Posted by: AGelbert
« on: October 18, 2024, 01:33:03 pm »👉 Emojies by AGelbert. 👈
October 18, 2024
AGelbert NOTE: Reality based comments on the reality based article posted here after the comments:
Charles_Beauchamp 11 hours ago edited
If the current trend of an upswing in denied prior authorizations coupled with rural - metropolitan disparities in application of rules, regulations & reimbursements continues, there will be an implosion of rural primary care independent of the hospital.
BeckyR 12 hours ago
And yet most Republicans say they want all seniors to transition to this type of care that only ensures profits for the insurance companies while putting people's health and safety at risk!!
Lou_L > BeckyR 2 hours ago
Over the years of making Hill visits to advocate for Long Term Care Hospitals, I’ve seen a remarkable change in the tone from the Republican offices. It used to be they didn’t want to hear any criticism of Medicare Advantage. During the past two years they’ve become increasingly aware of MA plans abusing prior auth to deny care. This report will really help hammer home the message.
Steven_B_MD 15 hours ago
Is anyone surprised that Medicare Advantage plans appear to be more interested in profits than patients?
Brant_S_Mittler_MD_JD a day ago
Thanks for Joyce Frieden's usual excellent reporting. But the last paragraph from the managed care lobby should be read with full understanding that Medicare HMO data is largely proprietary. The HMOs use it to their advantage when they want to. They use researchers who they know will produce results they want. if you look at their data sharing arrangements you will see that you can't get the data or have to pay $millions to get it if they would even sell it to you. These data reflect care produced with taxpayer dollars yet taxpayer institutions can't use them for objective outside reviews. Virtually all the quality data on Medicare comes from Fee for Service (FFS) Medicare. Those data are produced by non-HMO medical practices i.e. individual doctors, NPs, PAs, nurses laboring late into the day and night producing the data that Medicare beneficiaries get to use to look at quality, diagnosis + prognosis, test ordering and outcomes. The HMO part of Medicare is largely opaque and contributes NOTHING to transparency and quality analyses while making outrageous profits for its overpaid executives and armies of prior authorization clerks. It's a national disgrace that is impossible to change due to the power of the HMO lobby in DC and state legislatures. "Plea for service" runs U.S. health care.
October 17, 2024 by Joyce Frieden, Washington Editor, MedPage Today
Medicare Advantage plans have increased their use of prior authorization and appear to be targeting certain types of care -- such as expensive post-acute hospital care -- for coverage denials, according to a report issued Thursday by the Senate Permanent Subcommittee on Investigations.
💵🎩 Insurers "are using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices," the subcommittee's report concluded.
"This is particularly troubling when recent analyses indicate that Medicare Advantage is more expensive than traditional Medicare," the report continued. "There is a role for the free market to improve the delivery of healthcare
to America's seniors, but there is nothing inevitable about the harms done by the current arrangement. Insurers can and must do better, for the sake of the American healthcare system and the patients the government entrusts to them."
Four Years
of Data
The subcommittee sought data about prior authorization requests and denials between 2019 and 2022 from three of the largest Medicare Advantage insurers:
UnitedHealthcare, Humana, and CVS. "This date range aligned with increases in concern from patients and providers that prior authorization was threatening seniors' well-being and the viability of medical practices," the report authors noted. "The time period also overlapped with reporting showing that Medicare Advantage insurers were expanding their use of AI [artificial intelligence] and other methods of 
automating the 
processing of healthcare claims."
In addition, lawmakers "also collected documents used in training workers evaluating prior authorization requests, and explanations of the procedures used to evaluate or measure these workers and determine their prospects for advancement. The subcommittee has also obtained documents related to the use of algorithms, AI, and other predictive technologies, including the way the companies use these technologies in the context of prior authorization and other utilization management practices."
The report noted that "Medicare Advantage insurers are intentionally using prior authorization to 😈 boost 💰 profits by targeting costly yet critical stays in post-acute care facilities. Insurer
denials at these facilities, which help people recover from injuries and illnesses, can force 🥵 seniors to make difficult choices about their health and finances in the vulnerable days after exiting a hospital."
In particular, the report found:
In 2022, both UnitedHealthcare and CVS denied prior authorization requests for post-acute care at rates that were approximately three times higher than the companies' overall denial rates for prior authorization requests. In that same year, Humana's prior authorization denial rate for post-acute care was over 16 times higher than its overall rate of denial.
CVS's prior authorization denial rate for post-acute care remained relatively stable during the period reviewed. However, the number of post-acute care service requests CVS subjected to prior authorization increased by 57.5%, far higher than the company's roughly 40% growth in enrollment during that period.
In a May 2019 presentation, CVS determined that it had saved more than $660 million the previous year by denying prior authorization requests its Medicare Advantage beneficiaries submitted for inpatient facilities. A majority of these savings came from "denied admissions."
While the use of prior authorization has expanded significantly for all types of insurance since the 1980s, its use in Medicare Advantage plans has particularly increased in the last 5 years. The American Journal of Managed Care found that the share of Medicare Advantage enrollees in a plan requiring prior authorization for at least one category of healthcare services was 72.6% in 2019, which was similar to the rate it had been in 2009. But by 2023, KFF reported that 99% of Medicare Advantage enrollees were in a plan requiring prior authorization for some services.
"Although post-acute care facilities represent a significant share of all prior authorization denials, they represent only a portion of all prior authorization requests, meaning that an insurer's denial rate for post-acute care could increase significantly from one year to the next even as the insurer's overall denial rate, which is publicly available, appears relatively unchanged," the report found. "At the facility level, these changes can be striking. For example, between 2019 and 2022, UnitedHealthcare's denial rate for skilled nursing facilities increased by a factor of nine."
Use of 🤖 AI Examined
In its investigation of the plans' use of artificial intelligence to consider prior authorization requests, the subcommittee found that:
Facing pressure to cut costs in the Medicare Advantage division, in April 2021 CVS deployed "Post-Acute Analytics," which used AI to reduce the amount of money spent on skilled nursing facilities. CVS initially expected that it would save approximately $4 million per year, but within 7 months, the company projected that an expanded version of the initiative would save the company more than $77 million over the next 3 years.
In April 2021, an internal UnitedHealthcare
committee voted to approve the use of 🤖 "Machine 😉 Assisted Prior Authorization" in the company's utilization management efforts. They were told that the doctor or nurse reviewing the case still had to "verif[y] that the primary evidence is acceptable," but also that testing of the technology had reduced the average time needed to review a request by 6 to 10 minutes.
In early 2021, UnitedHealthcare tested a "HCE [Healthcare Economics] Auto Authorization Model." Minutes from a meeting of an internal committee reviewing the model noted that initial testing had produced "faster handle times" for cases as well as "an increase in adverse determination rate," which the meeting minutes attributed to "finding contraindicated evidence missed in the original review." The committee voted to tentatively approve the model at a meeting the following month.
Recommendations for CMS
The subcommittee recommended several actions for the Centers for Medicare & Medicaid Services (CMS) to take to address some of the issues raised in the report, including requiring that prior authorization information be broken down by category, conducting targeted audits under certain circumstances, and implementing regulations to ensure that predictive technologies do not have "undue influence" on human reviewers.
In particular, regarding the plans' use of AI to evaluate prior authorization requests, "CMS has not provided sufficiently specific guidance on separating the use of predictive technologies from patient determinations regarding post-acute care," the authors concluded, adding that in a February 2024 memo, the agency said AI could be used to "assist" in predicting a patient's length of stay, but that medical necessity determinations had to be based on "the individual patient's circumstances." However, the agency provided no further guidance on ensuring that the AI prediction didn't have undue influence on the length-of-stay authorization, they said.
Asked to comment on the report, a spokesperson for America's Health Insurance Plans -- a trade group for health insurers -- said in an email that "More than 33 million seniors and people with disabilities choose Medicare Advantage for their health coverage because it provides them better care at a lower cost
than fee-for-service. Studies show that MA [Medicare Advantage] outperforms fee-for-service 
in nine out of 10 quality measures focused on prevention and chronic care, and 95% of MA beneficiaries say they are satisfied with their coverage and care." 
A
spokesperson for Humana told MedPage Today in an email that 
"This is a partisan report laden with errors and misleading claims. In fact, Senator [Richard] Blumenthal's team declined to correct those errors and mischaracterizations that Humana identified after reviewing certain heavily redacted excerpts prior to the report's release." 
https://www.medpagetoday.com/publichealthpolicy/medicare/112434
October 18, 2024
AGelbert NOTE: Reality based comments on the reality based article posted here after the comments:Charles_Beauchamp 11 hours ago edited
If the current trend of an upswing in denied prior authorizations coupled with rural - metropolitan disparities in application of rules, regulations & reimbursements continues, there will be an implosion of rural primary care independent of the hospital.
BeckyR 12 hours ago
And yet most Republicans say they want all seniors to transition to this type of care that only ensures profits for the insurance companies while putting people's health and safety at risk!!
Lou_L > BeckyR 2 hours ago
Over the years of making Hill visits to advocate for Long Term Care Hospitals, I’ve seen a remarkable change in the tone from the Republican offices. It used to be they didn’t want to hear any criticism of Medicare Advantage. During the past two years they’ve become increasingly aware of MA plans abusing prior auth to deny care. This report will really help hammer home the message.
Steven_B_MD 15 hours ago
Is anyone surprised that Medicare Advantage plans appear to be more interested in profits than patients?
Brant_S_Mittler_MD_JD a day ago
Thanks for Joyce Frieden's usual excellent reporting. But the last paragraph from the managed care lobby should be read with full understanding that Medicare HMO data is largely proprietary. The HMOs use it to their advantage when they want to. They use researchers who they know will produce results they want. if you look at their data sharing arrangements you will see that you can't get the data or have to pay $millions to get it if they would even sell it to you. These data reflect care produced with taxpayer dollars yet taxpayer institutions can't use them for objective outside reviews. Virtually all the quality data on Medicare comes from Fee for Service (FFS) Medicare. Those data are produced by non-HMO medical practices i.e. individual doctors, NPs, PAs, nurses laboring late into the day and night producing the data that Medicare beneficiaries get to use to look at quality, diagnosis + prognosis, test ordering and outcomes. The HMO part of Medicare is largely opaque and contributes NOTHING to transparency and quality analyses while making outrageous profits for its overpaid executives and armies of prior authorization clerks. It's a national disgrace that is impossible to change due to the power of the HMO lobby in DC and state legislatures. "Plea for service" runs U.S. health care.
October 17, 2024 by Joyce Frieden, Washington Editor, MedPage Today
Medicare Advantage plans have increased their use of prior authorization and appear to be targeting certain types of care -- such as expensive post-acute hospital care -- for coverage denials, according to a report issued Thursday by the Senate Permanent Subcommittee on Investigations.💵🎩 Insurers "are using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices," the subcommittee's report concluded."This is particularly troubling when recent analyses indicate that Medicare Advantage is more expensive than traditional Medicare," the report continued. "There is a role for the free market to improve the delivery of healthcare
to America's seniors, but there is nothing inevitable about the harms done by the current arrangement. Insurers can and must do better, for the sake of the American healthcare system and the patients the government entrusts to them." Four Years
of Data The subcommittee sought data about prior authorization requests and denials between 2019 and 2022 from three of the largest Medicare Advantage insurers:
UnitedHealthcare, Humana, and CVS. "This date range aligned with increases in concern from patients and providers that prior authorization was threatening seniors' well-being and the viability of medical practices," the report authors noted. "The time period also overlapped with reporting showing that Medicare Advantage insurers were expanding their use of AI [artificial intelligence] and other methods of automating the processing of healthcare claims."In addition, lawmakers "also collected documents used in training workers evaluating prior authorization requests, and explanations of the procedures used to evaluate or measure these workers and determine their prospects for advancement. The subcommittee has also obtained documents related to the use of algorithms, AI, and other predictive technologies, including the way the companies use these technologies in the context of prior authorization and other utilization management practices."
The report noted that "Medicare Advantage insurers are intentionally using prior authorization to 😈 boost 💰 profits by targeting costly yet critical stays in post-acute care facilities. Insurer
denials at these facilities, which help people recover from injuries and illnesses, can force 🥵 seniors to make difficult choices about their health and finances in the vulnerable days after exiting a hospital."In particular, the report found:
In 2022, both UnitedHealthcare and CVS denied prior authorization requests for post-acute care at rates that were approximately three times higher than the companies' overall denial rates for prior authorization requests. In that same year, Humana's prior authorization denial rate for post-acute care was over 16 times higher than its overall rate of denial.
CVS's prior authorization denial rate for post-acute care remained relatively stable during the period reviewed. However, the number of post-acute care service requests CVS subjected to prior authorization increased by 57.5%, far higher than the company's roughly 40% growth in enrollment during that period.
In a May 2019 presentation, CVS determined that it had saved more than $660 million the previous year by denying prior authorization requests its Medicare Advantage beneficiaries submitted for inpatient facilities. A majority of these savings came from "denied admissions."
While the use of prior authorization has expanded significantly for all types of insurance since the 1980s, its use in Medicare Advantage plans has particularly increased in the last 5 years. The American Journal of Managed Care found that the share of Medicare Advantage enrollees in a plan requiring prior authorization for at least one category of healthcare services was 72.6% in 2019, which was similar to the rate it had been in 2009. But by 2023, KFF reported that 99% of Medicare Advantage enrollees were in a plan requiring prior authorization for some services.
"Although post-acute care facilities represent a significant share of all prior authorization denials, they represent only a portion of all prior authorization requests, meaning that an insurer's denial rate for post-acute care could increase significantly from one year to the next even as the insurer's overall denial rate, which is publicly available, appears relatively unchanged," the report found. "At the facility level, these changes can be striking. For example, between 2019 and 2022, UnitedHealthcare's denial rate for skilled nursing facilities increased by a factor of nine."
Use of 🤖 AI Examined
In its investigation of the plans' use of artificial intelligence to consider prior authorization requests, the subcommittee found that:
Facing pressure to cut costs in the Medicare Advantage division, in April 2021 CVS deployed "Post-Acute Analytics," which used AI to reduce the amount of money spent on skilled nursing facilities. CVS initially expected that it would save approximately $4 million per year, but within 7 months, the company projected that an expanded version of the initiative would save the company more than $77 million over the next 3 years.
In April 2021, an internal UnitedHealthcare
committee voted to approve the use of 🤖 "Machine 😉 Assisted Prior Authorization" in the company's utilization management efforts. They were told that the doctor or nurse reviewing the case still had to "verif[y] that the primary evidence is acceptable," but also that testing of the technology had reduced the average time needed to review a request by 6 to 10 minutes.In early 2021, UnitedHealthcare tested a "HCE [Healthcare Economics] Auto Authorization Model." Minutes from a meeting of an internal committee reviewing the model noted that initial testing had produced "faster handle times" for cases as well as "an increase in adverse determination rate," which the meeting minutes attributed to "finding contraindicated evidence missed in the original review." The committee voted to tentatively approve the model at a meeting the following month.
Recommendations for CMS
The subcommittee recommended several actions for the Centers for Medicare & Medicaid Services (CMS) to take to address some of the issues raised in the report, including requiring that prior authorization information be broken down by category, conducting targeted audits under certain circumstances, and implementing regulations to ensure that predictive technologies do not have "undue influence" on human reviewers.
In particular, regarding the plans' use of AI to evaluate prior authorization requests, "CMS has not provided sufficiently specific guidance on separating the use of predictive technologies from patient determinations regarding post-acute care," the authors concluded, adding that in a February 2024 memo, the agency said AI could be used to "assist" in predicting a patient's length of stay, but that medical necessity determinations had to be based on "the individual patient's circumstances." However, the agency provided no further guidance on ensuring that the AI prediction didn't have undue influence on the length-of-stay authorization, they said.
Asked to comment on the report, a spokesperson for America's Health Insurance Plans -- a trade group for health insurers -- said in an email that "More than 33 million seniors and people with disabilities choose Medicare Advantage for their health coverage because it provides them better care at a lower cost
than fee-for-service. Studies show that MA [Medicare Advantage] outperforms fee-for-service in nine out of 10 quality measures focused on prevention and chronic care, and 95% of MA beneficiaries say they are satisfied with their coverage and care." A
spokesperson for Humana told MedPage Today in an email that "This is a partisan report laden with errors and misleading claims. In fact, Senator [Richard] Blumenthal's team declined to correct those errors and mischaracterizations that Humana identified after reviewing certain heavily redacted excerpts prior to the report's release." https://www.medpagetoday.com/publichealthpolicy/medicare/112434
amid an 
without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry.
comment.
Nelson has since left the company. 
prevent those conditions from becoming more serious," said 
something, because the whole system is going to collapse 😟. 
quietly contracting with for-profit companies to engage in “pilot programs” that insert middlemen into traditional Medicare without the beneficiary’s consent and often without their knowledge. The Trump Administration, which launched the program, contracted with 53 for-profit middlemen called Direct Contracting Entities (DCEs). The Biden Administration re-branded the program ACO-REACH (Accountable Care Organizations Realizing Equity, Access, and Community Health) and increased the number of corporate participants to 99.
Starting January 2023, the number of ACO-REACH programs managing the care of traditional Medicare beneficiaries is slated to increase dramatically, from 
99 to over 
200. 
