Valer’s Post

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

This sounds pretty inefficient. 40% denial and 97% overturn rate. Imagine the amount of cost on each side associated with writing the appeal (hospital), responding to the appeal (Plan) and then reprocessing the claim as a result. The cost to do this isn't minimal and imagine the teams required on each side to do this level of work. I'm not against authorizations at all, they do have value - you can see a lot of variation that occurs by hospitals as it relates to an Inpatient admission vs outpatient ER visit or observation case. The cost differences can be dramatic based on those decisions but these costly inefficient transactions add cost to an already high cost healthcare system and consumers and employers pay the cost of this inefficiency. #processandworkflowmatters "At Duke, UHC denies payment for care 40% more than other national insurance carriers we contract with. Duke Health overturns 97% of these denials after significant effort (people, time and technology)," CEO Craig Albanese, MD, told Becker's. Duke employs 236 full-time workers to appeal all denials from payers, which is not in the spirit of partnering to provide value to beneficiaries, patients and communities, according to Dr. Albanese, who said UnitedHealthcare "has been 57% slower to pay claims than our other payers and takes over 60 days to respond to claims they deny."

The upcoming challenges for Medicare Advantage (MA), particularly regulatory changes proposed by the Centers for Medicare & Medicaid Services (CMS) are changes aim to reduce costs and increase transparency, which could disrupt the current structure of MA plans. Key issues include concerns about overpayments to insurers and the risk adjustment model. As a result, insurers and healthcare providers are preparing for potential shifts in reimbursement and plan offerings that could significantly impact the healthcare landscape. https://lnkd.in/gAC-kRA7 #MedicareAdvantage #HealthcareReform #HealthInsurance #HealthcarePolicy #MedicareChanges #HealthCareCosts #MedicareAdvantage2024

ICYMI: As part of an initiative to keep folks covered after the PHE, the “Unwinding SEP” has been extended to 11/30/24. Read more ⬇️ “CMS is extending a temporary special enrollment period (SEP) to help people who are no longer eligible for Medicaid or CHIP transition to Marketplace coverage in states using HealthCare.gov. The end date of this “Unwinding SEP” will be extended from July 31, 2024, to November 30, 2024, which will help more people leaving Medicaid or CHIP secure affordable, comprehensive coverage through the start of the next open enrollment period. This extension will be crucial to ensuring people remain covered, including in states that have given people additional time to renew their coverage, as CMS has recommended, to help eligible people stay enrolled.” https://lnkd.in/epE5sAwk

More big news for Medicare Advantage: The Centers for Medicare & Medicaid Services (CMS) agreed to recalculate MA quality ratings after a series of court decisions found CMS improperly calculated star ratings for the 2024 plan year. The new CMS guidance would recalculate quality ratings industry-wide, likely increasing bonus payments for many insurers. As the landscape of MA quality ratings continues to evolve, we stand ready to support MA plans in navigating these changes and achieving excellence in member care. Read more: https://bit.ly/3xkfNDv #HealthcareInnovation #HEDIS2024 #MedicareAdvantage #QualityImprovement #HealthTech

⚕️ How “Dual-Eligible” Beneficiaries Fare in Traditional Medicare vs. Medicare Advantage Nearly 13 million Americans are enrolled in both Medicare and #Medicaid for health coverage. In addition to having low income and few resources, “dual-eligible” beneficiaries typically have more complex health care needs than the average Medicare enrollee. A new resource from The Commonwealth Fund offers insights into how the health care experiences of dual-eligible beneficiaries enrolled in the traditional #Medicare program compare with those in #MedicareAdvantage, which provides Medicare benefits through private insurance plans. In nine charts, we show: 📈 How the proportion of dual-eligible beneficiaries enrolled in Medicare Advantage plans has grown. 📊 How the demographic profiles of dual-eligible beneficiaries in Medicare Advantage and traditional Medicare compare. ⭐️ Differences in satisfaction ratings, cost-related delays in care, access to dental, vision, and hearing services, and more.

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 Medicare Advantage (MA) program is facing a "great disruption" ahead of its annual enrollment period in mid-October. Key factors include increased government scrutiny, stricter Centers for Medicare & Medicaid Services regulations, and reduced payments amid rising healthcare costs. MA carriers are responding by focusing on margins over membership, reducing benefits, and exiting unprofitable markets, while strained negotiations with providers lead some health systems to drop certain MA plans. A "seven-figure" lobbying campaign is underway to highlight the benefits of MA plans. Dr. Sachin H. Jain, MD, MBA, CEO of SCAN, emphasizes that stability in benefits will be more attractive to beneficiaries than innovation. MA carriers must enhance care management, focusing on chronic condition management and reducing hospitalizations. Competition will shift to effectiveness and service quality, brokers will play a more prominent role, and stronger, focused partnerships will become more valuable than broad collaborations. Our RCM and consulting professionals assist Medicare Advantage carriers by optimizing care management strategies, ensuring compliance with CMS regulations, and streamlining reimbursement processes. We help navigate provider negotiations, enhance financial margins, and offer strategic insights to maintain benefit stability and improve service quality amid shifting market dynamics. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

The Centers for Medicare & Medicaid Services recently issued final rules on access and managed care, introducing significant changes that will impact states in regard to payment, operations, oversight, reporting, compliance, and staffing. Guidehouse breaks down these new rules and provides in-depth guidance on key actions for states. #CMS #access #managedcare

Through Medscape's comprehensive analysis, you can gain valuable perspectives on the critical issues affecting healthcare providers in Medicaid and Medicare. Issues such as payment complexities, administrative burdens, and the impact on patient care are among the main concerns. Chorus Community Health Plans recognizes these challenges and strives to make it easier, not harder, for our providers to navigate this complex system. Understanding these challenges is crucial for navigating healthcare policy and improving service delivery. Stay informed and engaged in shaping the future of healthcare reform. #Medicaid