Michael Ruiz de Somocurcio’s Post

MedPage Today reports that analysts anticipate health systems will increasingly opt out of Medicare Advantage plans due to ongoing disputes regarding insurance rates and increased claims denials from #PriorAuthorizations. With increased claims denials comes decreased organizational revenue and delayed patient access to care. Claims denials often stem from various factors. At Valer, we work to mitigate these issues, targeting the manual, error-prone portions of the prior auth process and helping to foster better alignment between payers and providers. Read the full MedPage Today piece here: https://hubs.la/Q02sHNL_0 Learn more about how Valer can support your prior auth process today: https://hubs.la/Q02sHKQR0

News too important not to share! CMS in with some prospective payment fixes for providers impacted by the Change Healthcare debacles. Check out Mike Rawaan post below for details. Please repost and share this message with your networks! #changehealthcare #providers

The 9th U.S. Circuit Court of Appeals found last week that the U.S. Department of Health and Human Services overstepped its authority when it boosted Medicare reimbursements to hospitals in low-wage areas at the cost of other hospitals. This rule has already been rescinded effective 2025, but this can have significant implications for service dates going back to 2020. Operating margins continue to be squeezed for all hospitals, as reimbursements fail to keep up with increased expenses. Meanwhile insurance providers' margins are improving as claim denial rates increase. Mantl Health offers revenue cycle safety net solutions for big health systems, critical access hospitals, outpatient clinics, and diagnostic laboratories. Reach out today to learn more about how Mantl Health can help you combat claim denials.

Through some insurance companies, Medicare Advantage plans are causing patient care to suffer. This is causing delays, extended hospital stays, and even denials of claims. We can no longer tolerate this; it is time for these companies to make a change. They are reimbursing home health agencies at 60% below our direct costs, particularly from Medicare Advantage. As we continue to provide quality care to our patients at NVNA and Hospice, I am committed to recruiting and retaining great staff—especially as we are seeing more and more agencies shutting their doors due to the financial impact.   Access to care will worsen over the next 3-5 years. We must continue to put our patients first.

There is continued fallout from the SCAN Health Plan lawsuit against CMS, in which they argued that CMS did not accurately calculate their quality scores. This led to CMS revising their 2024 Medicare Advantage Star ratings, which reportedly increased scores for over 40 insurers across 60 Medicare Advantage plans. For plans that passed the 4 star threshold due to the recalculation, this means they are now eligible for maximum bonus payments in 2025. How do you believe this will impact the MA landscape over the next 12 months? Will health plans leverage the additional reimbursement to strengthen their bids for future years? Will more payers throw their hat into the ring for MA plans? Are additional lawsuits to come? #A&MHealthcare #MedicareAdvantage #CMS #Stars https://lnkd.in/esYJE3JF

Medicare Advantage Policies Strain Critical Access Hospitals A recent U.S. Senate report reveals that Medicare Advantage (MA) insurers—UnitedHealthcare, CVS, and Humana—are increasingly using prior authorization to limit post-acute care, placing an undue burden on Critical Access Hospitals (CAHs). Swing-bed programs, a cornerstone of rural healthcare, are facing reduced utilization as insurers deny necessary post-acute care stays. These practices push patients into less costly but often less effective care settings, such as home health, undermining CAHs’ ability to meet the recovery needs of their communities. The report highlights troubling practices that prioritize cost savings over patient care. Post-acute care denial rates are significantly higher than for other services, with UnitedHealthcare increasing skilled nursing facility denials ninefold between 2019 and 2022. CVS and Humana use algorithms to identify cases likely to be denied, focusing on financial savings while forcing patients into premature discharges. These discharges often compromise recovery, increase caregiver burdens, and lead to worsened outcomes. For CAHs, these policies reduce swing-bed utilization, threatening a vital service line essential for post-acute recovery in rural areas. They also lead to increased emergency department visits as patients denied care often return with complications. Additionally, insurers’ denials place financial strain on CAHs, which frequently provide unreimbursed care to patients unable to safely transition to home health. Navigating appeals for denied care adds further administrative burden, straining already limited resources. Swing-bed programs are lifelines for rural communities with limited healthcare options. Denials of post-acute care jeopardize health outcomes, increase hospital readmissions, and erode community trust in local healthcare systems. Policymakers must address these practices to ensure rural hospitals can continue providing the recovery care their communities need. Together, we can advocate for fairer policies and protect access to care for rural patients. #RuralHealth #CriticalAccessHospitals #SwingBedAdvocacy

The Centers for Medicare & Medicaid Services (CMS) announced they will rework the quality ratings system for Medicare Advantage (MA) plans for 2024. This decision comes after private insurers challenged the initial calculations in court. The Wall Street Journal initially reported this news, highlighting the potential financial benefit for insurers. Some health plans could receive "hundreds of millions in additional payments" due to the recalculations. While insurers recently submitted bids for 2025 plans, those with ratings of at least 3.5 stars that increase by half a star or more under the new calculations will need to resubmit their quality ratings and potentially revise their bids. Learn more: https://hubs.ly/Q02C3C3Z0

Providence Health & Services in Medford, Oregon, led by Chief Executive Christopher Pizzi, is optimizing value-based care to address its challenging payer mix. With 60% of patients on Medicare and 20% on Medicaid, Providence faces financial pressures due to lower reimbursement rates compared to commercial insurance. To combat these challenges, Providence has focused on risk-based contracts, especially through the Medicare Shared Savings Program (MSSP). These contracts allow for shared savings or losses, contributing significantly to the medical group's revenue. Value-based care now accounts for 20-25% of the group's total revenue. Despite competition from nearby Asante Health Systems, Inc. and low Medicare rate increases, Providence has improved financial sustainability by setting aggressive care coordination goals.  Aaron Rust, executive director of Providence Medical Group, highlights outreach efforts such as transition care management, reducing readmission rates by nearly 50%. Physician engagement and strong data analysis have been crucial in aligning financial incentives with operational changes, resulting in significant margin improvements since 2021. Our RCM and credentialing team support by ensuring accurate billing and payer compliance for value-based care contracts, optimizing reimbursement processes for Medicare and Medicaid. We streamline credentialing, ensuring timely enrollment with payers, while reducing denials and addressing challenges like readmissions, ultimately improving financial outcomes and patient care coordination. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Healthcare Finance News

A significant disruption expected for Medicare Advantage (MA) plans in 2025. Key changes include reductions in bonus payments for insurers, increased scrutiny around marketing practices, and regulatory adjustments to ensure better alignment with health equity. These reforms will place pressure on MA providers to adapt while navigating complex market exits and member education challenges ahead of the 2025 enrollment season. The changes, led by the Centers for Medicare & Medicaid Services (CMS), are aimed at improving transparency and fairness, especially regarding supplemental benefits and services for specific diagnoses. MA plans will also face more stringent requirements related to health equity, such as adding experts in health equity to their utilization management committees. Overall, this "great disruption" will create challenges for insurers and beneficiaries alike, especially in terms of navigating the new regulations and preparing for potential frustrations from market exits and plan changes. https://lnkd.in/gAC-kRA7 #MedicareAdvantage #HealthcareReform #CMSUpdates #HealthEquity #Medicare2025

A RAND study published in Health Affairs found that hospitals gained $14.6 billion in extra payments in 2019 by billing for higher-intensity care, a practice known as "upcoding." Medicare, Medicaid, and private insurers paid significantly more as hospitals documented patient cases with higher complexity, increasing high-intensity care discharges by 41% from 2011 to 2019—far exceeding the expected 13% rise. Critics argue that this practice inflates healthcare costs, driving up premiums and taxpayer burdens. The American Hospital Association and Federation of American Hospitals challenged the study, citing data limitations and other factors contributing to higher-intensity discharges.