data shows that commercial insurers serving public programs are more likely to deny inpatient prior authorization requests. Specifically, MA plans have the highest inpatient prior authorization denial rate, followed by Medicaid managed care and commercial products. These rates vary despite physicians following the same clinical guidelines regardless of a patient’s type of coverage.</p> </div> </li> </ul> <hr> <div class="row"> <div class="col-md-10"> <h2 id="reimbursement"><span>Reimbursement Delays and Denials</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=13" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <p>Some commercial health insurers are increasingly delaying and denying coverage of medically necessary care, a trend that continued in 2020 despite the emergence of the COVID-19 pandemic.<sup><a href="#fnxxxiii">xxxiii</a></sup> Yet, approximately half of all claims denials that are appealed are ultimately overturned. And even in cases where the denial stands, the 2022 OIG report shows that a portion of those upheld denials were for care that should have been covered.</p> <p>The financial consequences of these delays and denials for health care providers can be significant, even in cases where a denial is overturned on appeal. In our most recent survey, 50% of hospitals and health systems reported having more than $100 million in accounts receivable for claims that are older than six months. This amounts to $6.4 billion in delayed or potentially unpaid claims that are six months old or more among the 772 reporting hospitals, leaving providers with untenable financial liability.<sup><a href="#fnxxxiv">xxxiv</a></sup> Furthermore, 35% of survey respondents reported $50 million or more in foregone revenue as a result of denied claims after all appeals have been exhausted.</p> <p>These payment delays and denials for medically necessary care have serious implications for the financial stability of health care providers and compound fiscal challenges plaguing our health care system. In 2022, more than 50% of hospitals are projected to end the year with negative operating margins. The cost of caring for patients has increased by nearly 20% since pre-pandemic levels due to unprecedented surges in labor and supply costs, as well as staffing issues and inflation. Expenses for hospitals and health systems are projected to increase by $135 billion over 2021 levels, driven largely by labor costs. Inappropriate payment delays and denials exacerbate these financial challenges. One 133-bed rural hospital reported experiencing 180 MA denials in the last six months alone, which translated to nearly $1.2 million of disputed reimbursement for services already rendered, or approximately $2.4 million annualized.<sup><a href="#fnxxxv">xxxv</a></sup> Absorbing financial losses of this magnitude is simply untenable for the majority of hospitals and health systems.</p> <p>Below are several reasons why claims can end up disputed in whole or part:</p> <ul class="red"> <li class="red"><span><strong>Failure to Obtain Prior Authorization.</strong></span> To prevent harm and adequately care for patients, providers sometimes must begin treatment or move a patient to a more appropriate site of care before obtaining a response to a prior authorization request. In such instances, some insurers will deny care that they acknowledge to be medically necessary simply because the provider did not wait for the prior authorization approval.</li> <li class="red"><span><strong>Basing Medical Necessity Determinations on Information Only Known After the Fact.</strong> Some insurers adjudicate medical necessity based on information known about the patient’s condition after the care was provided. For example, it is not uncommon for some insurers to downcode a claim if the diagnostic results show that the patient has a less severe condition than was known prior to the test having been completed.</span></li> <li class="red"> <p><span><strong>Observation Status/Short Stay Denials.</strong></span> Hospitals and health systems report a steep increase in short stay denials, even when clinical indicators and the severity of illness meet the standards for inpatient admission. In these instances, some insurers downcode the inpatient claims to observation status. In our most recent survey, approximately 75% of respondents noted that insurers are reimbursing more care as observation instead of inpatient.<sup><a href="#fnxxxvi">xxxvi</a></sup> This is supported by an AHA analysis of data from Strata Decision Technology’s StrataSphere data set showing that the length of stay for observation cases has increased across all payers since 2019, but that this trend is particularly pronounced in MA, where the length of stay for observation has increased by 15.6% from 2019 to 2022.<sup><a href="#fnxxxvii">xxxvii</a></sup></p> <p>In some cases, hospitals report that insurers will request the provider resubmit a claim as observation instead of inpatient for the claim to be paid. In effect, this results in underpayment to the provider and ensures the transaction does not appear as a denial so long as the provider agrees to resubmit. This practice obscures the true prevalence of denials and often results in providers accepting lower levels of payment to avoid prolonged payment delays and costly escalations or appeals.</p> </li> <li class="red"> <p><span><strong>Sepsis.</strong> </span>Several of the large, commercial insurers are now reimbursing providers for sepsis care using the Sepsis-3 clinical criteria, instead of the broadly adopted Sepsis-2. The primary difference between the two sets of criteria is that Sepsis-3 recognizes more severe forms of sepsis. This is a payment policy, not a change in clinical guidelines. Specifically, by basing provider payment on Sepsis-3, these insurers are declining to reimburse providers for early sepsis interventions. However, they are not requesting or requiring providers to stop treating early cases of sepsis; they simply will not pay for care provided to patients in the early stages of sepsis. These payment policy changes are inconsistent with the CMS sepsis quality measure (“Severe Sepsis and Septic Shock: Management Bundle”), as well as some state laws. Indeed, the CMS has expressly rejected adoption of Sepsis-3.<sup><a href="#fnxxxviii">xxxviii</a></sup> One independent hospital noted that this insurer practice results in a per-case reduction in reimbursement ranging from $500 to $6,000 depending upon the factors involved. This represents a loss of more than $100,000 annually for this single hospital.<sup><a href="#fnxxxix">xxxix</a></sup></p> <p>Further, adoption of the Sepsis-3 criteria introduces conflict and confusion in the field around the appropriate clinical pathway and signals a retreat on standardization of clinical care. Early treatment is critical to prevent the progression of sepsis and any reduction in early intervention could result in increased mortality. The misguided adoption of Sepsis-3 clinical criteria results in underpayment for these very critical early interventions. This change misaligns incentives among providers and insurers to achieve a shared goal of reducing sepsis, which can be a life-threatening condition for patients.</p> </li> <li class="red"> <p><span><strong>Site of Service Exclusions.</strong></span> Several insurers will only cover services when provided in certain sites of care. While these policies may in part be intended to drive care to the most cost-effective site of care, they often do not take into account the full range of considerations for when a patient may need a higher level of care. In addition, certain insurers implement such policies unilaterally in the middle of a contract cycle, which has the effect of changing enrollees' coverage mid-year.</p> <p><span><strong>In practice, this means that consumers evaluated and selected their coverage options based on one set of rules, only to find themselves with a different health plan product with little recourse.</strong></span> This creates a barrier to patients understanding their coverage, and in some circumstances, to continuing treatment with their established providers.</p> <p>Site of service policies are most often applied to certain diagnostic tests and surgical procedures; however, they also have been applied in the emergency setting. Specifically, some large commercial insurers have questoned patients' use of the emergency department without full regard as to why the individual sought emergency services. These decisions may provide a disincentive for patients to seek emergency treatment in the future. Avoiding necessary emergency treatment could result in serious harm to or death of a patient.</p> <p>These site of service exclusions also make the coordination of routine and chronic care more difficult. The policies often require that patients go to alternate sites of care that are unaffiliated with their primary providers, cannot offer the exact service required (most frequently an issue with certain types of sophisticated imaging), or cannot easily communicate results back to the referring provider. For example, some insurers have implemented site of care policies for certain specialty medications that require patients to travel to off-site freestanding infusion centers. These practices can cause stress for patients with complex illnesses such as cancer, who can no longer receive infusions at their primary provider. It also creates additional challenges for providers to maintain accurate records of doses administered in unaffiliated facilities, which can impede medication reconciliation and monitoring of side effects, creating further safety risks.</p> </li> <li class="red"> <p><span><strong>White Bagging Requirements.</strong></span> Certain insurers require health care providers to obtain physician-administered drugs from the insurer’s owned or affiliated specialty pharmacy instead of allowing the health care facility to provide the drug on-site from its own inventory; this practice is known as “white bagging.” When unilaterally imposed by an insurer, white bagging may create safety concerns or result in delays in patient care, while potentially adding additional cost and burden to the health care system. These practices appear to be growing because of vertical integration between pharmacy benefit managers and large health insurance companies.</p> <p>Specific safety issues and administrative burdens that result from white bagging mandates include:</p> <ul> <li>Circumventing established safety systems designed to ensure safe ordering and management of patient medications in a health care facility;</li> <li>Causing delays in time-sensitive patient care when medications are not delivered or are shipped late by the external pharmacy, or if changes in a patient’s treatment plan or dosing requires more medication than was provided by the third-party pharmacy;</li> <li>Inhibiting health care providers from validating that specialty medications, which often have specific temperature and handling requirements, were managed appropriately throughout the supply chain and delivery processes and are safe to administer to patients; and</li> <li>Creating opportunities for error by requiring hospitals to develop and maintain a separate inventory of drugs for individual patients subject to white bagging policies.</li> </ul> <div> <p><span>An oncology patient was scheduled to receive an infusion drug, but their insurer required white bagging, even though the drug was readily available through the hospital pharmacy. The drug was left in the truck overnight, rendering it unusable. The service had to be cancelled and subsequently was delayed several additional weeks following further problems in obtaining the drug from the third-party specialty pharmacy due to weather- related delivery delays. Concerned for the patient’s health, the hospital team continued to press the insurer to approve use of the hospital’s stock to prevent harm to the patient. The insurer finally approved one dose from the hospital stock, but no more.</span><sup><a href="#fnxl"><span>xl</span></a></sup></p> </div> </li> <li class="red"><span><strong>Inaccurate Enrollment Files.</strong></span> Claims denials also occur because of inaccurate enrollment files. These errors can occur both when the insurer indicates the patient does not have active coverage when they actually do, as well as when an insurer pays a claim only to subsequently claw back the payment when they realize the patient is no longer enrolled in their plan and recoup the payment. In the latter scenario, the correct payer often will not allow retroactive authorization and denies the claim as well, leaving the provider with unreimbursed costs for medically necessary care. These problems occur most frequently in the first quarter of the year when insurer membership files may not be fully up to date.</li> <li class="red"><span><strong>Inadequate Vendor (or Delegated Entity) Oversight.</strong></span> Many insurers contract with vendors or other delegated entities to analyze claims and make prior authorization and reimbursement determinations. These third parties are not always in sync with the insurer's rules and policies, which can contribute to inappropriate delays and denials, as well as difficulty escalating issues to the appropriate staff. For example, hospitals and health systems report being told one thing by the insurer only to be told another by the vendor, such as whether prior authorization is required. Hospitals and health systems report that they are frequently unable to communicate with insurers on these issues because they are not provided accurate contact information and often get caught in endless automated voice answering service loops or directed back to the vendor again. While vendors contracted with MA plans and Medicaid managed care plans are required to follow applicable state and federal rules that apply to the plan, there does not appear to be sufficient oversight of vendor activities on behalf of commercial health plans.</li> </ul> <div> <p><strong>Third- and fourth-party vendors.</strong> An insurer with more than 20 million members uses a third-party vendor to manage imaging authorizations and a fourth-party vendor to direct patients to facilities it determines to be lower in cost. The third-party authorization vendor will not issue an authorization until the provider contacts the fourth-party vendor to gain approval for the patient’s selected location. One health system reported their staff spends on average 20 minutes for each patient in conversations with the fourth- party vendor for one insurer, which not infrequently results in selecting the original location as planned.<sup><a href="#fnxli"><span>xli</span></a></sup></p> </div> <hr> <div class="row"> <div class="col-md-10"> <h2 id="policy"><span>Policy Solutions</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=18" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <p>Patients and the providers who care for them deserve a rational, predictable and efficient system to ensure access to high-quality care. Below are a series of policy solutions to ensure fair prior authorization and payment policies and procedures. Implementing standards for prior authorization would better ensure that patients receive timely access to the services they need while reducing substantial cost and burden on the health care system. Many of these recommendations align with the Improving Seniors’ Timely Access to Care Act, federal legislation that would streamline prior authorization processes in the MA program. That legislation is currently under consideration in the U.S. Senate after passing the U.S. House of Representatives. However, it will not address prior authorization in other types of coverage.</p> <p>We recognize that standardization will require effort on the part of all parties, including by requiring providers to adjust their technology applications and implement new workflows. However, we believe it is critical to take on this additional effort in the short term to reduce the complexity and burden associated with prior authorization over time.</p> <ol class="blue"> <li class="blue"> <p><span><strong>Standardize Prior Authorization Requirements and Processes.</strong></span> The AHA supports streamlining prior authorization processes in the following ways.<sup><a href="#fnxlii">xlii</a></sup></p> <ul class="red"> <li class="red"><span><strong>Standardize the format for communicating services subject to prior authorization.</strong></span> While insurers generally provide lists of services subject to prior authorization via their websites, it can be challenging for providers to locate the right list for the right plan and keep up with any changes, especially when insurers and their vendors provide inconsistent information. Insurers should adhere to a standard format for posting prior authorization requirements, provide accurate staff contact information for follow-up, and ensure oversight of vendors. Ideally this information could be conveyed within a provider’s clinical information system, which would ensure that the provider knows when developing a treatment plan whether prior authorization is required.</li> <li class="red"><span><strong>Standardize the format for prior authorization requests and responses.</strong></span> All prior authorization requests and responses should be transmitted using a standardized electronic format, including the submission of clinical documentation. The format for requests should have standardized fields for the clinical information required. Denials should include a detailed rationale. Where feasible, electronic standards should integrate with provider clinical information systems to eliminate time spent transposing clinical data from one system to another. Alternate mechanisms, such as fax, only should be used in rare circumstances, such as in areas with limited broadband or other technical limitations. One member estimates that switching from verbal/fax processes to an electronic transmission process would reduce the amount of provider staff time for each request by at least 50% — from a current average of 30 to 45 minutes per request to 15 minutes per request.</li> <li class="red"><span><strong>Require 24/7 prior authorization capabilities.</strong></span> Hospitals care for patients 24 hours a day, 365 days a year. To prevent patients from waiting unnecessarily for care, often in the emergency department, insurers should be required to have staff available 24 hours, seven days a week to respond to prior authorization requests.</li> <li class="red"><span><strong>Establish timely response requirements.</strong></span> Insurers should abide by the same timeframes for responses: 72 hours for certain scheduled, non-urgent services and 24 hours for urgent services. The clock should begin when the provider submits the request with the information available at the time the provider’s request is made. There also should be a period of retroactive consideration of prior authorization requests for urgent services for which the patient’s clinical condition warranted immediate intervention or for situations when prior authorization was not possible (e.g., a patient’s condition changes during a procedure or treatment requiring a change in the course of care).</li> <li class="red"><span><strong>Require full and complete denial notices.</strong></span> Insurers should communicate denials in writing and transmit them electronically. Denial letters must include specific information on the rationale for the denial so that the provider knows exactly what is required to appeal.<sup><a href="#fnxliii">xliii</a></sup></li> <li class="red"><span><strong>Standardize appeals processes.</strong></span> Insurers should follow a standard appeals process, which should include an opportunity for external review of denials. In addition, insurers must have the ability to conduct timely peer-to-peer consultations with appeals reviewed by someone with the appropriate level of clinical knowledge and training on the particular service.</li> </ul> <div> <h3>Value-based Purchasing as Part of the Solution</h3> <p>Value-based purchasing (VBP) arrangements may be part of the solution to reduce the administrative burdens inherent in many health insurer/provider interactions. Specifically, VBP models that compensate providers on a capitated or sub-capitated basis may reduce or eliminate health insurer prior authorization requirements, as well as individual claims adjudication. The provider assumes primary responsibility for not only access to and quality of care, but also managing the financial risk associated with a given population.</p> <p>Hospitals and health systems are eager to explore these arrangements with insurers but have faced considerable barriers to doing so. Not only do they require substantial resources to erect, but successful arrangements require alignment across both parties to achieve a common objective for the patient population served. This means that the insurer and the provider must agree to the objectives and parameters of the relationship, ensure clarity regarding responsibilities for care management, set performance metrics and targets, and agree to common technology and information sharing. These are highly complex arrangements that require willing and committed partners with dedicated staff and near constant communication. It can be challenging for providers who routinely contract with many different insurers to participate in even just a few payer-specific models at once. Ideally, providers and payers would be aligned under multi-payer contracts to reduce variation in metrics and align under a consistent payment model.</p> <p>Despite this interest, many hospitals and health systems report that the large, commercial insurers in their communities have been uninterested or unwilling to enter into capitated payment arrangements. The AHA believes there is significant opportunity for collaboration between insurers and providers to advance adoption of VBP arrangements that support patient access to quality care.</p> </div> </li> <li class="blue"><span><strong>Increase Oversight to Prevent Inappropriate Prior Authorization and Payment Delays and Denials.</strong></span> Regulators should conduct routine oversight to ensure that patients have access to covered services, that the rules are fair for contract providers, and that, as appropriate, taxpayer dollars are well-spent. We encourage improving oversight in the following ways: <ul class="red"> <li class="red"><span><strong>Improve data collection and public reporting.</strong></span> Regulators should require reporting of standardized performance measures related to prior authorization and payment delays and denials, including the rate of denials overturned upon appeal, at the plan level. This information is necessary for policymakers and regulators to conduct appropriate oversight of health insurance rules and should be available for public review as well.</li> <li class="red"><span><strong>Set thresholds.</strong></span> Oversight bodies should establish thresholds for “appropriate” levels of prior authorization and payment delays and denials to identify and target potential bad actors for increased scrutiny. Plans identified as such should be subject to more frequent audits for suspected or potential violation of federal rules.</li> <li class="red"><span><strong>Apply financial penalties for inappropriate denials.</strong></span> Regulators should create a financial disincentive for plans to inappropriately deny prior authorization requests or claims for reimbursement. This may take the form of a penalty paid to the government in instances where an insurer has a high rate of inappropriate delays or denials or an additional fee paid to the provider for denials that are overturned on appeal.</li> <li class="red"><span><strong>Ensure adequate provider networks.</strong></span> Inadequate networks may contribute to prior authorization delays, and we urge regulators to further explore the relationship between the two. This may be accomplished through routinely testing health plan’s networks (or delegated network), including through “secret shopping” efforts to ensure that providers are indeed in- network and accepting patients from that health plan or a delegate.</li> </ul> </li> </ol> <div> <h3>Role of Contracts in Dispute Resolution</h3> <p>Insurers and providers enter into contracts to define the terms of their agreements, including things such as reimbursement, network participation, licensing and insurance requirements, and credentialing. Insurers also use provider manuals to further elaborate on certain elements of the contract, especially how certain provisions may be operationalized, such as prior authorization requirements and appeals processes. These manuals often can be changed by the insurer during the contract period.</p> <p>Contracts are one of the most important tools that insurers and providers have to ensure that the terms of the relationship are fair and allow for appropriate redress if either party violates a term.</p> <p>However, contracts are limited by certain factors, including the relative negotiating power of each party and that enforcement of the terms can be expensive and lengthy. Terms or requirements that should be universally adopted may more appropriately be handled through federal or state policy. An example of this is prompt pay policies, which not only help efficient processing of claims but also ensure that patients receive bills in a timely manner.</p> </div> <hr> <div class="row"> <div class="col-md-10"> <h2 id="conclusion"><span>Conclusion</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=22" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <p>Patients and their network providers should not face unnecessary or inappropriate barriers to care. Recent trends in prior authorization and payment delays and denials suggest that certain commercial health insurer practices threaten patient access to care and drive excessive administrative costs and burden in the health care system. Regulators should ensure appropriate oversight of insurers, as well as streamline prior authorization requirements and processes. These efforts will go a long way to allow for a more rational, navigable health system for patients and reduce addressing unnecessary costs and burdens in the system.</p> <hr> <div class="row"> <div class="col-md-10"> <h2 id="endnotes"><span>Endnotes</span></h2> </div> <div class="col-md-2"> <p class="text-align-right"><small><em><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf#page=23" target="_blank">[View in PDF.]</a></em></small></p> </div> </div> <ol type="i"> <li id="fni">2021-2022 AHA Survey</li> <li id="fnii">Shrank, W. et al., <a href="https://jamanetwork.com/journals/jama/article-abstract/2752664" target="_blank" title="JAMA Network: Waste in the US Health Care System Estimated Costs and Potential for Savings">“Waste in the US Health Care System: Estimated Costs and Potential for Savings,”</a> JAMA: The Journal of the American Medical Association. October 7, 2019.</li> <li id="fniii">Addressing Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. 2022. <a href="https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf" target="_blank">https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf</a></li> <li id="fniv">U.S Department of Health and Human Services Office of Inspector General. “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns about Beneficiary Access to Medically Necessary Care,” OEI-09-18-00260. April 27, 2022. <a href="https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp" target="_blank">https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp</a>.</li> <li id="fnv"><a href="https://www.forbes.com/sites/brucejapsen/2021/10/01/parade-of-health-insurers-expand-medicare-advantage-into-hundreds-of-new-counties/?sh=591ab1106b69" target="_blank">https://www.forbes.com/sites/brucejapsen/2021/10/01/parade-of-health-insurers-expand-medicare-advantage-into-hundreds-of-new-counties/?sh=591ab1106b69</a>.</li> <li id="fnvi"><a href="https://www.kff.org/report-section/financial-performance-of-medicare-advantage-individual-and-group-health-insurance-markets-issue-brief/" target="_blank">https://www.kff.org/report-section/financial-performance-of-medicare-advantage-individual-and-group-health-insurance-markets-issue-brief/</a>.</li> <li id="fnvii">See Appendix B, Example D385.</li> <li id="fnviii">See Appendix B, Example D270.</li> <li id="fnix">See Appendix B, Example D232.</li> <li id="fnx">Id.</li> <li id="fnxi">U.S. Department of Health and Human Services Office of Inspector General. <a href="https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp" target="_blank" title="Office of Inspector General: Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials">“Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials,”</a> OEI-09-16-00410. September 2018.</li> <li id="fnxii"><a href="https://www.reviewjournal.com/crime/courts/united-healthcare-owes-60m-to-er-doctors-jury-rules-2492856/amp/" target="_blank">https://www.reviewjournal.com/crime/courts/united-healthcare-owes-60m-to-er-doctors-jury-rules-2492856/amp/</a>.</li> <li id="fnxiii"><a href="https://oci.georgia.gov/press-releases/2022-03-29/georgia-insurance-commissioners-office-fines-anthem-blue-cross-blue" target="_blank">https://oci.georgia.gov/press-releases/2022-03-29/georgia-insurance-commissioners-office-fines-anthem-blue-cross-blue</a>.</li> <li id="fnxiv"><a href="https://www.beckerspayer.com/payer/anthem-ordered-to-pay-4-5m-to-indiana-hospitals-over-er-billing-issues#:~:text=The%20arbitrator%20ruled,to%20May%202020." target="_blank">https://www.beckerspayer.com/payer/anthem-ordered-to-pay-4-5m-to-indiana-hospitals-over-er-billing-issues</a>. html#:~:text=The%20arbitrator%20ruled%20that%20Anthem,January%202017%20to%20May%202020.</li> <li id="fnxv"><a href="https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2020_s01_cl2020_08" target="_blank">https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2020_s01_cl2020_08</a>.</li> <li id="fnxvi"><a href="https://www.ahip.org/wp-content/uploads/Prior-Authorization-FAQs.pdf" target="_blank">https://www.ahip.org/wp-content/uploads/Prior-Authorization-FAQs.pdf</a>.</li> <li id="fnxvii">American Medical Association, “2021 AMA Prior Authorization (PA) Physician Survey,” Feb. 2022. Accessed at: <a href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank">https://www.ama-assn.org/system/files/prior-authorization-survey.pdf</a>.</li> <li id="fnxviii">American Medical Association, “1 in 4 doctors say prior authorization has led to a serious adverse event,” Feb. 2019. Accessed at: <a href="https://www.ama-assn.org/practice-management/sustainability/1-4-doctors-say-prior-authorization-has-led-serious-adverse" target="_blank">https://www.ama-assn.org/practice-management/sustainability/1-4-doctors-say-prior-authorization-has-led-serious-adverse</a>.</li> <li id="fnxix"><a href="https://www.cms.gov/newsroom/press-releases/cms-news-alert-april-23-2020" target="_blank">https://www.cms.gov/newsroom/press-releases/cms-news-alert-april-23-2020</a>.</li> <li id="fnxx">National Academies of Medicine, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” Oct. 2019. Accessed at: <a href="https://nam.edu/wp-content/uploads/2019/10/CR-report-highlights-brief-final.pdf" target="_blank">https://nam.edu/wp-content/uploads/2019/10/CR-report-highlights-brief-final.pdf</a>.</li> <li id="fnxxi"><a href="https://www.hfma.org/topics/financial-sustainability/article/front-line-stories--how-today-s-prior-authorization-processes-cr.html" target="_blank">https://www.hfma.org/topics/financial-sustainability/article/front-line-stories--how-today-s-prior-authorization-processes-cr.html</a>.</li> <li id="fnxxii">American Medical Association, “2021 AMA Prior Authorization (PA) Physician Survey,” Feb. 2022. Accessed at: <a href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank">https://www.ama-assn.org/system/files/prior-authorization-survey.pdf</a>.</li> <li id="fnxxiii">2019 AHA Survey</li> <li id="fnxxiv">U.S Department of Health and Human Services Office of Inspector General. “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns about Beneficiary Access to Medically Necessary Care,” OEI-09-18-00260, pp.11-12. April 27, 2022. <a href="https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp" target="_blank">https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp</a>.</li> <li id="fnxxv">See Appendix B, Example D199</li> <li id="fnxxvi">Example provided by an AHA member hospital.</li> <li id="fnxxvii">Example provided by an AHA member hospital.</li> <li id="fnxxviii">2019 AHA Survey</li> <li id="fnxxix">U.S. Department of Health and Human Services Office of Inspector General. <a href="https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp" target="_blank" title="Office of Inspector General: Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials">“Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials,”</a> OEI-09-16-00410. September 2018.</li> <li id="fnxxx">Example provided by an AHA member hospital.</li> <li id="fnxxxi"><a href="https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/" target="_blank">https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/</a>.</li> <li id="fnxxxii">Example provided by an AHA member hospital.</li> <li id="fnxxxiii">AHA Survey</li> <li id="fnxxxiv">2021-2022 AHA Survey</li> <li id="fnxxv">Example provided by an AHA member hospital.</li> <li id="fnxxxvi">2021-2022 AHA Survey</li> <li id="fnxxxvii">AHA analysis of data from Strata Decision Technology’s StrataSphere data set, 2019-2022. xxxviii Braun D., <a href="https://www.amjmed.com/article/S0002-9343(18)31052-0/fulltext" target="_blank" title="The American Journal of Medicine: A Retrospective Review of the Sepsis Definition after Publication of Sepsis-3">“A Retrospective Review of the Sepsis Definition after Publication of Sepsis-3,”</a> American Journal of Medicine. March 13, 2019.</li> <li id="fnxxxix">Example provided by an AHA member hospital.</li> <li id="fnl">Example Provided by an AHA member hospital.</li> <li id="fnxli">Example adapted from <a href="https://www.hfma.org/topics/financial-sustainability/article/front-line-stories--how-today-s-prior-authorization-processes-cr.html" target="_blank">https://www.hfma.org/topics/financial-sustainability/article/front-line-stories--how-today-s-prior-authorization-processes-cr.html</a>.</li> <li id="fnxlii"><a href="https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/" target="_blank">https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/</a></li> <li id="fnxliii"><a href="https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/#:~:text=Plan-level%20claims%20denial%20data&text=Denial%20rates%20varied%20somewhat%20based,and%2018.3%25%20for%20catastrophic%20plans" target="_blank">https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/#:~:text=Plan-level%20claims%20denial%20data&text=Denial%20rates%20varied%20somewhat%20based,and%2018.3%25%20for%20catastrophic%20plans</a></li> </ol> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2022/10/Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage-for-Patients-and-Providers.pdf" target="_blank" title="Click here to download the Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers PDF."><img alt="Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers cover. ���������� Association. www.aha.org." data-entity-type="file" data-entity-uuid="b5642257-cb33-48e6-938b-c0680a371816" src="/sites/default/files/inline-images/Page-1-Addressing-Commercial-Health-Plan-Challenges-to-Ensure-Fair-Coverage_0.png" width="695" height="900"></a></p> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to go to the Health Plan Accountability landing page for more AHA resources.">More Health Plan Accountability Resources</a></div> <hr> <h3>Other AHA Health Plan Accountability Resources</h3> <div><a href="/white-papers/2022-07-28-commercial-health-plans-policies-compromise-patient-safety-and-raise-costs" target="_blank" title="Click here to read the Commercial Health Plans’ Policies Compromise Patient Safety and Raise Costs white paper."><img alt="Commercial Health Plans’ Policies Compromise Patient Safety and Raise Costs cover. ���������� Association. " data-entity-type="file" data-entity-uuid="fe5c4e7e-558b-464c-b05e-4bcaed3f82fb" src="/sites/default/files/inline-images/Commercial-Health-Plans-Policies-Compromise-Patients-Safety-Page-1.png" width="695" height="900"></a></div> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2022/07/Commercial-Health-Plans-Policies-Compromise-Patient-Safety-White-Paper.pdf" target="_blank" title="Click here to download the complete Commercial Health Plans’ Policies Compromise Patient Safety and Raise Costs white paper PDF.">Download the PDF</a></div> </div> </div> </div> Tue, 01 Nov 2022 06:00:00 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) /news/headline/2022-09-29-house-passes-bill-strengthen-mental-health-parity-protections-workers <p>The House voted 220-205 today to pass legislation to hold employer-based health plans more accountable for improper denials of mental health and substance use benefits. The <a href="http://H.R. 7780 https://edlabor.house.gov/imo/media/doc/mental_health_matters_act_fact_sheet1.pdf">Mental Health Matters Act</a> would give the Department of Labor more authority to enforce plan requirements under the Mental Health Parity and Addiction Equity Act and Employee Retirement Income Security Act, ban forced arbitration agreements when plans improperly deny benefits and ensure a fair standard of review by the courts. The bill also would provide grants to develop, recruit and retain school-based mental health professionals and link schools with local mental health systems, among other provisions.</p> Thu, 29 Sep 2022 15:11:06 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) /news/headline/2022-09-21-maternal-home-visiting-mental-health-bills-advance-house <p>The House Ways and Means Committee today <a href="https://waysandmeans.house.gov/legislation/markups/markup-worker-and-family-support-and-health-legislation">voted</a> to advance to the full House bipartisan legislation (H.R.8876) that would reauthorize the federal Maternal, Infant, and Early Childhood Home Visiting Program, and double annual funding for the program to $800 million over five years. The committee also passed five packages of mental health bills. Among other provisions, the bills would: <br /> •    Add Medicare outpatient mental health treatment options and direct the Health and Human Services secretary to revise the Medicare payment system for inpatient psychiatric facilities.<br /> •    Add marriage and family therapists and mental health counselors as Medicare providers; remove regulatory barriers that prevent hospitals from offering wellness benefits to all physicians; and direct the Administration to consider ways to increase access to stimulant addiction therapy.<br /> •    Require coverage of forensic medical exams with no cost sharing.<br /> •    Require private health plans to provide more data on their mental health benefits.<br /> •    Evaluate health plans on their mental health network adequacy and require plans to submit machine-readable files describing their mental health and substance use disorder benefits.<br />  </p> Wed, 21 Sep 2022 16:01:00 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA) /news/headline/2022-04-28-agencies-release-resources-mental-health-coverage-parity-rights <p>The departments of Health and Human Services, Labor and the Treasury have released <a href="https://www.hhs.gov/about/news/2022/04/27/hhs-new-mental-health-and-substance-use-disorder-benefit-resources-will-help-people-seeking-care-to-better-understand-their-rights.html">three new resources</a> to help Americans know their mental health coverage rights under federal law.</p> <p>“It is vital for people to understand that insurance companies covering mental health and substance use conditions must do so as they would other medical conditions, and to understand the steps consumers can take to seek redress if the requirements of the law are not being met,” said Miriam Delphin-Rittmon, HHS assistant secretary for mental health and substance use. </p> Thu, 28 Apr 2022 14:22:42 -0500 Mental Health Parity and Addiction Equity Act (MHPAEA)