/ en Sat, 26 Apr 2025 02:37:09 -0500 Fri, 28 Mar 25 10:36:59 -0500 /health-care-plan-accountability-update-march-25-2025 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3><a class="ck-anchor" id="challenges"><span>AHA report examines how growth of MA heightens challenges for rural hospitals</span></a></h3><p>A new AHA <a href="/guidesreports/growing-impact-medicare-advantage-rural-hospitals-across-america" target="_blank">report</a> highlights how certain practices by Medicare Advantage plans are increasing rural hospitals' vulnerabilities and threatening access to care in rural communities.   </p><p>In the report, the AHA found that rural hospitals are receiving only 90.6% of Traditional Medicare rates on a cost basis from MA plans. The report also found that insurers’ requirements interfere with clinicians’ ability to provide timely and effective care. For example, 81% of rural clinicians report declines due to insurer requirements. Rural MA patients face longer hospital stays as well, spending 9.6% more time in the hospital before transitioning to post-acute care compared to similar Traditional Medicare patients. Administrative burdens have also grown, with nearly 4 in 5 rural clinicians reporting an increase in administrative tasks over the past five years, and 86% saying these demands have negatively impacted patient outcomes.</p><p>“With MA plans accounting for more than half of total Medicare enrollment and growing, it’s more important than ever that the program works for patients and the providers who care for them,” <a href="/press-releases/2025-02-20-new-aha-report-shows-growing-pressure-medicare-advantage-rural-hospitals-ability-care-communities" target="_blank">said</a> AHA President and CEO Rick Pollack. “It is critical for policymakers to address the harmful impact of Medicare Advantage’s low reimbursements and excessive administrative burdens to help ensure rural hospitals can continue to provide care to their patients and communities." </p><h3><a class="ck-anchor" id="agendas"><span>AHA releases 2025 Advocacy and Rural Advocacy agendas</span></a></h3><p>The AHA released its 2025 <a href="/system/files/media/file/2025/01/AHA-2025-Advocacy-Agenda-20250114.pdf">Advocacy Agenda</a>  detailing the association's key priorities for Congress, the Administration, regulatory agencies and courts. AHA also released its 2025 <a href="/rural-advocacy-agenda" target="_blank" title="2025 Rural Advocacy Agenda">Rural Advocacy Agenda</a> which includes the difficulties rural hospitals face due to challenges imposed by commercial and Medicare Advantage plans. </p><h3><a class="ck-anchor" id="payment"><span>CMS finalizes notice of benefit and payment parameters for 2026 </span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services <a href="https://www.federalregister.gov/documents/2025/01/15/2025-00640/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2026-and" target="_blank">released</a> its standards for the health insurance marketplaces for 2026, including those for the issuers and brokers who assist marketplace enrollees. The final rule enhances CMS' authority to address and curtail misconduct by agents and brokers, such as fraudulent changes to an enrollee's health care coverage. The final rule went into effect Jan. 15.  </p><h3><a class="ck-anchor" id="marketplace"><span>CMS says record 24.2 million enrolled in Marketplace coverage for 2025 </span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services <a href="https://www.cms.gov/newsroom/press-releases/over-24-million-consumers-selected-affordable-health-coverage-aca-marketplace-2025" target="_blank">announced</a> a record 24.2 million consumers selected health coverage through the Health Insurance Marketplace for the 2025 enrollment period that ended Jan. 15. The total was more than double the number of enrollees from 2021, CMS said. Of this year's total, 3.9 million consumers signed up for the first time. </p><h3><a class="ck-anchor" id="partd"><span>AHA supports policy, technical changes to Medicare Advantage, Part D for 2026</span></a> </h3><p>The AHA voiced <a href="/2025-01-27-aha-comments-cms-medicare-advantage-part-d-proposed-rule-contract-year-2026?utm_source=newsletter&utm_medium=email&utm_campaign=aha-today" target="_blank">support</a> for the Centers for Medicare & Medicaid Services' proposed rule on policy and technical changes to Medicare Advantage and Part D for contract year 2026. The proposal includes strengthened oversight of Medicare Advantage Organizations and provided additional protections to ensure MA beneficiary access to basic benefits. It also includes provisions promoting more timely access to care, strengthening behavioral health provider networks, and reducing the administrative burden of plan requirements on health care providers.  <strong> </strong></p><h2><span>MEDICARE ADVANTAGE NEWS </span></h2><h3><a class="ck-anchor" id="insurers"><span>KFF: MA insurers made nearly 50 million prior authorization determinations in 2023</span></a><span> </span></h3><p>An <a href="https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/" target="_blank">analysis</a> by KFF released Jan. 28 found that Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. The finding reflects continued year-over-year increases from 2022 (42 million) and 2021 (37 million) as more people have enrolled in MA. KFF also found that in 2023 there was an average of nearly two prior authorization determinations per MA enrollee.   </p><p>The analysis found that insurers fully or partially denied 3.2 million prior authorization requests (6.4%) in 2023, a smaller share than 2022 (7.4%). In 2023, 11.7% of denied prior authorization requests were appealed in MA and of those cases, 81.7% were partially or fully overturned </p><h2><span>TELL US YOUR STORY</span></h2><p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p><img src="/sites/default/files/inline-images/image_16.png" data-entity-uuid="305ddbc5-61b2-404d-b383-76d70b82b7b2" data-entity-type="file" alt="image" width="759" height="311"><p>Log in to our AHA.org to access the <a href="/healthplanaccountability" target="_blank" title="Health Care Plan Accountability Page">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.</p></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#challenges">AHA report examines how growth of MA heightens challenges for rural hospitals</a></li><li><a href="#agendas">AHA releases 2025 Advocacy and Rural Advocacy agendas</a></li><li><a href="#payment">CMS finalizes notice of benefit and payment parameters for 2026</a></li><li><a href="#marketplace">CMS says record 24.2 million enrolled in Marketplace coverage for 2025</a></li><li><a href="#partd">AHA supports policy, technical changes to Medicare Advantage, Part D for 2026</a></li><li><a href="#insurers">KFF: MA insurers made nearly 50 million prior authorization determinations in 2023</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-1e28dfed40feb1b1a55050134d29634c2486a7a154c5c303d2d8b70326fa2394 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/03/health-plan-accountability-update-3-25-2025.pdf" target="_blank" title="Click here to download the March Health Plan Accountability Update.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Fri, 28 Mar 2025 10:36:59 -0500 Health Plan Accountability Update /health-care-plan-accountability-update-december-2024 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3 id="drugs" name="drugs"><a href="/news/headline/2024-11-26-cms-releases-proposed-rule-2026-medicare-advantage-prescription-drug-plans" target="_blank" title="Article"><span>CMS releases proposed rule for 2026 Medicare Advantage, prescription drug plans</span></a></h3><p>The Centers for Medicare & Medicaid Services Nov. 26 proposed changes to the Medicare Advantage and prescription drug programs for contract year 2026. Those changes would permit coverage of anti-obesity medications in the Medicare and Medicaid programs; fortify existing limitations on insurer use of internal coverage criteria and requirements for MA plans to provide coverage for all reasonable and necessary Medicare Part A and B benefits; and apply additional guardrails to insurer use of artificial intelligence to ensure it does not result in inequitable treatment or access to care. CMS also proposes to update MA and Part D plan medical loss ratio reporting requirements to improve oversight, align reporting with commercial and Medicaid reporting, and request additional information on MLR and vertical integration.</p><h3 id="MAO" name="MAO"><a href="/news/headline/2024-11-12-aha-makes-recommendations-supporting-cms-proposed-mao-data-collection-and-audit-protocol" target="_blank" title="AHA Recommendations">AHA makes recommendations supporting CMS’ proposed MAO data collection and audit protocol</a></h3><p>The AHA Nov. 11 voiced strong support for the Centers for Medicare & Medicaid Services’ proposed plan for data collection and reporting requirements for Medicare Advantage organizations. In addition, the AHA supports CMS’ proposed audit protocol, which would assess MAO compliance with MA utilization management program requirements codified in the calendar year 2024 MA final rule.</p><h2><span>OTHER NEWS</span></h2><h3 id="GAO" name="GAO"><a href="/news/headline/2024-11-15-gao-finds-private-insurance-market-became-increasingly-concentrated-last-decade" target="_blank" title="GAO news article"><span>GAO finds private insurance market became increasingly concentrated last decade</span></a></h3><p>The Department of Health and Human Services' Government Accountability Office Nov. 14 released a report that determined the private health insurance market became increasingly concentrated from 2011-2022. GAO considered a market concentrated if three or fewer insurers held at least 80% of the market share, which it found for individual and employer group markets in at least 35 states. In addition, the GAO found that for the large group market, the number of states where 80% of market share was held by a single insurer doubled from six to 12.</p><h2><span>MEDICARE ADVANTAGE</span></h2><h3 id="analysis" name="analysis"><a href="/news/headline/2024-10-24-analysis-ma-plans-classify-3-4-times-many-hospital-stays-observation-visits-compared-traditional" target="_blank"><span>Analysis: MA plans more likely to classify hospital stays as observation visits, compared with traditional Medicare</span></a></h3><p>A report released Oct. 23 by Kodiak Solutions found that Medicare Advantage plans classified three to four times as many hospital stays as observation visits from July 2023 through June 2024 when compared with traditional Medicare. MA plans began classifying fewer stays as observation visits in January when a new federal regulation required MA plans to offer their members the same services received by traditional Medicare beneficiaries. But MA plans continue to classify hospital stays as observation at a much higher rate than fee-for-service Medicare. Observation rates for MA plans ranged between 18.1% to 20.2% of claims in the final six months of 2023, then fluctuated within a range of 14.4% and 16.1% in the first six months of this year. Meanwhile, observation rates in traditional Medicare within the 12-month period trended at a much lower range of 5.2% to 3.7%.</p><h3 id="oig" name="oig"><a href="/news/headline/2024-10-24-oig-report-finds-insurers-collected-billions-questionable-ma-payments" target="_blank">OIG report finds insurers collected billions in questionable MA payments</a></h3><p>A report released Oct. 24 by the Office of Inspector General for the Department of Health and Human Services found that insurers received an estimated $7.5 billion in Medicare Advantage risk-adjustments for 2023 through health risk assessments and related medical record reviews. OIG said the lack of any other follow-up visits, procedures, tests or supplies for diagnoses in the MA encounter data raises concerns that either the diagnoses are inaccurate, thus the payments are improper, or MA enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews. In-home HRAs and HRA-linked chart reviews generated nearly two-thirds of the estimated $7.5 billion, the report said. According to OIG, UnitedHealth Group and Humana accounted for over $5.4 billion of the estimated $7.5 billion.</p><h2><span>LEGISLATIVE ACTIVITY</span></h2><ul><li><a href="/lettercomment/2024-11-11-aha-responds-cms-medicare-advantage-data-and-audit-proposed-protocol">AHA Responds to CMS Medicare Advantage Data and Audit Proposed Protocol,</a> Nov. 11</li><li><a href="/2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session">AHA Urges Congress to Act on Key Priorities in Lame-duck Session, </a>Nov. 12</li><li><a href="/action-alert/2024-11-13-aha-asks-congressional-leadership-fund-hospitals-protect-health-care-workers">AHA Asks Congressional Leadership to Fund Hospitals, Protect Health Care Workers, </a>Nov. 13</li><li><a href="/press-releases/2024-11-26-aha-statement-cms-medicare-advantage-proposed-rule">AHA Statement on CMS Medicare Advantage Proposed Rule,</a> Nov. 26</li><li><a href="/special-bulletin/2024-11-27-special-bulletin-cms-issues-proposed-rule-cy-2026-medicare-advantage-prescription-drug-plans">Special Bulletin: CMS Issues Proposed Rule for CY 2026 Medicare Advantage, Prescription Drug Plans</a>, Nov. 27</li></ul><h2><span>TELL US YOUR STORY</span></h2><p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p><img src="/sites/default/files/inline-images/image_16.png" data-entity-uuid="305ddbc5-61b2-404d-b383-76d70b82b7b2" data-entity-type="file" alt="image" width="759" height="311"><p>Log in to our AHA.org to access the <a href="/healthplanaccountability" target="_blank" title="Health Care Plan Accountability Page">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.</p></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#drugs">CMS releases proposed rule for 2026 Medicare Advantage, prescription drug plans</a></li><li><a href="#MAO">AHA makes recommendations supporting CMS’ proposed MAO data collection and audit protocol</a></li><li><a href="#GAO">GAO finds private insurance market became increasingly concentrated last decade</a></li><li><a href="#analysis">Analysis: MA plans more likely to classify hospital stays as observation visits, compared with traditional Medicare</a></li><li><a href="#oig">OIG report finds insurers collected billions in questionable MA payments</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-7ef721ebee71ec21e9484e007eb7e6e1928ead96c64c0193db9106ad94adc0ef resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/12/health-care-plan-accountability-update-december-2024.pdf" target="_blank" title="Click here to download the December Health Plan Accountability Update.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Mon, 16 Dec 2024 16:04:56 -0600 Health Plan Accountability Update /health-plan-accountability-update-october-2024 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3 id="question" name="skyrocket"><span>CMS releases new Medicare Advantage question and complaint process</span></h3><p>The Centers for Medicare & Medicaid Services released a new <a href="https://www.cms.gov/medicare/appeals-grievances/managed-care">complaint process</a> for providers seeking assistance from the agency in resolving Medicare Advantage claims issues. MA oversight occurs across ten regional offices; however, with the new complaint process, MA provider inquiries and complaints will be processed through a centralized email, replacing the current process. While CMS reminds providers that the agency’s role is not to determine medical necessity or payment amounts in disputed cases, the agency will seek to identify trends in provider complaints to investigate and address broader issues with MA plans where appropriate. AHA members can see the AHA’s <a href="https://email.advocacy.aha.org/NzEwLVpMTC02NTEAAAGVEIp5H7xmVeAKytpq80hzXFLPxLGP_ZnR7PY3d_zkOj4I8X6M7ORFiAwCc1j30TtZOBKsphk=">Member Advisory</a> for more details on the new CMS process.</p><h3 id="skyrocket" name="skyrocket"><a href="/news/headline/2024-09-10-report-skyrocketing-hospital-administrative-costs-burdensome-commercial-insurer-policies-affecting">Report: Skyrocketing hospital administrative costs, burdensome commercial insurer policies affecting patient care</a></h3><p>Hospitals and health systems are seeing significant increases in administrative costs, including due to burdensome practices by commercial insurers that often delay and deny care for patients, according to a <a href="/guidesreports/2024-09-10-skyrocketing-hospital-administrative-costs-burdensome-commercial-insurer-policies-are-impacting">new report</a> released Sept. 10 by the AHA.  Among other findings, the report highlights recent data from Strata Decision Technology showing that administrative costs alone account for more than 40% of total expenses hospitals incur in delivering care to patients. In addition, between 2022 and 2023, care denials increased an average of 20.2% and 55.7% for commercial and Medicare Advantage claims, respectively. For more on the significant financial pressures that continue to challenge hospitals’ ability to provide 24/7 care for the patients and communities they serve, see the recent <a href="/costsofcaring">AHA Costs of Caring Report</a>.</p><h3 id="agencies" name="agencies"><a href="/news/headline/2024-09-09-agencies-release-final-rule-requiring-mental-health-coverage-parity">Agencies release final rule requiring mental health coverage parity</a></h3><p>The departments of Labor, Health and Human Services and the Treasury Sept. 9 released a final rule 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><h3 id="unforeseen" name="unforeseen"><a href="/news/headline/2024-08-01-report-highlights-unforeseen-health-care-bills-and-coverage-denials-commercial-insurers">Report highlights unforeseen health care bills and coverage denials by commercial insurers</a></h3><p>A <a href="https://www.commonwealthfund.org/publications/issue-briefs/2024/aug/unforeseen-health-care-bills-coverage-denials-by-insurers" target="_blank">Commonwealth Fund report</a> published Aug. 1 examines how frequently insured, working-age adults are denied care by insurers; how often they are billed for services they believed were covered; and their experiences challenging such bills or care denials. The report shows that 45% of insured, working-age adults reported receiving a medical bill or being charged a copayment in the past year for a service they thought should have been free or covered by their insurance. Among other findings, 17% of respondents said that their insurer denied coverage for care that was recommended by their doctor, and nearly six of 10 adults who experienced a coverage denial said their care was delayed as a result.</p><h2><span>MEDICARE ADVANTAGE</span></h2><h3 id="scrutinize" name="scrutinize"><a href="/news/headline/2024-09-17-aha-urges-hhs-oig-further-scrutinize-medicare-advantage-organizations-use-prior-authorization-post">AHA urges HHS OIG to further scrutinize Medicare Advantage organizations' use of prior authorization for post-acute care</a></h3><p>The AHA Sept. 17 urged the Department of Health and Human Services’ Office of Inspector General to further scrutinize policies and practices by certain Medicare Advantage Organizations (MAOs) that impede patient access to post-acute care and circumvent rules designed to ensure access and coverage parity between MA and Traditional Medicare. HHS OIG in June <a href="/news/headline/2024-07-03-hhs-announces-investigation-ma-prior-authorization-use-post-acute-care">initially announced</a> it would examine MAOs' prior authorization denials for post-acute care after a qualifying hospital stay.</p><h3 id="data" name="data"><a href="/news/headline/2024-09-11-cms-accepting-comments-data-collection-audit-requirements-medicare-advantage-plans-regarding">CMS accepting comments on data collection, audit requirements for Medicare Advantage plans regarding compliance with CY 2024 final rule</a></h3><p>The Centers for Medicare & Medicaid services Sept. 10 announced the opening of a <a href="https://www.federalregister.gov/documents/2024/09/10/2024-20400/agency-information-collection-activities-proposed-collection-comment-request" target="_blank">60-day public comment period</a> regarding its proposed plan for new data collection and audit requirements for Medicare Advantage plans in relation to compliance with the<a href="https://www.federalregister.gov/documents/2023/04/12/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program" target="_blank"> contract year 2024 MA final rule</a>. CMS will accept comments until Nov. 12.</p><h3 id="prior" name="prior"><a href="/news/headline/2024-08-06-analysis-medicare-advantage-prior-authorization-requests-increase-9-million-3-years">Analysis: Medicare Advantage prior authorization requests increase by 9 million in 3 years</a></h3><p>More than 46 million prior authorization requests were submitted to Medicare Advantage insurers in 2022, according to KFF <a href="https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022/" target="_blank">analysis</a> released Aug. 6 examining data submitted by MA insurers to the Centers for Medicare & Medicaid Services on prior authorization requests, denials and appeals from 2019 through 2022. The 46 million requests in 2022 increased from 37 million in 2019. MA insurers fully or partially denied 3.4 million (7.4%) prior authorization requests in 2022, which is a larger share of denied prior authorization requests by MA plans compared to previous years. Only one in 10 (9.9%) denials from that year were appealed, however, a majority of those appeals (83.2%) resulted in overturned denials.</p><h2><span>PRIOR AUTHORIZATION</span></h2><h3 id="group" name="group"><a href="/news/headline/2024-08-01-unitedhealth-group-creates-gold-card-program">UnitedHealth Group creates gold card program</a></h3><p>UnitedHealth Group Aug. 1 <a href="https://www.uhcprovider.com/content/dam/provider/docs/public/policies/protocols/UHC-Gold-Card-Program-Protocol.pdf" target="_blank">announced</a> the creation of a gold card program for qualified practices. Under the program, the practices that earn gold card status will not be required to submit prior authorization requests for certain medical, behavioral and mental health services. On Sept. 1, UHG said it will provide a full list of eligible services under <a href="https://www.uhcprovider.com/en/prior-auth-advance-notification/gold-card.html">the program</a> and publish details on how to determine if your provider group has qualified for the program. The program is set to launch Oct. 1.</p><h2><span>LEGISLATIVE ACTIVITY</span></h2><h3 id="house" name="house"><a href="/news/headline/2024-09-11-house-education-and-workforce-committee-holds-hearing-contracting-provisions-telehealth-legislation">House Education and Workforce Committee holds hearing on contracting provisions, telehealth legislation</a></h3><p>The House Education and Workforce Committee advanced several bills Sept. 11, including legislation that would empower commercial insurance companies at the expense of patients and a bill that would ban facility fees for telehealth visits. The AHA sent the committee a <a href="/testimony/2024-09-11-aha-statement-house-committee-education-and-workforce-markup-hearing-sept-11-2024">statement</a> opposing these bills. "This bill includes harmful contracting provisions that would prevent doctors and hospitals from negotiating reasonable agreements with commercial health insurance plans," AHA said about the Healthy Competition for Better Care Act. AHA also opposed the Transparent Telehealth Bills Act of 2024, which would cut hospital reimbursements for telehealth services since payment — including facility fees and any additional services — would be capped for facility-based providers at non-facility rates.</p><h3 id="aging" name="aging"><a href="/news/headline/2024-07-11-senate-aging-committee-holds-hearing-transparency-health-care-costs">Senate Aging Committee holds hearing on transparency, health care costs</a></h3><p>The AHA submitted a <a href="/testimony/2024-07-11-aha-senate-statement-record-health-care-transparency-lowering-costs-and-empowering-patients" target="_blank">statement</a> July 11 for a Senate Special Committee on Aging <a href="https://www.aging.senate.gov/hearings/health-care-transparency-lowering-costs-and-empowering-patients" target="_blank">hearing</a> on health care transparency and lowering health care costs. The AHA highlighted commercial insurer operating methods and prescription drug costs as cost drivers incurred by hospitals and health systems. AHA urged Congress for additional oversight of Medicare Advantage plans to stop tactics that restrict and delay care access and called for regulatory and legislative solutions to improve prior authorization processes</p><h2><span>NEW RESOURCES</span></h2><p><a href="/fact-sheets/2024-08-09-fact-sheet-improving-access-care-medicare-advantage-beneficiaries">Fact Sheet: Improving Access to Care for Medicare Advantage Beneficiaries</a></p><p><a href="/2024-07-24/managed-medicaid-ensuring-quality-health-care-delivery">Data-driven strategies to combat MCO denial tactics</a></p><h2><span>TELL US YOUR STORY</span></h2><p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p><img src="/sites/default/files/inline-images/image_14.png" data-entity-uuid="73fd3bb2-4d29-4a36-b6f1-7eb107bcaece" data-entity-type="file" width="759" height="311"><p>Login to our AHA member site, <a href="/healthplanaccountability">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material. </p><p><strong>CONTACT US</strong> </p><p> </p><table><tbody><tr><td> </td><td> </td><td><p class="text-align-center">Michelle Kielty Millerick<br>Senior Associate Director<br>Health Insurance & <br>Coverage Policy<br><a class="ck-anchor" href="mailto:mmillerick@aha.org" id="mailto:mmillerick@aha.org">mmillerick@aha.org</a></p></td><td> </td><td><p class="text-align-center">Molly Smith<br>Group Vice President<br>Public Policy<br><a class="ck-anchor" href="mailto:mollysmith@aha.org" id="mailto:mollysmith@aha.org">mollysmith@aha.org</a> <br> </p></td></tr></tbody></table><p> </p></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#question">CMS releases new Medicare Advantage question and complaint process</a></li><li><a href="#skyrocket">Report: Skyrocketing hospital administrative costs, burdensome commercial insurer policies affecting patient care</a></li><li><a href="#agencies">Agencies release final rule requiring mental health coverage parity</a></li><li><a href="#unforeseen">Report highlights unforeseen health care bills and coverage denials by commercial insurers</a></li><li><a href="#scrutinize">AHA urges HHS OIG to further scrutinize Medicare Advantage organizations' use of prior authorization for post-acute care</a></li><li><a href="#data">CMS accepting comments on data collection, audit requirements for Medicare Advantage plans regarding compliance with CY 2024 final rule</a></li><li><a href="#prior">Analysis: Medicare Advantage prior authorization requests increase by 9 million in 3 years</a></li><li><a href="#group">UnitedHealth Group creates gold card program</a></li><li><a href="#house">House Education and Workforce Committee holds hearing on contracting provisions, telehealth legislation</a></li><li><a href="#aging">Senate Aging Committee holds hearing on transparency, health care costs</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-ab4d3acda5669470cafe1e0e1fc000ed1f2cea6a7dc105b6276efad2a996a5b3 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"> </div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/10/health-plan-accountability-update-october-2024.pdf" target="_blank" title="Click here to view the Health Plan Accountability Update - October 2024.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Tue, 15 Oct 2024 23:47:39 -0500 Health Plan Accountability Update /health-care-plan-accountability-update-march-28-2024-july-1-2024 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3 id="responds" name="responds"><a href="/news/headline/2024-05-29-aha-responds-cms-request-information-medicare-advantage-data"><span>AHA responds to CMS request for information on Medicare Advantage data</span></a></h3><p>The AHA May 29 submitted a <a href="/lettercomment/2024-05-29-aha-rfi-response-cms-medicare-advantage-data-and-oversight">letter</a> to the Centers for Medicare & Medicaid Services responding to a request for information regarding Medicare Advantage data, urging CMS to increase oversight of the program. The AHA raised concerns about certain prior authorization practices, access to post-acute care services, vertical integration of large, national insurers, and the timeliness of insurer payment for services, among other issues, suggesting additional data collection, reporting and policy changes that could help to improve oversight and transparency in these areas. Finally, the association discussed implications for the continued rapid growth in MA enrollment and how it may affect Traditional Medicare, as well as special considerations for rural and critical access hospitals that may be uniquely affected by growing MA penetration.</p><h2><span>MEDICARE ADVANTAGE</span></h2><h3 id="final" name="final"><a href="/news/headline/2024-04-01-cms-finalizes-medicare-advantage-part-d-payment-changes-cy-2025"><span>CMS finalizes Medicare Advantage, Part D payment changes for CY 2025</span></a></h3><p>The Centers for Medicare & Medicaid Services April 1 finalized proposed changes to Medicare Advantage plan capitation rates and Part C and Part D payment policies for calendar year 2025, which the agency estimates will increase MA plan revenues by an average 3.7% from 2024 to 2025. The notice implements expected changes to the Part C risk adjustment model that were finalized in the CY 2024 final rule and are being phased-in over three years, such as transitioning the model to reflect ICD-10 condition categories and using more recent data available for fee-for-service diagnoses and expenditures, in addition to providing technical updates to the methodology for CY 2025. It also finalizes technical updates to the Part C and D star ratings; includes certain adjustments to provide stability for the MA program in Puerto Rico; and implements changes to the standard Part D drug benefit required by the Inflation Reduction Act of 2022, including capping annual out-of-pocket costs for people with Medicare Part D at $2,000 in 2025. CMS also reminds stakeholders to consider submitting comments to the Medicare Advantage Data Request for Information announced in January; comments are due May 29.</p><p>For more on the rule, see the CMS <a href="https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f">fact sheet</a>. AHA members received a Special Bulletin with further details from the final rule.</p><h3 id="drugplan" name="drugplan"><a href="/news/headline/2024-04-05-cms-finalizes-rule-2025-medicare-advantage-prescription-drug-plans"><span>CMS finalizes rule for 2025 Medicare Advantage, prescription drug plans</span></a></h3><p>The Centers for Medicare & Medicaid Services April 4 finalized changes to the Medicare Advantage and prescription drug programs for contract year 2025 intended to improve access to behavioral health care; cap and standardize MA plan compensation to brokers, including prohibiting volume-based bonuses for enrollment into certain plans; limit the distribution of personal beneficiary data by third-party marketing organizations; ensure that MA plans offer appropriate supplemental benefits; streamline enrollment for individuals dually eligible for Medicare and Medicaid; and annually review MA utilization management policies for health equity considerations.</p><p>Among other changes, the <a href="https://public-inspection.federalregister.gov/2024-07105.pdf">final rule</a> streamlines the appeals process for enrollees if their MA plan terminates coverage for certain post-acute care services; standardizes the appeals process for MA Risk Adjustment Data Validation audit findings; limits out-of-network patient cost-sharing for certain plans serving dually eligible enrollees; and gives Part D plans more flexibility to substitute biosimilars for reference drug products.</p><h3 id="race" name="race"><a href="/news/headline/2024-05-03-cms-report-medicare-advantage-coverage-disparities-based-race-ethnicity-and-sex"><span>CMS releases report on Medicare Advantage coverage disparities based on race, ethnicity and sex</span></a></h3><p>A <a href="https://www.cms.gov/files/document/national-stratified-final.pdf">report</a> from the Centers for Medicare & Medicaid Services examining disparities in care based on race, ethnicity and sex shows that in 2023, clinical care disparities were most common for Native American and African American enrollees. Native American and African American enrollees scored below average on measures in diabetes care, while African Americans additionally scored below average measures in behavioral health, cardiovascular care and care coordination. Results for Asian American, Hispanic, Native Hawaiian or Pacific Islander enrollees were mixed, while scores for male and female MA enrollees on patient experience and clinical care measures were similar.</p><h3 id="prior" name="prior"><a href="/news/headline/2024-05-08-aha-urges-senate-budget-committee-streamline-prior-authorization-process-hearing-reducing"><span>AHA urges Senate Budget Committee to streamline prior authorization process in hearing on reducing administrative burden in health care</span></a></h3><p>In a statement submitted May 8 for a Senate Budget Committee hearing on reducing administrative burden in health care, AHA <a href="/testimony/2024-05-08-aha-statement-senate-budget-committee-alleviating-administrative-burden-health-care">urged</a> Congress to streamline the prior authorization process in Medicare Advantage.</p><p>AHA urged legislators to make prior authorization requirements simpler and more uniform; conduct more frequent audits to specific MA plans with a history of inappropriate denials or delayed prior authorization response timeframes; establish a provider complaint process for suspected federal violations by MA plans; enforce penalties for MA plans failing to comply with federal rules; and provide clarity on states' role in MA oversight.</p><p>Additionally, AHA urged Congress to add prompt payment requirements for MA plans when services are furnished by in-network providers to enrollees and to subject those plans to interest penalties if they fail to make timely payments. AHA also expressed support for legislation supporting gold carding programs, and CMS’s proposed rule to standardize claims attachments under HIPAA.</p><h3 id="GAO" name="GAO"><a href="/news/headline/2024-05-30-gao-report-finds-lack-oversight-medicaid-managed-care-plans-prior-authorization-requirements-children"><span>GAO report finds lack of oversight on Medicaid managed care plans’ prior authorization requirements for children</span></a></h3><p>A <a href="https://www.gao.gov/products/gao-24-106532">report</a> released May 29 by the Government Accountability Office found a lack of state oversight on Medicaid managed care plans’ use of prior authorization for children’s health care services. It found that none of the states sampled reviewed a representative sample of commercial Medicaid plans’ claim denials or used data to assess “the appropriateness of the full scope of plans’ prior authorization decisions.” The study underscores concerns that Medicaid managed care plans may implement policies that deny medically necessary care to children enrolled in Medicaid.</p><h3 id="announce" name="announce"><a href="/news/headline/2024-07-03-hhs-announces-investigation-ma-prior-authorization-use-post-acute-care"><span>HHS announces investigation of MA prior authorization use for post-acute care</span></a></h3><p>The Department of Health and Human Services’ Office of Inspector General the week of June 24 <a href="https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp">announced</a> its intent to investigate Medicare Advantage Organizations’ prior authorization denials for post-acute care after a qualifying hospital stay. </p><p>“Medicare Advantage plans must cover at least the same services as original Medicare, but Medicare Advantage Organizations (MAOs) may impose additional administrative requirements, such as requiring prior authorization before certain services can be provided,” OIG said on its website. “We will examine selected MAOs' processes for reviewing prior authorization requests for post-acute care in long-term acute care hospitals, inpatient rehabilitation facilities and skilled nursing facilities. We will also review the extent to which the selected MAOs denied requests for post-acute care and examine the care settings to which patients were discharged from the hospital.” OIG expects to issue findings in 2026.</p><h2><span>PRIOR AUTHORIZATION</span></h2><h3 id="AMA" name="AMA"><a href="/news/headline/2024-06-20-ama-survey-shows-physicians-patients-heavily-burdened-prior-authorization"><span>AMA survey shows physicians, patients heavily burdened by prior authorization</span></a></h3><p>A majority of physicians say the prior authorization process continues to have a negative impact on patient outcomes and employee productivity, according to a survey by the American Medical Association. Nearly a quarter of physicians (24%) reported that prior authorization led to an adverse event for a patient, and more than nine in 10 reported prior authorization has a negative impact on patient outcomes (93%) and delays access to care (94%). More than a quarter of physicians (27%) reported prior authorization requests are often or always denied, and more than four in five (87%) reported prior authorization requirements lead to higher overall use of resources that result in unnecessary waste.</p><h3 id="access" name="access"><a href="/news/perspective/2024-06-21-continuing-push-medicare-coverage-protects-patient-access"><span>Perspective: Continuing the Push for Medicare Coverage that Protects Patient Access</span></a></h3><p>“Slightly more than half of America’s eligible Medicare population — more than 33 million people — are enrolled in Medicare Advantage (MA) plans, and they are more likely than those in traditional Medicare to report delays in care due to needed insurance approvals” wrote AHA President and CEO Rick Pollack June 21 in his Perspective column. “The misuse or misapplication of prior authorization requirements has led to dangerous delays in treatment, clinician burnout and waste in the health care system.”</p><h2><span>NEW RESOURCES</span></h2><ul><li><p>Costs of Caring: <a href="/news/headline/2024-05-02-new-aha-report-highlights-mounting-financial-challenges-hospitals">New AHA report highlights mounting financial challenges for hospitals</a></p><p>The AHA May 2 released a <a href="/costsofcaring">new report</a> highlighting how hospitals and health systems continue to experience significant financial pressures that challenge their ability to provide 24/7 care for patients and communities.</p></li><li><p><a href="/news/headline/2024-05-31-aha-podcast-impact-prior-authorization-clinicians-and-patients">Podcast: The Impact of Prior Authorization on Clinicians and Patients</a></p><p>Andrea Preisler, AHA senior associate director of administrative simplification policy, Jennifer Cameron, executive director of patient access at Children's National Health System, and David Jacobson, M.D., division chief of blood and marrow transplantation at Children's National Hospital, discuss what the new prior authorization rule means for ensuring clinicians can do what they do best: take care of their patients. <a href="/news/headline/2024-05-31-aha-podcast-impact-prior-authorization-clinicians-and-patients">LISTEN NOW</a></p></li></ul><h2><span>WORTH A LOOK</span></h2><ul><li><a href="https://www.nytimes.com/2024/03/14/opinion/health-insurance-prior-authorization.html?searchResultPosition=1">‘What’s My Life Worth?’ The Big Business of Denying Medical Care</a>, Alexander Stockton, The New York Times, March 14</li><li><a href="https://www.nytimes.com/2024/05/25/science/medicare-seniors-authorization.html">When ‘Prior Authorization’ Becomes a Medical Roadblock</a>, Paula Span, The New York Times, May 25</li><li><a href="https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp">Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care</a>, Department of Health and Human Services Office of Inspector General</li><li><a href="https://www.nytimes.com/2024/04/07/us/health-insurance-medical-bills.html">Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill.</a> Chris Hamby, The New York Times, April 7</li><li><a href="https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d?mod=hp_lead_pos7&mkt_tok=NzEwLVpMTC02NTEAAAGUMwNTQyRp3CFxol5tLAph9l5nAsh7o2Sx9TZI52rT-RarWg-216DELFGoXky6of80vR3LE07QcajzsSp61QA">Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated</a>, Christopher Weaver, Tom McGinty, Anna Wilde Mathews, Mark Maremont, The Wall Street Journal, July 8</li></ul><h2><span>LETTERS/ADVISORIES/STATEMENTS</span></h2><ul><li><a href="/lettercomment/2024-04-09-following-nyt-investigation-aha-urges-dol-investigate-actions-multiplan-and-commercial-insurers">Following NYT Investigation, AHA Urges DOL to Investigate Actions of MultiPlan and Commercial Insurers</a>, April 9</li><li><a href="/special-bulletin/2024-04-12-cms-issues-final-rule-cy-2025-medicare-advantage-prescription-drug-plans">CMS Issues Final Rule for CY 2025 Medicare Advantage, Prescription Drug Plans</a>, April 12</li><li><a href="/testimony/2024-05-08-aha-statement-senate-budget-committee-alleviating-administrative-burden-health-care">AHA Statement to Senate Budget Committee on Alleviating Administrative Burden in Health Care</a>, May 8</li><li><a href="/lettercomment/2024-05-29-aha-rfi-response-cms-medicare-advantage-data-and-oversight">AHA RFI Response to CMS on Medicare Advantage Data and Oversight</a>, May 29</li></ul></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#responds">AHA responds to CMS request for information on Medicare Advantage data</a></li><li><a href="#final">CMS finalizes Medicare Advantage, Part D payment changes for CY 2025</a></li><li><a href="#drugplan">CMS finalizes rule for 2025 Medicare Advantage, prescription drug plans</a></li><li><a href="#race">CMS releases report on Medicare Advantage coverage disparities based on race, ethnicity and sex</a></li><li><a href="#prior">AHA urges Senate Budget Committee to streamline prior authorization process in hearing on reducing administrative burden in health care</a></li><li><a href="#GAO">GAO report finds lack of oversight on Medicaid managed care plans’ prior authorization requirements for children</a></li><li><a href="#announce">HHS announces investigation of MA prior authorization use for post-acute care</a></li><li><a href="#AMA">AMA survey shows physicians, patients heavily burdened by prior authorization</a></li><li><a href="#access">Perspective: Continuing the Push for Medicare Coverage that Protects Patient Access</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-0a1ba771ac463a8113b929675147c477255e4c609cee35dce704317dde26efa0 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/07/health-care-plan-accountability-update-march-28-2024-through-july-1-2024.pdf" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Mon, 08 Jul 2024 00:46:22 -0500 Health Plan Accountability Update /health-plan-accountability-update-march-2024 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3><a href="/news/headline/2024-01-17-cms-finalizes-prior-authorization-rule-hospital-event-highlights-need-rule">CMS finalizes prior authorization rule; hospital event highlights need for rule</a></h3><p>The Centers for Medicare & Medicaid Services Jan. 17 released a <a href="https://www.cms.gov/files/document/cms-0057-f.pdf">final rule</a> requiring Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes. AHA has <a href="/news/news/2023-10-27-aha-reiterates-need-quickly-finalize-cms-prior-authorization-rule">urged</a> the agency to finalize the rule to alleviate provider burden and ensure timely access to care for patients. </p><p>In a statement shared with the media, AHA said, “The AHA commends CMS for removing barriers to patient care by streamlining the prior authorization process. Hospitals and health systems especially appreciate the agency’s plan to require Medicare Advantage plans to adhere to the rule, create interoperable prior authorization standards to help alleviate significant burdens for patients and providers, and to require more transparency and timeliness from payers on their prior authorization decisions.</p><p>“With this final rule, CMS addresses a practice that too often has been used in a manner that leads to dangerous delays in patient treatment and clinician burnout in the health care system. AHA is grateful to CMS for its efforts to improve patient access to care and help clinicians focus on patient care rather than paperwork.”</p><p>CMS Administrator Chiquita Brooks-LaSure Jan. 17 visited Inova Fairfax Medical Campus in Virginia for a tour and roundtable discussion featuring hospital leaders and AHA staff. The event illustrated the patient impact of current prior authorization practices and procedures and the need for reform.</p><h3><a href="/news/perspective/2024-01-19-protecting-patient-care-enhanced-medicare-advantage-oversight-and-prior-authorization-changes">Perspective: Protecting Patient Care with Enhanced Medicare Advantage Oversight and Prior Authorization Changes</a></h3><p>Stated in the Jan. 19 Perspective column, “The good news is that some MA plans live up to their responsibility to support patient care and access. The bad news is that not all of them do, including some of the largest commercial insurers.” </p><h2><span>MEDICARE ADVANTAGE NEWS</span></h2><h3><a href="/news/headline/2023-11-06-house-letter-ai-use-medicare-advantage-denials">House letter on AI use in Medicare Advantage denials</a></h3><p>Over 30 members of the House of Representatives Nov. 3 <a href="https://chu.house.gov/sites/evo-subsites/chu.house.gov/files/evo-media-document/chu-nadler-ma-ai-oversight-letter-11.3.2023.pdf" target="_blank">urged</a> the Centers for Medicare & Medicaid Services to monitor and evaluate how Medicare Advantage plans use artificial intelligence and algorithms to guide their coverage decisions, and ensure these tools comply with Medicare rules and do not create barriers to care. Among specific actions, they urged CMS to require MA plans to report prior authorization data (including the reason for denial) by type of service, beneficiary characteristics and timeliness of prior authorization decisions, and attest that their coverage guidelines are not more restrictive than traditional Medicare. The House members also urged CMS to compare “guidance” generated by these tools with actual MA coverage decisions, and assess the data used to make coverage determinations and whether the AI/algorithms self-correct when a plan denial or premature termination of services is reversed on appeal.</p><p>“Medicare Advantage plans are entrusted with providing medically necessary care to their enrollees,” they wrote. “While CMS has recently made considerable strides in ensuring that this happens, more work is needed with respect to reining in inappropriate use of prior authorization by MA plans, particularly when using AI/algorithmic software.”</p><h3><a href="/news/headline/2023-11-17-report-us-hospitals-face-diminished-reserves-mounting-reimbursement-challenges">Report: U.S. hospitals face diminished reserves, mounting reimbursement challenges</a></h3><p>Payment denials by Medicare Advantage plans jumped 56% for the median health system between January 2022 and June 2023, contributing to a 28% decline in median cash reserves, according to the <a href="https://www.syntellis.com/resources/report/hospital-vitals-financial-and-operational-trends-23" target="_blank">latest analysis</a> of data from over 1,300 hospitals and health systems by Syntellis Performance Solutions and the AHA. At the same time, maintenance expenses jumped 90% due to facility needs deferred during the COVID-19 pandemic, utility expenses rose 35%, professional fee expenses rose 33%, drug expenses rose 30%, and total labor expense rose 24% due to long-running labor shortages and other workforce challenges, the analysis found.<br> <br>“The latest data highlight the persistent challenges that hospitals and health systems face in having the financial resources needed to maintain access to care for their patients, and to be prepared for the next crisis that may arise at any time,” the report notes. “…Such challenges will only worsen unless regulatory agencies conduct greater oversight of problematic payer practices and address other administrative hurdles that further strain hospital resources, deplete cash reserves, and inhibit medically necessary care.”</p><h3><a href="/news/headline/2024-01-05-unitedhealthcare-clarifies-new-hospital-services-review-process-medicare-advantage-plans">UnitedHealthcare clarifies new hospital services review process for Medicare Advantage plans</a></h3><p>UnitedHealthcare has released a <a href="https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/medicare/MedAdv-Hospital-Services-Review-Process-FAQ.pdf" target="_blank">FAQ</a> to clarify its hospital services review process for Medicare Advantage products effective Jan. 1, 2024, under the calendar year 2024 Medicare Advantage final rule. The FAQ explains a <a href="https://www.uhcprovider.com/content/dam/provider/docs/public/policies/index/macs/hospital-services-01012024.pdf" target="_blank">policy</a> the insurer posted last November on hospital, emergency and ambulance services, which took effect Jan. 1.</p><h2><span>MEDICARE ADVANTAGE RULEMAKING</span></h2><h3><a href="/news/headline/2024-01-26-cms-seeks-input-strengthen-medicare-advantage-data-transparency">CMS seeks input to strengthen Medicare Advantage data, transparency</a></h3><p>The Centers for Medicare & Medicaid Services seeks input through May 29 on ways to strengthen Medicare Advantage data to guide policymaking and advance transparency. The <a href="https://public-inspection.federalregister.gov/2024-01832.pdf" target="_blank">request for information</a>, which builds on a similar request in 2022, particularly expresses interest in data recommendations related to: beneficiary access to care, including provider directories and networks; prior authorization and utilization management, including care denials, appeals processes and use of algorithms; cost and use of supplemental benefits; MA marketing and consumer decision-making; care quality and outcomes; the impact of mergers, acquisitions and vertical integration; and special populations, such as individuals dually eligible for Medicare and Medicaid or with complex conditions.</p><p>AHA has<a href="/news/perspective/2024-01-19-protecting-patient-care-enhanced-medicare-advantage-oversight-and-prior-authorization-changes">urged</a> CMS to hold MA plans accountable for inappropriately restricting beneficiary access to medically necessary care, including in <a href="/news/headline/2022-09-01-aha-comments-medicare-advantage-oversight">comments</a> responding to the 2022 RFI and <a href="/news/headline/2024-01-05-aha-comments-proposed-medicare-advantage-policies-2025">recent comments</a> on MA proposals for contract year 2025, which include recommendations on improving data collection and reporting necessary to conduct appropriate oversight of the MA program.</p><h3><a href="/news/headline/2024-01-31-cms-proposes-medicare-advantage-part-d-payment-changes-cy-2025">CMS proposes Medicare Advantage, Part D payment changes for CY 2025</a></h3><p>The Centers for Medicare & Medicaid Services accepted comments through March 1 on its advance<a href="https://www.cms.gov/newsroom/press-releases/cms-releases-proposed-payment-updates-2025-medicare-advantage-and-part-d-programs" target="_blank">notice</a> of proposed changes to Medicare Advantage plan capitation rates and Part C and Part D payment policies for calendar year 2025, which the agency estimates will increase MA plan revenues by an average 3.70%. This amounts to a $16 billion increase in overall payments but represents a -0.16% reduction in the 2025 benchmark rate compared to current policy. The notice proposes updating the Part C risk adjustment model through a phased approach to reflect ICD-10 condition categories, 2018 fee-for-service diagnoses and 2019 FFS expenditures; and Part C and Part D Star Ratings to reflect the latest regulations. It also describes changes and additions to the standard Part D drug benefit under the Inflation Reduction Act of 2022. CMS expects to publish the final 2025 rate announcement by April 1.</p><h3><a href="/news/headline/2024-02-07-cms-releases-faqs-2024-medicare-advantage-rule">CMS releases FAQs on 2024 Medicare Advantage rule</a></h3><p>The Centers for Medicare & Medicaid Services Feb. 6 released <a href="/frequently-asked-questions-faqs/2024-02-07-cms-faqs-2024-medicare-advantage-rule" target="_blank">FAQs</a> clarifying coverage criteria and utilization management requirements for Medicare Advantage plans under its <a href="/news/headline/2023-04-05-cms-issues-final-rule-2024-medicare-advantage-prescription-drug-plans" target="_blank">final rule</a> for calendar year 2024, which includes provisions intended to increase program oversight and create better alignment between MA and Traditional Medicare. Topics addressed by the FAQs include medical necessity determinations; algorithms and artificial intelligence; internal coverage criteria; post-acute care; the two-midnight benchmark for inpatient admission criteria; prior authorization; and enforcement.</p><p>AHA has <a href="/news/headline/2023-11-20-aha-urges-cms-swiftly-correct-ma-polices-violate-cy-2024-rule" target="_blank">urged</a> CMS to increase oversight of the MA program and conduct rigorous enforcement of the new rules, highlighting the need for additional clarification of specific policies to ensure plan compliance.</p><h3><a href="/news/headline/2023-12-14-cms-warns-ma-part-d-plans-and-pbms-comply-new-access-requirements">CMS warns MA, Part D plans and PBMs to comply with new access requirements</a></h3><p>The Centers for Medicare & Medicaid Services will closely monitor Medicare Advantage and Part D plans for compliance with new requirements effective Jan. 1 to ensure timely access to care, medications and vaccinations, the agency <a href="https://www.cms.gov/newsroom/fact-sheets/cms-letter-plans-and-pharmacy-benefit-managers" target="_blank">warned</a> plans and pharmacy benefit managers Dec. 14.<br><br>“We remind plans that CMS will be conducting robust oversight to ensure Medicare Advantage organizations are complying with these new requirements, and we continue to review comments received on the additional proposals from the second rulemaking,” the letter notes. Among other concerns, CMS said, “We urge plans and PBMs to engage in sustainable and fair practices with all pharmacies — not just pharmacies owned by PBMs — and we are closely monitoring plan compliance with CMS network adequacy standards and other requirements.”<br><br>AHA has <a href="/news/headline/2023-11-20-aha-urges-cms-swiftly-correct-ma-polices-violate-cy-2024-rule">urged</a> CMS to swiftly correct plans that appear to violate the MA final rule for calendar year 2024.</p><h2><span>LEGISLATIVE ACTIVITY</span></h2><h3><a href="/news/headline/2024-02-01-aha-releases-2024-advocacy-agenda">AHA releases 2024 advocacy agenda</a></h3><p>AHA Feb. 1 released its 2024 advocacy agenda, which details the association’s key priorities for Congress, the Administration, regulatory agencies and courts. The agenda is focused on ensuring access to care, addressing government underfunding and providing financial sustainability; strengthening the health care workforce; advancing health care quality, equity and innovation; and relieving administrative burden.</p><h3><a href="/news/headline/2023-12-11-senators-call-cms-increase-ma-plan-oversight-reporting-requirements">Senators call for CMS to increase MA plan oversight, reporting requirements</a></h3><p>The Centers for Medicare & Medicaid Services should require Medicare Advantage plans to submit additional data and the agency should publicly release the MA data it already collects, a bipartisan group of senators told the agency in December. The <a href="https://www.warren.senate.gov/imo/media/doc/2023.12.07%20Letter%20to%20Admin.%20Brooks-LaSure%20re%20MA%20Data.pdf" target="_blank">letter</a> requested a staff-level briefing by Dec. 27 on CMS’ plan to improve its data collection and reporting practices for MA plans. <br><br>“Without publicly available plan-level data on prior authorization requests by type of service, timeliness of determinations and reasons for denials; claims and payment requests denied after a service has been provided; beneficiary out-of-pocket spending; and disenrollment patterns, policymakers and regulators are unable to adequately oversee the program and legislate potential reforms,” wrote Sens. Elizabeth Warren, D-Mass.; Bill Cassidy, R-La.; Catherine Cortez Masto, D-Nev.; and Marsha Blackburn, R-Tenn. <br><br>AHA has <a href="/news/headline/2022-05-19-aha-calls-increased-cms-oversight-doj-action-hold-medicare-advantage-plans" target="_blank">urged</a> CMS and the Department of Justice to hold Medicare Advantage plans accountable for inappropriately restricting beneficiary access to medically necessary care; and CMS to rigorously <a href="/lettercomment/2023-11-20-aha-urges-cms-swiftly-correct-medicare-advantage-plan-policies-appear-violate-cy-2024-rule" target="_blank">enforce</a> changes included in the calendar year.</p><h3><a href="/news/headline/2024-01-24-committee-probes-medicare-advantage-marketing-tactics">Committee probes Medicare Advantage marketing tactics</a></h3><p>Senate Finance Committee Chairman Ron Wyden, D-Ore., Jan. 23 <a href="https://www.finance.senate.gov/chairmans-news/wyden-questions-medicare-marketers-business-tactics" target="_blank">asked</a> five third-party marketing organizations that participate in Medicare Advantage enrollment to provide certain information by Jan. 31 about their business practices as the committee continues its inquiry into problematic MA marketing practices. The request to eHealth, GoHealth, Agent Pipeline, SelectQuote, and TRANZACT seeks information on how the organizations use insurance agents, lead generators and other data.<br><br>“It has become clear that the lead generation industry remains a significant factor in the outrageous practices seniors have reported and TPMOs are complicit in these practices through the purchase of leads,” the letter states.</p><h2><span>PRIOR AUTHORIZATION</span></h2><h3><a href="/news/blog/2024-02-15-prior-authorization-final-rule-will-improve-patient-access-alleviate-hospital-administrative-burdens">Prior Authorization Final Rule Will Improve Patient Access, Alleviate Hospital Administrative Burdens</a></h3><p>Andrea Preisler, AHA’s senior associate director of administrative simplification policy, wrote Feb. 15 why the recent final rule requiring Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes should help reduce the burden on hospitals and clinicians and speed needed care for patients.</p><h3><a href="/news/headline/2024-02-22-survey-ma-enrollees-more-likely-report-care-delays-due-prior-authorization">Survey: MA enrollees more likely to report care delays due to prior authorization</a></h3><p>People enrolled in Medicare Advantage are more likely than those in traditional Medicare to report delays in care due to needed insurance approvals, according to a <a href="https://www.commonwealthfund.org/publications/surveys/2024/feb/what-do-medicare-beneficiaries-value-about-their-coverage" target="_blank">survey</a> released Feb. 22 by the Commonwealth Fund, with 13% of traditional Medicare enrollees reporting associated delays compared with 22% of MA enrollees. The survey also included findings related to wait time to see a doctor, beneficiary use of supplemental benefits and overall coverage satisfaction.</p><h3><span>NEW RESOURCES</span></h3><ul type="disc"><li>Handbook: <a href="/guidesreports/2023-11-14-cy2024-medicare-advantage-final-rule-implementation-handbook">CY 2024 Medicare Advantage Final Rule Implementation Handbook</a></li><li>Podcast: <a href="/news/headline/2024-01-31-aha-podcast-effects-medicare-advantage-rural-hospitals-st-bernards-healthcare">The Effects of Medicare Advantage on Rural Hospitals With St. Bernards Healthcare</a></li><li>Webinar: <a href="/webinar-recordings/2023-11-16-medicare-advantage-ma-hospital-perspectives-and-next-steps-cy24-ma-final-rule">Medicare Advantage: Hospital Perspectives and Next Steps on the CY24 MA Final Rule</a></li><li>Study: <a href="/news/headline/2023-12-13-study-commercial-health-insurance-markets-becoming-more-concentrated">Commercial health insurance markets becoming more concentrated</a></li></ul><h2><span>WORTH A LOOK</span></h2><ul><li>Seventy-three percent of U.S. commercial health insurance markets were highly concentrated in 2022, according to the <a href="https://www.ama-assn.org/system/files/competition-health-insurance-us-markets.pdf" target="_blank">latest annual report</a> on health insurance competition by the American Medical Association. In 90% of metropolitan statistical area markets, at least one insurer had a commercial market share of 30% or more, and in 48% of MSAs a single insurer’s share was at least 50%. Fifty-three percent of markets that were highly concentrated in 2014 became even more concentrated by 2022, the study found. Among Medicare Advantage plans, UnitedHealth Group was the largest insurer by market share in 42% of MSAs.</li><li><a href="https://www.statnews.com/2024/03/11/unitedhealth-outpatient-surgery-centers-medicare-advantage-ncp-fresenius/?mkt_tok=NzEwLVpMTC02NTEAAAGRzgmYop3mNraoISDEE1mgCdz5QxWHQ6rY6pJTd3L2FBTD3j6qhAdtBhXKBPJzzpNdpZlUZp8iTi0e-Th2tEE">United Health is on a buying spree of outpatient surgery centers</a>, STAT, Bob Herman, March 11</li></ul><h2><span>LETTERS ADVISORIES AND STATEMENTS</span></h2><ul type="disc"><li><a href="/lettercomment/2023-11-20-aha-urges-cms-swiftly-correct-medicare-advantage-plan-policies-appear-violate-cy-2024-rule">AHA Urges CMS to Swiftly Correct Medicare Advantage Plan Policies That Appear to Violate CY 2024 Rule</a><u>,</u> Nov. 20</li><li><a href="/lettercomment/2023-11-20-aha-urges-cms-swiftly-correct-medicare-advantage-plan-policies-appear-violate-cy-2024-rule">AHA Urges CMS to Swiftly Correct Medicare Advantage Plan Policies That Appear to Violate CY 2024 Rule</a><u>,</u> Nov. 20</li><li><a href="/lettercomment/2023-11-28-aha-expresses-support-no-fees-efts-act">AHA Expresses Support for the No Fees for EFTs Act</a><u>,</u> Nov. 28</li><li><a href="/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket">AHA Urges MedPAC to Examine Medicare Advantage Denials, Hospital Market Baskets</a><u>,</u> Nov. 30</li><li><a href="/lettercomment/2024-01-05-aha-comments-cms-proposed-medicare-advantage-policies-2025">AHA Comments on CMS’ Proposed Medicare Advantage Policies for 2025</a><u>,</u> Jan. 5</li><li><a href="/2024-01-30-aha-statement-health-care-spending-united-states-unsustainable-patients-employers-and-taxpayers">AHA Statement on “Health Care Spending in the United States: Unsustainable for Patients, Employers, and Taxpayers,”</a> Jan. 31</li><li><a href="/2024-02-21-cms-issues-frequently-asked-questions-related-cy-2024-medicare-advantage-final-rule">CMS Issues Frequently Asked Questions Related to CY 2024 Medicare Advantage Final Rule</a><u>,</u> Feb. 21<br><a class="ck-anchor" id="story"></a><span><strong>TELL US YOUR STORY</strong></span></li></ul><p><span><span>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission</span></span></p><img src="/sites/default/files/inline-images/health-plan-accountability-circle-image.png" data-entity-uuid="40a6564f-6193-40ab-b1a3-05acb43c7fa9" data-entity-type="file" alt="health plan accountability image" width="510" height="209" class="align-center"><p><br>Login to our AHA member site, <a href="/healthplanaccountability" target="_blank">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.<br> </p><p class="text-align-center"><span><strong>CONTACT US</strong></span></p><table align="center" border="0" cellpadding="1" cellspacing="1"><tbody><tr><td class="text-align-center">Michelle Kielty Millerick<br>Senior Associate Director<br>Health Insurance & Coverage Policy<br><a href="mailto:mmillerick@aha.org">mmillerick@aha.org</a></td><td class="text-align-center">Molly Smith<br>Group Vice President<br>Public Policy<br><a href="mailto:mollysmith@aha.org">mollysmith@aha.org</a></td></tr></tbody></table></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#prior">CMS finalizes prior authorization rule; hospital event highlights need for rule</a></li><li><a href="#perspective">Perspective: Protecting Patient Care with Enhanced Medicare Advantage Oversight and Prior Authorization Changes</a></li><li><a href="#houselet">House letter on AI use in Medicare Advantage denials</a></li><li><a href="#face">Report: U.S. hospitals face diminished reserves, mounting reimbursement challenges</a></li><li><a href="#united">UnitedHealthcare clarifies new hospital services review process for Medicare Advantage plans</a></li><li><a href="#transparency">CMS seeks input to strengthen Medicare Advantage data, transparency</a></li><li><a href="#proposes">CMS proposes Medicare Advantage, Part D payment changes for CY 2025</a></li><li><a href="#faqs">CMS releases FAQs on 2024 Medicare Advantage rule</a></li><li><a href="#warns">CMS warns MA, Part D plans and PBMs to comply with new access requirements</a></li><li><a href="#agenda">AHA releases 2024 advocacy agenda</a></li><li><a href="#senators">Senators call for CMS to increase MA plan oversight, reporting requirements</a></li><li><a href="#committee">Committee probes Medicare Advantage marketing tactics</a></li><li><a href="#finalrule">Prior Authorization Final Rule Will Improve Patient Access, Alleviate Hospital Administrative Burdens </a></li><li><a href="#survey">Survey: MA enrollees more likely to report care delays due to prior authorization</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-08a9bbc31a40991a2328790771ba1e129b61d68e2848bd1399317a2a8029642e resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/03/health-plan-accountability-update-march-2024.pdf" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Thu, 28 Mar 2024 13:38:13 -0500 Health Plan Accountability Update /health-plan-accountability-update-november-2023 <div class="container"> <div class="row"> <div class="col-md-8"> <p><span><strong>MEDICARE ADVANTAGE</strong></span></p> <h2 id="advantage" name="advantage"><a href="/special-bulletin/2023-11-08-cms-issues-proposed-rule-cy-2025-medicare-advantage-prescription-drug-plans">CMS issues proposed rule for CY 2025 Medicare Advantage, prescription drug plans</a></h2> <p>The proposed rule includes consumer and beneficiary protections as well as policies to promote access to behavioral health, advance health equity and streamline certain operational processes in the MA program. AHA members received a <a href="/special-bulletin/2023-11-08-cms-issues-proposed-rule-cy-2025-medicare-advantage-prescription-drug-plans">Special Bulletin</a> Nov. 8 on the rule.</p> <h2 id="rulecompliance" name="rulecompliance"><a href="/guidesreports/2023-11-14-cy2024-medicare-advantage-final-rule-implementation-handbook">AHA releases guide for monitoring 2024 Medicare Advantage rule compliance</a></h2> <p>AHA Nov. 14 released a guide to help member hospitals and health systems understand and hold Medicare Advantage plans accountable for policy changes effective in January under the final rule for contract year 2024 to increase oversight and better align MA coverage with Traditional Medicare. <a href="/guidesreports/2023-11-14-cy2024-medicare-advantage-final-rule-implementation-handbook">Members can access the guide.</a></p> <h2 id="supportsbill" name="supportsbill"><a href="/news/headline/2023-08-29-aha-supports-bill-offering-providers-gold-card-exemptions-under-medicare-advantage">AHA supports bill offering providers gold card exemptions under Medicare Advantage</a></h2> <p>In an Aug. 28 letter to House sponsors, the AHA <a href="/news/headline/2023-08-29-aha-supports-bill-offering-providers-gold-card-exemptions-under-medicare-advantage">voiced support</a> for the GOLD Card Act of 2023 (H.R. 4968) that would exempt qualifying providers from prior authorization requirements under Medicare Advantage plans. “America’s hospital and health systems support gold carding programs, which substantially reduce administrative burdens and costs and streamline access to care for Medicare beneficiaries,” AHA said in the <a href="/lettercomment/2023-08-28-aha-letter-support-gold-card-act-2023-hr-4968A">letter</a>.</p> <h2 id="drawscrutiny" name="drawscrutiny"><a href="/news/headline/2023-08-31-medicare-advantage-medicaid-managed-care-plans-draw-scrutiny-hhs-watchdog">Medicare Advantage, Medicaid managed care plans to draw scrutiny from HHS watchdog</a></h2> <p>The Health and Human Services Office of Inspector General Aug. 28 released a <a href="https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/Strategic_Plan_Managed_Care.pdf" target="_blank">strategic plan</a> to align its audits, evaluations, investigations and enforcement of managed care plans in Medicare Advantage and Medicaid. HHS OIG said it will evaluate each part of the Medicare Advantage and Medicaid managed care contracts, tracking them from creation to payments to renewals with a goal of promoting access to care for people enrolled in managed care, providing comprehensive financial oversight, and promoting data accuracy and encourage data-driven decisions.</p> <h2 id="drugplans" name="drugplans"><a href="/news/headline/2023-08-31-medicare-advantage-medicaid-managed-care-plans-draw-scrutiny-hhs-watchdog">CMS releases details on Medicare Advantage, drug plans for 2024</a></h2> <p>The Centers for Medicare & Medicaid Services Sept. 26 released <a href="/news/headline/2023-09-27-cms-releases-details-medicare-advantage-drug-plans-2024">premium and cost-sharing information</a> for Medicare Advantage and Part D prescription drug plans for the 2024 calendar year.</p> <p>CMS projects the average monthly premium for MA plans will increase by 64 cents to $18.50 while the average monthly premium for a basic Medicare Part D prescription drug plan will increase by $2.41 to $34.50, as previously announced. The Inflation Reduction Act will continue to limit monthly cost sharing for insulin products to $35 and reduce costs for adult vaccines.</p> <p>Open enrollment for MA and Part D is Oct. 15 through Jan. 15.</p> <p><span><strong>OTHER NEWS</strong></span></p> <h2 id="proposedrule" name="proposedrule"><a href="/news/headline/2023-07-25-proposed-rule-targets-health-plan-mental-health-parity-compliance-0">Proposed rule targets health plan mental health parity compliance</a></h2> <p>The departments of Labor, Health and Human Services and the Treasury July 25 released a proposed rule that seeks to ensure commercial health plans comply with the Mental Health Parity and Addiction Equity Act of 2008, which prohibits them from imposing more restrictive requirements on mental health or substance use disorder benefits than on medical and surgical benefits. AHA submitted a comment letter Oct. 13.</p> <h2 id="healthinsurance" name="healthinsurance"><a href="/news/headline/2023-08-08-aha-op-ed-its-time-hold-commercial-health-insurers-accountable">Health Insurance Barriers Delay, Disrupt and Deny Patient Care</a></h2> <p>“Health insurance should be a bridge to medical care, not a barrier. Yet too many commercial health insurance policies often delay, disrupt and deny medically necessary care to patients,” wrote AHA President and CEO Rick Pollack in an op-ed Aug. 8 in U.S. News & World Report. <a href="https://www.usnews.com/opinion/articles/2023-08-08/health-insurance-barriers-delay-disrupt-and-deny-patient-care" target="_blank">READ MORE</a></p> <h2 id="perspective" name="perspective"><a href="/news/perspective/2023-08-11-inadequate-health-insurance-coverage-drives-medical-debt-four-solutions-address-significant-problem">Perspective: Inadequate Health Insurance Coverage Drives Medical Debt – Four Solutions to Address This Significant Problem</a></h2> <p>“We must tackle the root of the medical debt problem: Ensuring all individuals are enrolled in comprehensive health care coverage with affordable cost-sharing,” wrote AHA President and CEO Rick Pollack Aug. 11 in a column examining the causes of medical debt and offering four solutions to fight the problem of medical debt. <a href="/news/perspective/2023-08-11-inadequate-health-insurance-coverage-drives-medical-debt-four-solutions-address-significant-problem">READ MORE</a></p> <h2 id="naic" name="naic"><a href="/news/headline/2023-08-14-naic-report-calls-regulatory-oversight-aca-preventive-services-requirement">NAIC report calls for regulatory oversight of ACA preventative services requirement</a></h2> <p>A <a href="https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/" target="_blank">new report</a> by the National Association of Insurance Commissioners’ Consumer Representatives released Aug. 14 calls for regulatory oversight to ensure insurers comply with the Affordable Care Act requirement to cover certain preventive services without cost-sharing. The authors reviewed how six individual market plans in different jurisdictions complied with a sample of four services health plans must cover without cost sharing and found that “the ways that insurers organize and expose information to providers and consumers is a meaningful barrier to effective understanding and use of preventive service benefits.”</p> <p>The report recommends that state regulators analyze claims adjudication processes and assess drug formularies to understand whether plans are abiding by coverage and cost-sharing requirements; work with plans to ensure simple and transparent appeals processes for cost-sharing violations; hold plans accountable for educating consumers and providers; and promote uniform billing and coding guidance for use across plans.</p> <p>In light of a recent federal lawsuit challenging the ACA requirement that most health plans cover certain preventive services without cost sharing, the report also recommends commissioners secure voluntary commitments from plans in their states to ensure continued access to these services without cost sharing and monitor and enforce transparency and notice provisions for any plan design change.</p> <h2 id="federalcourt" name="federalcourt"><a href="/news/headline/2023-08-29-federal-court-revives-benefits-denial-class-action-suit-against-uhc-subsidiary">Federal court revives benefits denial class action suit against UHC Subsidiary</a></h2> <p>A three-judge panel in federal court the week of Aug. 21 <a href="/news/headline/2023-08-29-federal-court-revives-benefits-denial-class-action-suit-against-uhc-subsidiary">partially revived</a> a class action lawsuit against UnitedHealth Group subsidiary United Behavioral Health, reversing an earlier decision from 2020. Rehearing their initial decision in favor of UHG, the panel in the U.S. Court of Appeals for the 9th Circuit now ruled that some policyholders may be entitled to relief from United Behavioral Health because of an alleged breach of the organization’s fiduciary duties under the Employee Retirement Income Security Act of 1974, along with wrongful denial of benefits. AHA and other stakeholders filed an <a href="/amicus-brief/2022-05-13-amicus-brief-aha-other-hospital-and-health-care-organizations-re-wit-v">amicus brief</a> urging the panel to reconsider its earlier decision in favor of UHG.</p> <p><span><strong>NEW RESOURCES</strong></span></p> <ul> <li> <p><a href="/education-events/net-impact-payer-denial-tactics-hospitals">WEBINAR: Net Impact of Payer Denial Tactics on Hospitals</a></p> <p>Medicare Advantage payers run a for-profit business model, and any dollar they can avoid paying providers for care is a dollar they can count toward their profits. In this zero-sum game, your hospital’s revenue integrity strategy needs to evolve at the same velocity as the payers’ payment mitigation strategy. The Nov. 2 webinar discussed the range of tactics payers are using against providers and how we’ve partnered with hundreds of hospitals throughout the country to develop strategic programs and data-driven initiatives across the clinical revenue cycle (e.g., utilization management, documentation/coding, managed care/contracting, back-end revenue cycle functions) to combat these tactics.</p> </li> </ul> <p><span><strong>WORTH A LOOK</strong></span></p> <ul> <li><a href="https://www.propublica.org/article/how-often-do-health-insurers-deny-patients-claims" target="_blank">How Often Do Health Insurers Say No to Patients? No One Knows</a>. Robin Fields, Propublica, June 28, 2023</li> <li><a href="https://oig.hhs.gov/oei/reports/OEI-09-19-00350.asp#:~:text=Three%20factors%20raise%20concerns%20that,most%20States%2C%20and%20(3)" target="_blank">High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care</a>, Department of Health and Human Services Office of Inspector General, July 2023</li> <li><a href="https://www.statnews.com/2023/07/11/medicare-advantage-algorithm-navihealth-unitedhealth-insurance-coverage/" target="_blank">How UnitedHealth’s Acquisition of a Popular Medicare Advantage Algorithm Sparked Internal Dissent Over Denied Care</a>, Casey Ross and Bob Herman, July 11, 2023</li> <li><a href="https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/Strategic_Plan_Managed_Care.pdf" target="_blank">Managed Care Strategic Plan</a>, Department of Health and Human Services Office of Inspector General, August 2023</li> <li><a href="https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/" target="_blank">Preventative Services Coverage and Cost-Sharing Protections Are Inconsistently and Inequitably Implemented</a>, National Association of Insurance Commissioners’ Consumer Representatives, August 4, 2023</li> <li><a href="https://www.todaysgeneralcounsel.com/ford-sues-blue-cross-for-price-fixing-and-antitrust-violations/" target="_blank">Ford Sues Blue Cross for Price Fixing and Antitrust Violations</a>, Today’s General Counsel, August 10, 2023</li> <li><a href="https://www.propublica.org/article/the-hidden-fee-costing-doctors-millions-every-year" target="_blank">The Hidden Fee Costing Doctors Millions Every Year</a>, Cezary Podkul, Propublica, August 14, 2023</li> </ul> <p><span><strong><a id="story" name="story"></a>TELL US YOUR STORY </strong></span></p> <p><span><span><span><span><span><span><span><span>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</span></span></span></span></span></span></span></span></p> <img alt="health plan accountability image" data-entity-type="file" data-entity-uuid="40a6564f-6193-40ab-b1a3-05acb43c7fa9" height="209" src="/sites/default/files/inline-images/health-plan-accountability-circle-image.png" width="510" class="align-center"> <p><br> Login to our AHA member site, <a href="/healthplanaccountability" target="_blank">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.<br>  </p> <p class="text-align-center"><strong><span>CONTACT US</span></strong></p> <table align="center" border="0" cellpadding="1" cellspacing="1"> <tbody> <tr> <td class="text-align-center">Michelle Kielty Millerick<br> Senior Associate Director<br> Health Insurance & Coverage Policy<br> <a href="mailto:mmillerick@aha.org">mmillerick@aha.org</a></td> <td class="text-align-center">Molly Smith<br> Group Vice President<br> Public Policy<br> <a href="mailto:mollysmith@aha.org">mollysmith@aha.org</a></td> </tr> </tbody> </table> <p> </p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title"><span>In This Issue:</span></h3> </div> <div class="panel-body"> <ol> <li><a href="#advantage">CMS issues proposed rule for CY 2025 Medicare Advantage, prescription drug plans</a></li> <li><a href="#rulecompliance">AHA releases guide for monitoring 2024 Medicare Advantage rule compliance</a></li> <li><a href="#supportsbill">AHA supports bill offering providers gold card exemptions under Medicare Advantage</a></li> <li><a href="#drawscrutiny">Medicare Advantage, Medicaid managed care plans to draw scrutiny from HHS watchdog</a></li> <li><a href="#drugplans">CMS releases details on Medicare Advantage, drug plans for 2024</a></li> <li><a href="#proposedrule">Proposed rule targets health plan mental health parity compliance</a></li> <li><a href="#healthinsurance">Health Insurance Barriers Delay, Disrupt and Deny Patient Care</a></li> <li><a href="#perspective">Perspective: Inadequate Health Insurance Coverage Drives Medical Debt – Four Solutions to Address This Significant Problem</a></li> <li><a href="#naic">NAIC report calls for regulatory oversight of ACA preventative services requirement</a></li> <li><a href="#federalcourt">Federal court revives benefits denial class action suit against UHC Subsidiary</a></li> </ol> </div> </div> <section class="top-level-view js-view-dom-id-9558bc967a0f59ba3aad350eec7d62df33fef873eb645338106ebd9674b98681 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2023/11/Health-Plan-Accountability-Update-11202023.pdf" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Download the PDF.</a></div> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div> </div> </div> </div> Mon, 20 Nov 2023 09:21:24 -0600 Health Plan Accountability Update /health-plan-accountability-update-july-2023 <div class="container"> <div class="row"> <div class="col-md-8"> <p><br> <span><strong>TOP NEWS</strong></span></p> <h2><a id="advantage" name="advantage"></a>CMS issues final rule for 2024 Medicare Advantage, prescription drug plans</h2> <p><span><span><span><span><span><span>The Centers for Medicare & Medicaid Services April 5 released a <a href="https://www.govinfo.gov/content/pkg/FR-2022-05-09/pdf/2022-09375.pdf" target="_blank">final rule</a> that would increase oversight of Medicare Advantage plans and better align them with Traditional Medicare, address access gaps in behavioral health services and further streamline prior authorization processes. The rule also establishes additional health plan utilization management oversight processes to include required annual reviews of MA plans’ policies and coverage denial reviews by health care professionals with relevant expertise. In addition, the rule would tighten MA marketing rules to protect beneficiaries from misleading advertisements and pressure tactics; expand requirements for MA plans to provide culturally and linguistically appropriate services; make changes to MA star ratings to address social determinants of health; and implement Inflation Reduction Act provisions to make prescription drugs more affordable for eligible low-income individuals. Notably, it appears the proposal to change the legal standard for identifying an overpayment, which was of concern to hospitals and health systems, was not codified in the final regulation.</span></span></span></span></span></span></p> <p>In a <a href="/press-releases/2023-04-05-aha-statement-cms-medicare-advantage-final-rule" target="_blank">statemen</a>t shared with the media April 5, Ashley Thompson, AHA senior vice president of public policy analysis and development, said, “The AHA commends CMS for finalizing critical policies that will help ensure beneficiaries enrolled in Medicare Advantage have access to the medically necessary health care services to which they are entitled. In addition, we appreciate the agency’s increased attention to oversight of Medicare Advantage plans. Hospitals and health systems have raised the alarm that beneficiaries enrolled in some Medicare Advantage plans are routinely experiencing inappropriate delays and denials for coverage of medically necessary care. This rule will go a long way in protecting patients and ensuring timely access to care, as well as reducing inappropriate administrative burden on an already strained health care workforce.</p> <p>“The final rule includes helpful provisions to ensure more consistency between Medicare Advantage and traditional Medicare by curtailing overly restrictive coverage policies that can impede access to care and add cost and burden to the health care system. We also applaud CMS’ attention to addressing access gaps in behavioral health and post-acute care services where our members commonly report some of the most significant insurance-related barriers to patient care. The AHA will continue to carefully review the final rule and urges the agency to conduct rigorous oversight and enforcement to ensure meaningful compliance.”</p> <p>For more details, see the CMS <a href="https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f" target="_blank">fact sheet</a> on the final rule. The AHA May 10 released a members-only Regulatory Advisory on the Medicare Advantage and Part D Final Rule for CY 2024. Members can read the advisory <a href="/advisory/2023-05-10-medicare-advantage-and-part-d-final-rule-contract-year-2024" target="_blank">here</a>.</p> <h2><a id="united" name="united"></a>After Discussions with AHA, UnitedHealthcare Alters GI Policy to Preempt Care Delays and Claims Denials</h2> <p><span><span><span><span><span><span>Following discussions between the ���������� Association and United Healthcare, the insurer announced May 31 a <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/SB-GI_NWB_053123.pdf" target="_blank">refocused gastroenterology policy</a> that relies on additional provider education rather than prior authorizations to address the insurer’s concerns about possible overutilization. Members received a <a href="/special-bulletin/2023-06-01-after-discussions-aha-unitedhealthcare-alters-gi-policy-preempt-care-delays-and-claims-denials" target="_blank">Special Bulletin</a> on June 1 recognizing the AHA’s crucial role in the change. The refocused policy avoids potential care denials for patients, particularly vulnerable patients, and will not impact the coverage and payment of claims for these services. The GI policy, which pertains to certain non-screening endoscopy and colonoscopy services, went into effect June 1.</span></span></span></span></span></span></p> <p>UHC will instead implement a 7-month, or potentially longer, pilot program to collect data that substitutes notification and submission of standard clinical data when services are delivered for prior authorization, removing the risk of potential care delays and claim denials. This data will be applied to UHC’s gold-carding program, beginning sometime in 2024, in order to exempt physicians that are routinely aligned with the insurer’s guidelines. The insurer has yet to determine any additional controls that will be placed on non-gold-carded clinicians at the end of the pilot.</p> <p>The standard data required in advance of care are member information, requested procedure and diagnosis, referring provider information and rendering provider information and site of service. Other potentially relevant details of a patient’s condition or medical history, including the indication for the procedure and the results of prior testing, may also be requested when necessary.</p> <p>The data submitted will be reviewed by a board-certified gastroenterologist for adherence with applicable clinical guidelines and used as an opportunity to engage in physician education where appropriate. The focus on provider education should diminish the risk of patient access issues by removing the need for preauthorization in advance of the service and the accompanying risk of coverage or payment denials. The AHA agrees this refocused policy is a better approach and encourages UHC to implement the program in the most efficient way possible to avoid any duplication in the clinical information requested.</p> <p>“We appreciate UHC refocusing its GI policy on provider education to address member concerns about potential care denials and additional preauthorization requirements,” said Rick Pollack, AHA president and CEO. "We plan to collaborate with UHC to help ensure it meets its goal of providing meaningful education for providers while proactively addressing these concerns.”</p> <h2><a id="struggles" name="struggles"></a>Report: Hospitals struggle to collect payments from commercial insurers</h2> <p><span><span><span><span><span><span><span>One in three inpatient claims submitted by providers to commercial insurers in first quarter 2023 weren’t paid for over three months and 15% of inpatient and outpatient claims were initially denied, according to data from over 1,800 hospitals and 200,000 physicians analyzed by Crowe Revenue Cycle Analytics, AHA reported May 22. That’s nearly three times the number of claims delayed that long in traditional Medicare and over four times the initial denial rate for traditional Medicare claims over the period, <a href="https://www.crowe.com/insights/asset/k/kpi-benchmarking-report-time-for-a-commercial-break" target="_blank">the study found</a>. It also found that eight cents of every dollar providers bill to commercial insurers will never be received or will be taken back once received.</span></span></span></span></span></span></span></p> <p>“Providers feel that they are being forced to jump through hoops and undergo labor-intensive processes in order to receive payment, especially from commercial payors,” <a href="https://www.crowe.com/news/hospitals-revenues-continue-to-decline-due-to-increasing-delays-and-denials-by-commercial-insurers" target="_blank">said</a> Colleen Hall, managing principal of the healthcare group at Crowe. “During a time when labor shortages persist and expenses continue to rise, hospitals’ believe that their time and resources should be spent directly on patient care rather than managing increasingly bureaucratic reimbursement issues with insurers.”</p> <h2><a id="info" name="info"></a>Infographic: New Consumer Poll Finds Patients Are Concerned about Commercial Insurer Barriers to Care</h2> <p><span><span><span><span><span><span><span>AHA July 11 released and <a href="/infographics/2023-07-11-new-consumer-poll-finds-patients-are-concerned-about-commercial-insurer-barriers-care-infographic" target="_blank">infographic</a> showcasing findings of <a href="/press-releases/2023-07-11-new-surveys-find-majority-patients-doctors-nurses-say-health-insurer-policies-reduce-access-care" target="_blank">three new surveys</a> conducted by Morning Consult that examined how some commercial insurer practices impact the patient and provider health care experience. The surveys found that the vast majority of patients, nurses and physicians say insurer policies and practices are reducing access to medical care, driving up health care costs and increasing clinician burden and burnout. </span></span></span></span></span></span></span></p> <h2><a id="insurer" name="insurer"></a>Perspective: Let’s End Commercial Insurer Barriers that Reduce Access to Care</h2> <p><span><span><span><span><span><span>In his July 14 Perspective column, AHA President and CEO Rick Pollack wrote “many commercial health insurance policies and practices often disrupt, delay and deny medically necessary care to patients …Irresponsible commercial insurer policies don’t just limit health care access for patients, they also interfere with doctors’, nurses’ and other clinicians’ ability to do their jobs during a time of severe workforce challenges.” Read the column <a href="/news/perspective/2023-07-14-lets-end-commercial-insurer-barriers-reduce-access-care" target="_blank">here</a>. </span></span></span></span></span></span></p> <p><span><strong>MEDICARE ADVANTAGE</strong></span></p> <h2><a id="invest" name="invest"></a>Senate investigates Medicare Advantage coverage denials and delays</h2> <p><span><span><span><span><span><span><span>AHA May 17 shared with the Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations its concern that some MA plans inappropriately restrict beneficiary access to medically necessary covered services and urged Congress to increase its oversight of these plans. </span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>“These problems with MA plan utilization management and coverage policies have grown so large — and have lasted for so long — that strong, decisive and immediate enforcement action is needed to protect sick and elderly patients, the providers who care for them and American taxpayers who pay MA plans more to administer Medicare benefits to MA enrollees than they do to the Traditional Medicare program,” AHA said in a <a href="/testimony/2023-05-17-aha-statement-senate-subcommittee-medicare-advantage-delays-and-denials" target="_blank">statement</a> submitted to the subcommittee for a hearing on the issue. </span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>To ensure timely patient access, consumer protection and meaningful enforcement of new Centers for Medicare & Medicaid Services’ rules to better align MA coverage policies with Traditional Medicare, AHA urged Congress to direct further oversight of the MA program, including greater data collection and reporting on plan performance and more streamlined pathways to report suspected violations of federal rules. </span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>Testifying at the hearing were the widow of an MA enrollee and witnesses from the Department of Health and Human Services’ Office of Inspector General, Kaiser Family Foundation, Greater Wisconsin Agency on Aging Resources, and Marquette University College of Nursing. </span></span></span></span></span></span></span></p> <h2><a id="denials" name="denials"></a>AHA Statement to Senate Subcommittee on Medicare Advantage Delays and Denials</h2> <p><span><span><span><span><span><span><span>AHA submitted a statement to the Senate Subcommittee on Medicare Advantage Delays and Denials May 17. Read the full text of the statement <a href="/testimony/2023-05-17-aha-statement-senate-subcommittee-medicare-advantage-delays-and-denials" target="_blank">here</a>.</span></span></span></span></span></span></span></p> <h2><a id="model" name="model"></a>CMS releases details on Medicare Advantage model extension</h2> <p><span><span><span><span><span><span><span>The Centers for Medicare & Medicaid Services April 5 released <a href="https://innovation.cms.gov/innovation-models/vbid" target="_blank">additional information</a> on the Medicare Advantage Value-Based Insurance Design Model extension for calendar years 2025 through 2030. <a href="/news/headline/2023-03-23-cms-extend-medicare-advantage-value-based-model-through-2030" target="_blank">Announced last month</a>, the model extension will introduce changes intended to more fully address the health-related social needs of patients, advance health equity and improve care coordination for patients with serious illness. Fifty-two Medicare Advantage organizations representing over 9.3 million enrollees are participating in this year’s model, which focuses on MA plan innovations intended to reduce costs, increase quality and improve care coordination</span></span></span></span></span></span></span></p> <h2><a id="extend" name="extend"></a>CMS to extend Medicare Advantage value-based model through 2030</h2> <p><span><span><span><span><span><span><span>TThe Centers for Medicare & Medicaid Services plans to <a href="https://innovation.cms.gov/innovation-models/vbid" target="_blank">extend</a> the Medicare Advantage Value-Based Insurance Design Model for an additional five years, from 2025 through 2030, introducing changes to support health-related social needs and health equity, AHA reported March 23. Fifty-two Medicare Advantage organizations representing over 9.3 million enrollees are participating in this year’s model, which focuses on MA plan innovations intended to reduce costs, increase quality and improve care coordination. The Center for Medicare and Medicaid Innovation expects to share more information on model updates once available.</span></span></span></span></span></span></span></p> <p><span><strong>NEW RESOURCES</strong></span></p> <ul> <li>Podcast: <a href="/advancing-health-podcast/2023-04-25-cy24-medicare-advantage-final-rule-key-updates-and-changes" target="_blank">The CY24 Medicare Advantage Final Rule: Key Updates and Changes</a></li> </ul> <p><span><strong>WORTH A LOOK </strong></span></p> <ul> <li><span><span><span><span><span><span><span><a href="https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims" target="_blank">How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them</a>, Patrick Rucker, Maya Miller and David Armstrong, ProPublica, March 25, 2023<span> </span></span></span></span></span></span></span></span></li> <li><span><span><span><span><span><span><span><a href="https://energycommerce.house.gov/posts/e-and-c-republicans-press-cigna-for-clarification-after-investigative-report-accuses-insurance-company-of-denying-claims-without-reading-them" target="_blank">E&C Republicans Press Cigna for Clarification After Investigative Report Accuses Insurance Company of Denying Claims Without Reading Them</a>, House Energy and Commerce Committee, May 16, 2023</span></span></span></span></span></span></span></li> <li><span><span><span><span><span><span><span><a href="https://www.kff.org/policy-watch/half-of-all-eligible-medicare-beneficiaries-are-now-enrolled-in-private-medicare-advantage-plans/" target="_blank">Half of All Eligible Medicare Beneficiaries Are Now Enrolled in Private Medicare Advantage Plans</a>, Jeannie Fuglesten Biniek, Meredith Freed, Anthony Damico and Tricia Neuman, KIFF, May 12, 2023</span></span></span></span></span></span></span></li> <li><span><span><span><span><span><span><span><a href="https://www.fiercehealthcare.com/providers/commercial-payers-frequently-delayed-paying-out-providers-claims-q1-report-finds" target="_blank">Commercial payers frequently delayed paying out providers' claims in Q1, report finds</a>, Dave Muoio, Fierce Healthcare, May 19, 2023</span></span></span></span></span></span></span></li> <li><span><span><span><span><span><span><span><a href="https://www.statnews.com/2023/07/17/blue-cross-blue-shield-california-taxes-whistleblower/" target="_blank">Blue Cross Blue Shield plans in California evaded $170 million in taxes, whistleblower says, </a>, Bob Herman, Stat, July 17, 2023</span></span></span></span></span></span></span></li> </ul> <p><span><strong><a id="story" name="story"></a>TELL US YOUR STORY </strong></span></p> <p><span><span><span><span><span><span><span><span>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</span></span></span></span></span></span></span></span></p> <img alt="health plan accountability image" data-entity-type="file" data-entity-uuid="40a6564f-6193-40ab-b1a3-05acb43c7fa9" height="209" src="/sites/default/files/inline-images/health-plan-accountability-circle-image.png" width="510" class="align-center"> <p><br> Login to our AHA member site, <a href="/healthplanaccountability" target="_blank">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.<br>  </p> <p class="text-align-center"><strong><span>CONTACT US</span></strong></p> <table align="center" border="0" cellpadding="1" cellspacing="1"> <tbody> <tr> <td class="text-align-center">Michelle Kielty Millerick<br> Senior Associate Director<br> Health Insurance & Coverage Policy<br> <a href="mailto:mmillerick@aha.org">mmillerick@aha.org</a></td> <td class="text-align-center">Molly Smith<br> Group Vice President<br> Public Policy<br> <a href="mailto:mollysmith@aha.org">mollysmith@aha.org</a></td> </tr> </tbody> </table> <p> </p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title"><span>In This Issue:</span></h3> </div> <div class="panel-body"> <ol> <li><a href="#advantage">CMS issues final rule for 2024 Medicare Advantage, prescription drug plans</a></li> <li><a href="#united">After Discussions with AHA, UnitedHealthcare Alters GI Policy to Preempt Care Delays and Claims Denials</a></li> <li><a href="#struggles">Report: Hospitals struggle to collect payments from commercial insurers</a></li> <li><a href="#info">Infographic: New Consumer Poll Finds Patients Are Concerned about Commercial Insurer Barriers to Care</a></li> <li><a href="#insurer">Perspective: Let’s End Commercial Insurer Barriers that Reduce Access to Care</a></li> <li><a href="#invest">Senate investigates Medicare Advantage coverage denials and delays</a></li> <li><a href="#denials">AHA Statement to Senate Subcommittee on Medicare Advantage Delays and Denials</a></li> <li><a href="#model">CMS releases details on Medicare Advantage model extension</a></li> <li><a href="#extend">CMS to extend Medicare Advantage value-based model through 2030</a></li> </ol> </div> </div> <section class="top-level-view js-view-dom-id-8bbe63f2e3a7958d3ad3dea033a213ca10425386407fb339abf57ffd72102c56 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2023/03/health-plan-accountability-update-march-2023.pdf" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Download the PDF.</a></div> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div> </div> </div> </div> Wed, 19 Jul 2023 12:32:42 -0500 Health Plan Accountability Update <div class="container"> <div class="row"> <div class="col-md-8"> <p><br> <span><strong>TOP NEWS</strong></span></p> <h2><a id="prior" name="prior"></a>AHA urges CMS to finalize prior authorization rule</h2> <p><span><span><span><span><span><span>AHA March 21 urged the Centers for Medicare & Medicaid Services to quickly finalize a proposed rule that would require Medicare Advantage, Medicaid and federally-facilitated Marketplace plans to streamline their prior authorization processes, but urged the agency to adequately enforce and monitor the requirements and test and vet any electronic standards before mandating their adoption.</span></span></span></span></span></span></p> <p><span><span><span><span><span><span>“The proposed rule is a welcome step toward helping patients get timely access to care and clinicians focus their limited time on patient care rather than paperwork,” AHA </span></span></span><a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Femail.advocacy.aha.org%2FNzEwLVpMTC02NTEAAAGKe6EYELIsdptpJReP6Y86MIA_TfM2VOP2FphevGncpBjD2fSjPjOdlGGD8DTc4RyUJhoYcP4%3D&data=05%7C01%7Cmmillerick%40aha.org%7C757957f753f346d3d1c108db24017364%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C638143360904077321%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=NiICRxJkadUUSoME0MR0Png7DKBtW0ZgQdsvaSxBOl4%3D&reserved=0" target="_blank"><span><span><span><span>wrote</span></span></span></span></a><span><span><span>. “However, to truly realize these benefits, we urge CMS to ensure a baseline level of enforcement and oversight. In addition, while hospitals and health systems appreciate CMS’ effort to improve the electronic exchange of care data to reduce provider burden and streamline prior authorization processes, we urge CMS to ensure that any electronic standards are adequately tested and vetted prior to mandated adoption.”</span></span></span></span></span></span></p> <h2><a id="oig" name="oig"></a>OIG: CMS should require MA plans to identify denied claims</h2> <p><span><span><span><span><span><span>The Centers for Medicare & Medicaid Services should require Medicare Advantage organizations to definitively indicate when they deny payment of a claim for service, the Department of Health and Human Services’ Office of Inspector General </span></span></span><a href="https://oig.hhs.gov/oei/reports/OEI-03-21-00380.asp"><span><span><span>recommended</span></span></span></a><span><span><span> March 2. </span></span></span></span></span></span></p> <p><span><span><span><span><span><span>“We found that adjustment codes are not a definitive method for identifying denied claims in the MA encounter data,” OIG said. “The descriptions for some adjustment codes are too vague to clearly identify whether the MAO denied payment for a service. … We also found that most 2019 MA encounter records contained at least 1 adjustment code and 55 million of these records contained codes that may indicate the denial of payments by MAOs. However, without a definitive method for identifying denied claims in the MA encounter data, the full scope of payment denials in the data is unclear.”</span></span></span></span></span></span></p> <p><span><span><span><span><span><span>In a separate </span></span></span><a href="/news/headline/2022-04-28-oig-medicare-advantage-coverage-denials-raise-health-care-access-concerns"><span><span><span>report</span></span></span></a><span><span><span> last year, OIG said CMS also should take steps to prevent MAOs from denying coverage and payment for medically necessary care. </span></span></span></span></span></span></p> <p><span><span><span><span><span><span>AHA has </span></span></span><a href="/news/headline/2022-05-19-aha-calls-increased-cms-oversight-doj-action-hold-medicare-advantage-plans"><span><span><span>urged</span></span></span></a><span><span><span> CMS and the Department of Justice to hold MAOs and other commercial health insurers accountable for inappropriately and illegally restricting beneficiary access to medically necessary care, and CMS to strengthen data collection and reporting of plan performance metrics meaningful to beneficiary </span></span></span><a href="/lettercomment/2022-08-31-aha-comments-cms-request-information-regarding-medicare-advantage-program"><span><span><span>access</span></span></span></a><span><span><span>, including denials, appeals and grievances.</span></span></span></span></span></span></p> <h2><a id="voices" name="voices"></a>AHA voices support for CMS proposals to strengthen MA oversight</h2> <p><span><span><span><span><span><span><span>Commenting Feb. 13 on the Centers for Medicare & Medicaid Services’ proposed policy and technical changes to the Medicare Advantage program for contract year 2024, AHA voiced strong support for proposals to strengthen MA organization oversight and consumer protections and ensure greater equity between Traditional Medicare and the MA program. </span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>“We especially appreciate CMS’ proposals and clarifications to align and ensure greater equity between Traditional Medicare and the MA program and to explicitly codify that MAOs cannot indiscriminately deny services that would have been covered under Traditional Medicare,” AHA </span></span></span></span><a href="/lettercomment/2023-02-13-aha-comments-cms-proposed-rule-policy-and-technical-changes-medicare-advantage-program-cy-2024"><span><span><span><span>wrote</span></span></span></span></a><span><span><span><span>. “We believe the proposed changes will go a long way in ensuring that Medicare beneficiaries have equal access to medically necessary care and consumer protections and that those enrolled in MA will not continue to be unfairly subjected to more restrictive rules and requirements.”</span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>AHA urged CMS to quickly finalize and rigorously enforce these provisions.  </span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>”While these proposals are all critical steps forward in advancing patient access and holding MAOs accountable for adhering to federal rules, we believe a heightened level of enforcement and oversight is needed to facilitate meaningful change,” AHA wrote.</span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>Among other comments, AHA urged CMS to give hospitals and health systems a reasonable timeframe to quantify and return any potential government overpayments once identified.</span></span></span></span></span></span></span></p> <h2><a id="hipaa" name="hipaa"></a>AHA comments on proposed HIPAA transaction standards for health care attachments</h2> <p><span><span><span><span><span><span><span>The Department of Health and Human Services should adopt its proposed standard for claims attachments to help improve claims processing and eliminate unnecessary burdens on health care providers, AHA said in <a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Femail.advocacy.aha.org%2FNzEwLVpMTC02NTEAAAGKpOLAHh4gzUFSK_9INuZR7q2kqtpnXdAZU6HvGk7aVvpmtcdh8zDb1YmeveaJ1XJkPOMNg4Q%3D&data=05%7C01%7Cmmillerick%40aha.org%7C04937c63ecad464c7c5208db2a4cff40%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C638150282445197700%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=6MWwujQmP4M6zRHFWrFpnjdI%2Bmo8x8hGmLrNgG64MJk%3D&reserved=0" target="_blank">comments</a> submitted March 21. However, AHA recommends HHS refrain from proceeding with its proposed standard for prior authorization attachments, which it called inconsistent with a recently proposed Centers for Medicare & Medicaid Services standard for prior authorizations. </span></span></span></span></span></span></span></p> <p><span><span><span><span><span><span><span>HHS March 21 <a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Femail.advocacy.aha.org%2FNzEwLVpMTC02NTEAAAGKpOLAHu7EyZnhCv4X8hhwAB2peDBG-yRzTYnVD7zKsg1oir-aTOvEBTRxGeYAqKJcGjoaR5Y%3D&data=05%7C01%7Cmmillerick%40aha.org%7C04937c63ecad464c7c5208db2a4cff40%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C638150282445197700%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=QqEeXoj1fn9dn7VUhL%2B%2F8mkmTpPa69wber8brdISmSQ%3D&reserved=0" target="_blank">extended the comment deadline</a> for the proposed HIPAA transaction standards for health care attachments through 5 p.m. ET April 21. </span></span></span></span></span></span></span></p> <p class="MsoNormal"><span></span></p> <h2><a id="agenda" name="agenda"></a>AHA releases 2023 Advocacy Agenda</h2> <p><span><span><span><span><span><span>America’s hospitals and health systems are dedicated to providing high-quality care to all patients in every community across the country. The commitment to caring and devotion to advancing health has never been more apparent than during the last three years battling the greatest public health crisis in a century.</span></span></span></span></span></span></p> <p><span><span><span><span><span><span>At the same time, hospitals and health systems are dealing with unprecedented challenges as they manage the aftershocks and aftermath of COVID-19. These include historic workforce shortages, soaring costs of providing care, broken supply chains, severe underpayment by Medicare and Medicaid, and an overwhelming regulatory burden, just to name a few.</span></span></span></span></span></span></p> <p><span><span><span><span><span><span>The ���������� Association has been working to educate policymakers and the public about the significant challenges facing our field. The AHA in 2023 will work with Congress, the Administration, the regulatory agencies, the courts and others to positively influence the public policy environment for patients, communities and the health care field for years to come.</span></span></span></span></span></span></p> <p><span><span><span><span><span><span>Building on the critical support obtained for hospitals and health systems in 2022, our </span></span></span><a href="/system/files/media/file/2023/02/AHA-Advocacy-Agenda-2023.pdf"><span><span><span>2023 Advocacy Agenda</span></span></span></a><span><span><span> is focused on:</span></span></span></span></span></span></p> <ul> <li><span><span><span><span>Ensuring Access to Care and Providing Financial Relief</span></span></span></span></li> <li><span><span><span><span>Strengthening the Health Care Workforce</span></span></span></span></li> <li><span><span><span><span>Advancing Quality, Equity and Transformation</span></span></span></span></li> <li><span><span><span>Enacting Regulatory and Administrative Relief</span></span></span></li> </ul> <p><span><span><span><span><span><span>We will work hand in hand with our members, the state, regional and metropolitan hospital associations, national health care organizations, and other stakeholders to implement our advocacy strategy and fulfill our vision.</span></span></span></span></span></span></p> <p class="MsoNormal"><span></span></p> <p><span><strong>NEW RESOURCES</strong></span></p> <ul> <li><span><span><span><a href="https://www.youtube.com/watch?v=DRwNGwr80KM">Video</a>: AHA Reacts to CMS’ 2024 Medicare Advantage Proposed Rule</span></span></span></li> <li><span><span><span><a href="/webinar-recordings/2023-01-26-webinar-cms-proposed-rules-medicare-advantage-and-prior-authorization-january-23-2023">Webinar</a>: CMS Proposed Rules on Medicare Advantage and Prior Authorization (Jan. 23, 2023)</span></span></span></li> </ul> <p><span><strong>WORTH A LOOK </strong></span></p> <ul> <li><span><span><span><a href="https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/"><span><span><span><span>HealthCare.gov health plans denied 17% of in-network claims in 2021</span></span></span></span></a><span><span><span><span><span>, Kaiser Family Foundation, Feb. 9. 2023</span></span></span></span></span></span></span></span></li> <li><span><span><span><a href="https://www.kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021/?mkt_tok=NzEwLVpMTC02NTEAAAGJuFnqHtdgVmePfdzgCguFmZWvYsQWvAhz3OXrBDGMXm8dQaFpo-G1hMBSlgeXskFbIHLyDcoPCs2W_CbiBE4XbUI_PwNUeVCGMNED-mmCbE4gIQ"><span><span><span><span>When Medicare Advantage plans refuse to preauthorize care for patients, eight in 10 of those denials are overturned on appeal</span></span></span></span></a><span><span><span><span><span>, Kaiser Family Foundation, Feb. 2, 2023</span></span></span></span></span></span></span></span></li> <li><span><span><span><a href="https://www.modernhealthcare.com/legal/unitedhealth-change-healthcare-merger-doj-states-appeal"><span><span><span><span>Feds, states appeal UnitedHealth-Change Healthcare merger</span></span></span></span></a><span><span><span><span><span>, Nona Tepper, Modern Healthcare<i>,</i> Nov. 18, 2022</span></span></span></span></span></span></span></span></li> </ul> <p><span><strong><a id="story" name="story"></a>TELL US YOUR STORY </strong></span></p> <p><span><span><span><span><span><span><span><span>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</span></span></span></span></span></span></span></span></p> <img alt="health plan accountability image" data-entity-type="file" data-entity-uuid="40a6564f-6193-40ab-b1a3-05acb43c7fa9" height="209" src="/sites/default/files/inline-images/health-plan-accountability-circle-image.png" width="510" class="align-center"> <p><span><span><span><span><span><span><span>Login to our AHA member site, </span></span></span></span><a href="/healthplanaccountability"><span><span><span>Health Plan Accountability page</span></span></span></a><span><span><span><span> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material. </span></span></span></span></span></span></span></p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title"><span>In This Issue:</span></h3> </div> <div class="panel-body"> <ol> <li><a href="#prior">AHA urges CMS to finalize prior authorization rule</a></li> <li><a href="#oig">OIG: CMS should require MA plans to identify denied claims</a></li> <li><a href="#voices">AHA voices support for CMS proposals to strengthen MA oversight</a></li> <li><a href="#hipaa">AHA comments on proposed HIPAA transaction standards for health care attachments</a></li> <li><a href="#agenda">AHA releases 2023 Advocacy Agenda</a></li> </ol> </div> </div> <section class="top-level-view js-view-dom-id-b721ab8c3ae1aa115f48e6c617ecc0ff9d9f34594f9badf57471da9077b81714 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2023/03/health-plan-accountability-update-march-2023.pdf" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Download the PDF.</a></div> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div> </div> </div> </div> Mon, 20 Mar 2023 14:12:54 -0500 Health Plan Accountability Update <div class="container"> <div class="row"> <div class="col-md-8"> <p><br> <span><strong>TOP NEWS</strong></span></p> <h2><a id="newreport" name="newreport"></a>AHA releases new report highlighting how some commercial health insurers apply policies that can cause delays in care</h2> <p>AHA released Nov. 2 a new <a href="/guidesreports/2022-11-01-addressing-commercial-health-plan-challenges-ensure-fair-coverage-patients-and-providers?utm_source=newsletter&utm_medium=email&utm_campaign=aha-today" target="_blank">repor</a>t and <a href="/infographics/2022-11-01-survey-commercial-health-insurance-practices-delay-care-increase-costs-infographic" target="_blank">infographic</a> highlighting how some commercial health insurers apply policies can cause dangerous delays in care for patients, result in undue burdens on health care providers and add billions of dollars in unnecessary costs to the health care system.</p> <p>The report, which includes results of surveys conducted by the AHA, found 78% of hospitals and health systems reported their experience working with commercial insurers is getting worse, with fewer than 1% reporting it was getting better. The AHA fielded the surveys in 2019 with more than 200 hospitals responding and again between Dec. 2021 and Feb. 2022 with 772 hospitals responding. While some findings predate COVID-19, recent data reinforces challenges from before the public health emergency that have persisted.</p> <p>The report focuses specifically on patient and hospital experiences with prior authorization and payment delays, denials and appeals. Hospitals and health systems report growing rates of delays and denials for medically necessary care and that appeals frequently result in insurers overturning their earlier decisions. This calls into question the initial denials and the burden associated with challenging them. The tactics highlighted can delay patient care and put even more strain on an already overburdened workforce, with 95% of hospitals and health systems reporting increases in staff time spent seeking prior authorization approvals.</p> <p><span><strong>ADVOCACY </strong></span></p> <h2><a id="ahasubmits" name="ahasubmits"></a>AHA submits 43-page letter to CMS highlighting Medicare Advantage concerns and recommendations</h2> <p>On Aug. 31, AHA <a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Femail.advocacy.aha.org%2FNzEwLVpMTC02NTEAAAGGmfP_8pcPoQKp1OJHRNa9bAMoXz0jFHHOknpBUvrvLnfWvKS1xP6reAFQCVBKGripa6sM564%3D&data=05%7C01%7Cmmillerick%40aha.org%7Cca93da64270e4bd6fe5608da8c61f5f6%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C637976649625790983%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=KQAfjX6vEXtJIHd8T%2FVFmljUR1CW%2BfKPED8TGsKBzXg%3D&reserved=0" target="_blank">submitted comments</a> to the Centers for Medicare & Medicaid Services in response to a request for information on the Medicare Advantage program. AHA in its letter raised concerns over certain Medicare Advantage organization practices and policies that restrict or delay access to care; provided considerations for health equity, behavioral health access, and post-acute care services; outlined implications for continued enrollment growth in the program; and described the unique value that integrated health systems provide in serving Medicare Advantage beneficiaries. In addition, AHA provided a series of “specific recommendations that we believe are necessary to hold [Medicare Advantage organizations] accountable for complying with the law, protecting beneficiaries from harm and ensuring the sustainability of the Medicare program.”</p> <h2><a id="housepasses" name="housepasses"></a>House passes AHA-supported bill to streamline MA prior authorizations</h2> <p>The House passed by voice vote Sept. 14 the Improving Seniors’ Timely Access to Care Act (H.R. 3173), <a href="/lettercomment/2022-07-27-aha-voices-support-improving-seniors-timely-access-care-act-2022-hr-8487" target="_blank">AHA-supported</a> legislation that would streamline prior authorization requirements under Medicare Advantage plans. The bill would establish an electronic prior authorization process and reduce how long a health plan can consider a prior authorization request; create a “real-time decisions” process for routinely approved services; require plans to report on their prior authorization use and rate of approvals and denials; and encourage plans to adopt policies that adhere to evidence-based guidelines.</p> <p>“Hospitals and health systems commend the U.S. House of Representatives for their passage of the Improving Seniors’ Timely Access to Care Act,” <a href="/press-releases/2022-09-14-aha-statement-improving-seniors-timely-access-care-act" target="_blank">said</a> AHA Executive Vice President Stacey Hughes. “In particular, we thank Reps. DelBene, Kelly, Bera and Buschon and the leadership of the Ways and Means and Energy and Commerce Committees for their work on this important issue. This legislation takes important steps to reduce the burden and complexity of prior authorization requirements imposed by Medicare Advantage plans. These provisions will help Medicare patients access the care they need in a timely manner while reducing the strain on our already taxed health care workforce. The AHA is encouraged by Senate support on companion legislation and urges them to take action on these critical protections.”</p> <h2><a id="ahasends" name="ahasends"></a>AHA sends letter to Secretaries of Health and Human Services and Labor urging the Administration to ensure adequate oversight of commercial health insurers</h2> <p>In a <a href="/lettercomment/2022-11-01-letter-hhs-and-dol-addressing-commercial-health-plan-challenges-ensure-fair-coverage" target="_blank">letter</a> sent to Health and Human Services Secretary Xavier Becerra and Department of Labor Secretary Martin Walsh on Nov. 1, the AHA stressed the importance of comprehensive coverage for patients and urged the Administration to take additional actions to ensure adequate oversight of commercial health insurers. “We are deeply troubled to see certain commercial health insurers eroding the quality of coverage by erecting barriers to care and pushing more of the cost of care onto patients,” the letter says. “The actions of some commercial insurers undermine these benefits and protections by increasing the complexity patients face in navigating the health care system and leaving patients vulnerable to unnecessary delays in care, or, in some cases, the denial of medically necessary care that should be covered.”</p> <h2><a id="wallstreet" name="wallstreet"></a>Wall Street Journal advertorial calls for end to commercial insurer policies that hurt patients, raise costs</h2> <p>Some commercial insurer policies may hurt patients, contribute to clinician burnout and drive up the cost of care, AHA President and CEO Rick Pollack noted in an <a href="/news/headline/2022-08-16-aha-calls-end-commercial-insurer-policies-hurt-patients-raise-costs" target="_blank">advertorial</a> published Aug. 16 in the Wall Street Journal.</p> <h2><a id="ahapublishes" name="ahapublishes"></a>AHA publishes new Medicare Advantage Fact Sheet</h2> <p>AHA recently published a fact sheet Sept. 14 highlighting policy recommendations and opportunities to improve access to care for Medicare Advantage beneficiaries. Specifically, the AHA urges Congress to pass legislation to improve the oversight of MA plans and the ability of CMS to enforce existing regulations that are intended to ensure appropriate beneficiary access to medically necessary services. Additionally, congressional action is needed to specifically prohibit MA plans from using medical necessity criteria that is more restrictive than the criteria used for patients enrolled in traditional Medicare.</p> <p><span><strong>NEW RESOURCES</strong></span></p> <ul> <li><a href="/infographics/2022-11-01-survey-commercial-health-insurance-practices-delay-care-increase-costs-infographic" target="_blank">Infographic</a>: Commercial Health Insurance Practices That Delay Care, Increase Costs</li> <li><a href="/webinar-recordings/2022-10-11-insurer-watch-leverage-data-hold-payers-accountable" target="_blank">Members-only Webinar</a>: Insurer Watch: Leverage Data to Hold Payers Accountable</li> <li><a href="/news/blog/2022-10-10-cbos-proposals-do-not-address-real-causes-rising-commercial-health-insurance" target="_blank">Blog</a>: CBO’s Proposals Do Not Address the Real Causes of Rising Commercial Health Insurance Premiums</li> <li><a href="/advancing-health-podcast/2022-09-23-special-edition-how-prior-authorizations-can-harm-patient-care" target="_blank">Podcast</a>: How Prior Authorizations Can Harm Patient Care</li> <li><a href="/news/perspective/2022-07-29-protecting-access-care-confronting-commercial-insurers-harmful-policies" target="_blank">Perspective</a>: Protecting Access to Care by Confronting commercial Insurers’ Harmful Policies</li> </ul> <p><span><strong>WORTH A LOOK </strong></span></p> <ul> <li><em><a href="https://news.bloomberglaw.com/health-law-and-business/unitedhealth-results-look-good-for-payers-bad-for-hospitals-2" target="_blank">UnitedHealth Results Look Good for Payers, Bad for Hospitals</a></em><br> By John Tozzi, Bloomberg News, July 15, 2022</li> <li><em><a href="https://www.statnews.com/2022/07/18/unitedhealth-medicare-advantage-data-says-otherwise/?mkt_tok=ODUwLVRBQS01MTEAAAGFsCifbXk6dWdyM8vChS5KUgf0Xpch7NzXrMX6AZnvSLFoXZd4g5irCzaQFe7cC9DuxAHbAe8sbTeu2DSTQvNwlbEcYO7WJ8r6nqQg2IrMVM-b" target="_blank">UnitedHealth Group says Medicare Advantage saves money, but the data say otherwise</a></em><br> By Bob Herman, STAT, July 18, 2022</li> <li><em><a href="https://www.statnews.com/2022/07/18/unitedhealth-medicare-advantage-data-says-otherwise/?mkt_tok=ODUwLVRBQS01MTEAAAGFsCifbXk6dWdyM8vChS5KUgf0Xpch7NzXrMX6AZnvSLFoXZd4g5irCzaQFe7cC9DuxAHbAe8sbTeu2DSTQvNwlbEcYO7WJ8r6nqQg2IrMVM-b" target="_blank">Competition in Commercial PBM Markets and Vertical Integration of Health Insurers with PBMs</a></em><br> By José R. Guardado, American Medical Association, Oct.13, 2022</li> <li><a href="https://www.finance.senate.gov/imo/media/doc/Deceptive%20Marketing%20Practices%20Flourish%20in%20Medicare%20Advantage.pdf?mkt_tok=NzEwLVpMTC02NTEAAAGH5tpStw7B0YayaDm5xMajsSRLUqZ08G5gwDMq3Tkv0NAaMyMbbqotg_7wFkREhZFPMqOHaS5aPheSZsAfF_d4Ix31g0KviKHC2ZnsRXEK-qwD" target="_blank">Deceptive Marketing Practices Flourish in Medicare Advantage</a>,<br> U.S. Senate Committee on Finance, Nov. 2, 2022</li> </ul> <p><span><strong>SPOTLIGHT </strong></span></p> <h2><a id="propublica" name="propublica"></a>ProPublica Investigation on Medical Care Denials</h2> <p>ProPublica has launched <a href="https://www.propublica.org/getinvolved/insurance-denial-health-care-investigation" target="_blank">an investigation</a> into health insurance denials including the causes for denials of medical care, the consequences for patients and the appeals process. They are soliciting information, examples, and patient stories from the public, including patients and health care providers through their website.</p> <p><span><strong><a id="story" name="story"></a>TELL US YOUR STORY </strong></span></p> <p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p> <img alt="health plan accountability image" data-entity-type="file" data-entity-uuid="40a6564f-6193-40ab-b1a3-05acb43c7fa9" height="209" src="/sites/default/files/inline-images/health-plan-accountability-circle-image.png" width="510" class="align-center"> <p>Login to our AHA member site, <a href="/healthplanaccountability" target="_blank">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.</p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title"><span>In This Issue:</span></h3> </div> <div class="panel-body"> <ol> <li><a href="#newreport">AHA AHA releases new report highlighting how some commercial health insurers apply policies that can cause delays in care </a></li> <li><a href="#ahasubmits">AHA submits 43-page letter to CMS highlighting Medicare Advantage concerns and recommendations</a></li> <li><a href="#housepasses">House passes AHA-supported bill to streamline MA prior authorizations</a></li> <li><a href="#ahasends">AHA sends letter to Secretaries of Health and Human Services and Labor urging the Administration to ensure adequate oversight of commercial health insurers</a></li> <li><a href="#wallstreet">Wall Street Journal advertorial calls for end to commercial insurer policies that hurt patients, raise costs</a></li> <li><a href="#ahapublishes">AHA publishes new Medicare Advantage Fact Sheet</a></li> <li><a href="#propublica">ProPublica Investigation on Medical Care Denials </a></li> <li><a href="#story">Tell Us Your Story</a></li> </ol> </div> </div> <section class="top-level-view js-view-dom-id-a7cd5a68dbb7f3f5eb850309a7218dd35b4829c5423710fdd59df355912b3e10 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2022/11/health-plan-accountability-update-nov-2022.pdf" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Download the PDF.</a></div> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div> </div> </div> </div> Fri, 11 Nov 2022 22:53:17 -0600 Health Plan Accountability Update <div class="container"> <div class="row"> <div class="col-md-8"> <p><span><strong>TOP NEWS</strong></span></p> <h2 id="cmsoversight">AHA calls for increased CMS oversight, DOJ action to hold Medicare Advantage plans accountable</h2> <p>The AHA today urged the Centers for Medicare & Medicaid Services to “take swift action to hold Medicare Advantage plans accountable for inappropriately and illegally restricting beneficiary access to medically necessary care,” citing in part a recent <a href="/news/headline/2022-04-28-oig-medicare-advantage-coverage-denials-raise-health-care-access-concerns">report</a> from the Department of Health and Human Services’ Office of Inspector General that found an estimated 13% of prior authorization denials and 18% of payment denials should have been granted.</p> <p>“Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program,” AHA <a href="/lettercomment/2022-05-19-aha-urges-cms-hold-medicare-advantage-plans-accountable-inappropriately">wrote</a>. “This results in delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms. In addition, they add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements. … The findings of the HHS-OIG report, as well as the broader experience of MA beneficiaries, hospitals, and health systems, clearly indicates that greater oversight of MA plans is needed to ensure appropriate beneficiary access to care.”</p> <p>AHA recommended CMS take certain steps to increase MA plan oversight, improve patient access to care and address the issues raised in the OIG report. It also requested a meeting with CMS to further discuss these concerns.</p> <h3>AHA calls for task force to investigate False Claims Act violations</h3> <p>In a <a href="/lettercomment/2022-05-19-aha-department-justice-re-false-claims-act-investigations">separate letter</a>, AHA urged the Justice Department to establish a task force to conduct False Claims Act investigations into commercial health insurance companies that are found to routinely deny patients access to services and deny payments to health care providers.</p> <p>“It is time for the Department of Justice to exercise its False Claims Act authority to both punish those [Medicare Advantage Organizations] that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds,” AHA told the agency. “… And it is time for the Civil Division to focus more directly on the commercial insurers who commit this fraud. The AHA therefore urges you to create a ‘Medicare Advantage Fraud Task Force’ to investigate those MAOs that are failing to live up to the commitments they make to the federal government and the Medicare beneficiaries they have been entrusted to serve.”</p> <p>For more on the issue, see the recent <a href="/advancing-health-podcast/2022-05-12-special-edition-medicare-advantage-new-trends-raise-concerns">AHA Advancing Health podcast</a>, which examines how commercial insurers are impacting patient care through their policies.</p> <hr> <p><span><strong>ADVOCACY ON PRIOR AUTHORIZATION</strong></span></p> <h2 id="rulemaking">AHA comments on potential rulemaking to improve electronic prior authorization processes</h2> <p>In <a href="/lettercomment/2022-03-18-aha-comments-potential-rulemaking-improve-electronic-prior-authorization">comments</a> submitted March 18th to the Office of the National Coordinator for Health Information Technology, AHA said it “strongly supports creating a useable, scalable and efficient solution to help reduce prior authorization impacts on patients and providers. However, we urge ONC — in collaboration with the Centers for Medicare & Medicaid Services — to pilot the technologies and workflows described in the rule prior to taking any regulatory steps, including certification or codification of standards to minimize unintended negative consequences, such as an inadvertent increase in costs or burden in the health care system.”</p> <h2 id="mapriorauthorization">AHA urges changes to MA prior authorization requirements for public health emergencies</h2> <p>In a comment letter submitted March 7th, AHA encouraged the Centers for Medicare & Medicaid Services to work with Congress to require Medicare Advantage plans to waive prior authorization and other utilization management policies during public health emergencies, especially for hospitals transferring patients to post-acute care.</p> <p>While many plans worked with providers to waive or relax onerous prior authorization requirements during the COVID-19 emergency, others did not or only did so during the initial stages, exacerbating capacity issues, delaying patient care and resulting in inappropriate denials, AHA wrote, responding to a request for information on the issue included in CMS’ proposed rule for the MA program in 2023.</p> <p>The <a href="/lettercomment/2022-03-07-aha-comments-cms-urging-changes-ma-prior-authorization-requirements-public">AHA letter</a> also points to issues and concerns regarding access to appropriate behavioral health specialties in MA and recommends that CMS collect and publicly display data on the adequacy of MA behavioral health coverage. Finally, the letter offers general support for additional health plan oversight provisions included in the proposed rule.</p> <hr> <p><span><strong>LEGAL EFFORTS</strong></span></p> <h2 id="dojsues">DOJ sues to stop UnitedHealth from acquiring Change Healthcare</h2> <p>In March, the Justice Department joined Minnesota and New York in filing a <a href="https://www.justice.gov/opa/press-release/file/1476676/download" target="_blank">federal lawsuit</a> to stop UnitedHealth Group from acquiring Change Healthcare, alleging the proposed $13 billion transaction would harm competition in commercial health insurance markets and in the market for a vital technology used to process claims and reduce health care costs.</p> <p>“If America’s largest health insurer is permitted to acquire a major rival for critical health care claims technologies, it will undermine competition for health insurance and stifle innovation in the employer health insurance markets,” said Attorney General Merrick Garland. “The Justice Department is committed to challenging anticompetitive mergers, particularly those at the intersection of health care and data.”</p> <p>In a <a href="/press-releases/2022-02-24-aha-statement-department-justice-decision-proposed-unitedhealth-group">statement</a>, AHA General Counsel Melinda Hatton said, “The ���������� Association commends the Department of Justice for its efforts to protect patients and providers, including hospitals and health systems, from UnitedHealth Group’s attempt to acquire Change Healthcare. The AHA urged DOJ’s Antitrust Division to conduct a thorough investigation of the proposed transaction because of its anticompetitive potential to ‘produce a massive consolidation of competitively sensitive health care data’ under UHG’s exclusive control. We warned repeatedly ‘the combination of the parties data sets would impact (and likely distort) decisions about patient care and claims processing and denials to the detriment of consumers and health care providers ….’ Challenging this proposed combination was the right thing to do to prevent untold competitive harm for patients and health care providers.</p> <p>“Had DOJ allowed this transaction to move forward, it would have permitted a massive concentration of sensitive health care data in the hands of a single, powerful owner with an inherent conflict of interest. There is every indication that it is Change Healthcare that constrains UHG’s largest subsidiary’s (Optum) ability to prejudice payment accuracy in favor of its own financial outcomes by means of increased patient payment denials and coverage restrictions. And, allowing Optum the opportunity to own and then manipulate Change’s proprietary evidence-based clinical support criteria (InterQual) also would have allowed UHG to build its corporate profits by increasing patient claim denials.”</p> <h2 id="federaljudge">Federal judge in Texas strikes part of surprise billing rule</h2> <p>A federal judge in Texas last night struck down certain parts of the federal government’s surprise medical billing regulations related to the arbitration process for determining payment for services by out-of-network providers, saying the regulations conflict with the text of the No Surprises Act.</p> <p>The judge <a href="https://sponsors.aha.org/rs/710-ZLL-651/images/2022.02.23-TMA%20v.HHS-Mem.Op.pdf" target="_blank">ruled</a> in favor of the Texas Medical Association in its challenge of the Biden Administration’s Sept. 30, 2021, rule that directed arbiters under the independent dispute resolution process to presume that the median in-network rate is the appropriate out-of-network rate and limit when and how other statutory factors come into play.</p> <p>“The Court determines that the Act unambiguously establishes the framework for deciding payment disputes and concludes that the Rule conflicts with the statutory text,” wrote U.S. District Judge Jeremy Kernodle.</p> <p>The rule and provision took effect Jan. 1, 2022, and arbitrations were expected to begin in the spring. Yesterday’s court ruling struck down the challenged provisions for all providers throughout the country who may be subject to them. It did not strike down any of the patient protections of the No Surprises Act.</p> <p>The AHA and American Medical Association in December filed a <a href="/press-releases/2021-12-09-hospital-and-physician-groups-file-lawsuit-over-no-surprises-act-final">separate lawsuit</a> challenging parts of the rule saying the regulation places a heavy thumb on the scale of an independent dispute resolution process, unfairly benefiting commercial health insurance companies. The AHA and AMA lawsuit is being considered in the U.S. District Court for the District of Columbia.</p> <hr> <p><span><strong>NEW TOOLS</strong></span></p> <p id="ahavitalityindex"><img alt="AHA Vitality Index. An operational metrics dashboard focused on revenue flow, divided into four quadrants to measure Velocity, Variety, Volatility, and Value." data-entity-type="file" data-entity-uuid="2f1f30de-b5eb-4743-85f1-55307bcb46ca" src="/sites/default/files/inline-images/AHA-Vitality-Index-banner.png" width="1672" height="551"></p> <p>The COVID-19 pandemic has exposed commercial health insurance plan practices that are impacting patient access and choices for care and driving excessive administrative costs and burden in the health care system. These practices — including use of prior authorization, denials of unanticipated but medically necessary care (like emergency services and early sepsis interventions), and <a href="/guidesreports/2021-08-16-anticompetitive-conduct-commercial-health-insurance-companies">anticompetitive conduct</a> — are adversely affecting patients and providers.</p> <p>A recent AHA survey of hospitals and health systems found that 89% of respondents experienced an increase in payment denials over the past three years, and 51% reported experiencing a “significant” increase in denials.</p> <p><a href="https://www.ahadata.com/aha-vitality" target="_blank">AHA Vitality Index™</a>, a new solution from the AHA in collaboration with ATEX Financial, can help your team uncover how often your organization’s payment claims are denied, determine if those denial rates vary by payer or service line, and compare your organization’s metrics to other providers and peer groups.</p> <p>The AHA Vitality Index benchmarking solution gives you access to aggregated, de-identified hospital data, so your team can analyze the operational and financial efficiency of your hospital compared to the rest of the field. It will arm the hospital field with the data it needs to hold commercial health plans accountable for burdensome practices, while also enabling individual hospitals to benchmark their financial and operational performance on key metrics.</p> <p><a href="https://www.ahadata.com/aha-vitality" target="_blank">Click here to learn more</a> and watch a brief online demonstration.</p> <hr> <p><span><strong>LOOKING TOWARD THE FUTURE</strong></span></p> <div class="row"> <div class="col-md-3"> <p id="bluecard"><img alt="BlueCard Program logo" data-entity-type="file" data-entity-uuid="3e017fe1-85f1-4542-a58b-ca6ac0c737ed" src="/sites/default/files/inline-images/BlueCard-Program-logo.png" width="232" height="108"></p> </div> <div class="col-md-9"> <h2>BlueCard</h2> <p>AHA is developing a factsheet on the operational and anti-competitive concerns regarding Blue Cross Blue Shield’s BlueCard program and supporting ongoing legal efforts to resolve these issues.</p> </div> </div> <div class="row"> <div class="col-md-3"> <p id="whitebagging"><img alt="A white bag with RX printed on it." data-entity-type="file" data-entity-uuid="e046260e-610c-4d4b-a7a1-2df22cdc53de" src="/sites/default/files/inline-images/White-Bagging-and-Specialty-Pharmacy.jpg" width="200" height="200"></p> </div> <div class="col-md-9"> <h2>White Bagging & Specialty Pharmacy</h2> <p>AHA is exploring state and federal policy levers to curb insurer-mandated white bagging, as well as developing additional materials and an infographic to support advocacy efforts.</p> </div> </div> <hr> <p><span><strong>SPOTLIGHT</strong></span></p> <h2 id="ama">AMA releases physician survey on prior authorization</h2> <p>The American Medical Association (AMA) published its annual physician survey on the burden of prior authorization last month. The survey results and <a href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank" title="AMA: 2021 AMA prior authorization (PA) physician survey">infographic</a> highlight the negative impact of prior authorization on patients, physicians, and employers with data reported by physicians.</p> <p><img alt="Physician Impact. On average, practices complete 41 PAs per physician, per week. (See below. Survey question "B." Physicians and their staff spend an average of almost two business days (13 hours) each week completing PAs. (See below. Survey questions "C.") Two in five or 40% of physicians have staff who work exclusively on PA. (See below. Survey question "D.") 88% of physicians describe the burden associated with PA as high or extremely high. (See below. Survey question "E.")" data-entity-type="file" data-entity-uuid="2adf8266-f383-411b-9590-8dbe1b3eb92c" src="/sites/default/files/inline-images/Physician-Impact-infographic.png" width="1160" height="345"></p> <p>Source: <a href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank" title="AMA: 2021 AMA prior authorization (PA) physician survey">https://www.ama-assn.org/system/files/prior-authorization-survey.pdf</a></p> <hr> <p id="comingsoon"><strong>COMING SOON:</strong> AHA will be updating its white paper on <a href="/system/files/media/file/2020/12/addressing-commercial-health-plan-abuses-ensure-fair-coverage-patients-providers.pdf" target="_blank">health plan accountability</a> and producing related advocacy materials on the burden of prior authorization and denials resulting from information collected in AHA’s December 2021 member survey. We will also be issuing a new white paper later this month on the unnecessary administrative costs that insurer policies add to the health care system.</p> <hr> <h2 id="tellus">Tell Us Your Story</h2> <p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p> <p><img alt="Three connected circles, one with people talking to each other, one with a person with their heart highlighted and gears, and one with a hospital and a highlighted heart." data-entity-type="file" data-entity-uuid="4e471ed2-2659-4a46-9875-d6d50419d1aa" src="/sites/default/files/inline-images/Tell-Us-Your-Story.png" width="960" height="393"></p> <p>Login to our AHA member site, <a href="/healthplanaccountability#shareyourstory">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.</p> </div> <div class="col-md-4"> <div class="panel module-typeC"> <div class="panel-heading"> <h3 class="panel-title"><span>In This Issue:</span></h3> </div> <div class="panel-body"> <ol> <li><a href="#cmsoversight">AHA calls for increased CMS oversight, DOJ action to hold Medicare Advantage plans accountable</a></li> <li><a href="#rulemaking">AHA comments on potential rulemaking to improve electronic prior authorization processes</a></li> <li><a href="#mapriorauthorization">AHA urges changes to MA prior authorization requirements for public health emergencies</a></li> <li><a href="#dojsues">DOJ sues to stop UnitedHealth from acquiring Change Healthcare</a></li> <li><a href="#federaljudge">Federal judge in Texas strikes part of surprise billing rule</a></li> <li><a href="#ahavitalityindex">AHA Vitality Index</a></li> <li><a href="#bluecard">BlueCard</a></li> <li><a href="#whitebagging">White Bagging & Specialty Pharmacy</a></li> <li><a href="#ama">AMA releases physician survey on prior authorization</a></li> <li><a href="#comingsoon">Coming Soon</a></li> <li><a href="#tellus">Tell Us Your Story</a></li> </ol> </div> </div> <section class="top-level-view js-view-dom-id-0f27e31b6edac828850e624482d5acd53beb50c243897a64759bd537de6a0d09 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Health Plan Accountability</a></div> </div> </div> </div> Wed, 08 Jun 2022 12:00:00 -0500 Health Plan Accountability Update