Plans Announce PA Initiatives To Forestall Regulatory Action
After commitments by Trump administration officials to reform prior authorization (PA), about fifty health plans, including some of the biggest, met with Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz to unveil their plans to streamline PA and tackle claims denials. The health plans represent as many as 75% of America’s insured. The Blue Cross and Blue Shield Association and trade group AHIP also attended the meeting.
Health plans will commit to reduce the number of codes that are subject to PA and to establish a standard framework to increase how many authorizations are adjudicated electronically and in real time. PA changes will occur by 1/1/2026, with electronic PA reforms in one year later. The plans also will increase education on PA and appeals, accountability, and transparency around denials of PAs and claims. Plans will also honor PAs for 90 days when a consumer changes plans.
The federal government will not take regulatory action pending how insurers perform under the new system but will do so if officials are not satisfied. Dr. Oz also noted that this is just a first step, indicating that regulatory changes could be coming down the road anyway.
A healthcare policy group KFF study looked at MA claims denials, appeals and their outcomes from the 2023 contract year. About 6.4% of all claims submitted for prior authorization were denied in full or part. About 12% of those denials were appealed, and 82% of denials were overturned.
Additional articles: https://www.fiercehealthcare.com/regulatory/oz-insurers-prior-auth-pledge-opportunity-industry-show-itself and https://www.modernhealthcare.com/insurance/mh-medicare-advantage-prior-authorization-denial-rates-kff/ and https://www.ahip.org/health-plans-are-making-voluntary-commitments-to-support-patients-and-providers and https://thehill.com/policy/healthcare/5364803-hhs-cms-kennedy-oz-preauthorization/?tbref=hp and https://www.beckerspayer.com/payer/payers-to-reduce-prior-authorizations/ and https://www.cms.gov/newsroom/press-releases/hhs-secretary-kennedy-cms-administrator-oz-secure-industry-pledge-fix-broken-prior-authorization
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#healthplans #priorauthorization #claimsdenials #oz #rfkjr
https://www.fiercehealthcare.com/payers/insurers-pledge-smooth-out-prior-authorization-process
Budget Reconciliation News
The American Hospital Association (AHA) launched an ad campaign urging Congress to reject healthcare cuts and protect hospital funding. At the same time, most GOP lawmakers are discounting the impacts on providers with the exception of rural providers. The GOP is contemplating a rural hospital relief fund to compensate.
Meanwhile, Senate Majority Leader John Thune, R-SD, announced the Senate will remain in session until a bill is passed. He wanted to pass a bill this week.
A Kaiser Health News article discusses the impact of the provider tax limitations on states, especially California. The conservative Paragon Health Institute details what it sees as major enrollment fraud in the Exchanges.
Additional articles: https://www.modernhealthcare.com/providers/mh-american-hospital-association-ad-tax-bill/ and https://www.modernhealthcare.com/politics-regulation/mh-tommy-tuberville-mike-rounds-john-hawley-medicaid-cuts/ and https://kffhealthnews.org/news/article/mco-medicaid-provider-taxes-matching-funds-threatened-cms-house-california/ and https://www.fiercehealthcare.com/finance/federal-proposals-threaten-provider-taxes-key-source-medicaid-funding-states and https://paragoninstitute.org/private-health/the-greater-obamacare-enrollment-fraud/
(Some articles may require a subscription.)
#budgetreconciliation #trump #congress #coverage #medicaid #exchanges
https://thehill.com/homenews/senate/5364395-thune-senate-bill-july-4-recess/?tbref=hp
Part B Impacts In Budget Bill
Provisions in the budget reconciliation bill would make it harder for people to enroll in the Medicare Savings Program, a Medicaid program that helps the low income pay for certain costs in Medicare. The Congressional Budget Office (CBO) says 1.3 million would lose Part B premium assistance and other support.
#medicare #medicaid #coverage
CMS Raises Agent Compensation in Medicare Advantage
Despite allegations of major fraud in marketing between Medicare Advantage (MA) plans and third-party marketing organizations (TPMOs), CMS will raise payments to brokers for 2026. Plans will be able to pay brokers up to $694 for new enrollments in MA plans, and $347 for renewing existing members.
Many large plans have cut commissions or eliminated them given their ongoing financial woes. UnitedHealthcare will cut most commissions on July 1. Aetna, Elevance, and Cigna have already done so in part.
#medicareadvantage #marketing #agents #brokers
— Marc S. Ryan
