Fortune Well’s Post

What we’ve learned over the past year, neck-deep in clinic workflows can be summed up in one sentence: Providers and patients are drowning in health insurance admin work. They’re still… 🔺Calling and waiting on hold for hours 🔺Faxing pages upon pages of forms 🔺Resubmitting paperwork when they don’t get a response 🔺Mucking through mountains of claims denials 🔺Delaying care because of denied or delayed authorizations 🔺Paying more than they should for care and care delivery 🔺Burning out and hemorrhaging staff And we wonder why patients’ trust in our healthcare system has declined and why providers are leaving healthcare? It’s often not the care itself, but the payer hoops that cause a decline in patient experience. This is why we focus so heavily at EmployWell on improving payer-specific workflows - because they make or break both patient and provider experiences. Onward! Steffany Benton

🏥 New study from American Medical Association on insurer consolidation finds that insurance markets are HIGHLY concentrated and that insurers can use their monopoly status to raise premiums for patients and lower payments to providers. Quote: "In sum, we find that the vast majority of health insurance markets in the United States are highly concentrated. Coupled with external evidence on their anticompetitive behavior, this strongly suggests that health insurers are exercising market power in many parts of the country and, in turn, causing competitive harm to consumers and providers of care." https://bit.ly/490IvrF You can read what the Federation of American Hospitals has said about the impact of insurer consolidation here: https://bit.ly/4hUy3WB

Key points from Discovery Health CEO Ron Whelan on President Ramaphosa’s signing of the NHI Bill - President Ramaphosa to sign National Health Insurance (NHI) Bill. - Discovery Health CEO Ron Whelan expresses disappointment due to flaws in the bill. - Discovery Health supports universal health coverage but deems current NHI Bill unconstitutional and unfeasible. - No immediate impact on medical schemes expected; status quo remains for now. - Implementation of NHI projected to take several years, possibly decades. - Funding remains a critical barrier to NHI's viability. - Discovery Health advocates for private sector collaboration in healthcare. - Flaws in the NHI Bill and legislative processes may lead to legal challenges and delays. - Discovery Health pledges to engage constructively while defending rights of medical scheme members. - Commitment to supporting healthcare partners, investing in both public and private healthcare systems.

Legal Update: Proposed Rule Would Expand ACA's Contraceptive Coverage Mandate On Oct. 21, 2024, the Departments of Labor, Health and Human Services, and the Treasury released a proposed rule that, if finalized, would expand access to contraceptive coverage without cost sharing under the Affordable Care Act’s(ACA) preventive care mandate. Notably, the proposed rule would require most health plans and health insurance issuers to cover over-the-counter (OTC)contraceptives without imposing cost sharing (e.g., deductibles, copayments or coinsurance) or requiring a prescription. For more Info, Click the Link below! https://lnkd.in/g8j7eceN

Agents, you've probably gathered this already, but it's interesting to put data to it: when asked, 28% of consumers and 47% of physicians blame #healthcare costs on #healthinsurance companies. Only 10% and 9% blame the hospitals themselves, respectively. But, according to the same study, its flat out untrue. The Health Affairs Scholar Report found that hospitals actually have a higher profit margin than health insurance companies. and the price increases in hospitals have risen more than those in health insurance. And, if you have read our other posts, they came to a similar conclusion as other studies: areas with more hospital mergers and consolidation have higher prices.

New Law Prohibits AI Use in Denying Healthcare Coverage California has enacted the Physicians Make Decisions Act (SB 1120), authored by Senator Josh Becker (D-Menlo Park). This law prohibits health insurance companies from using AI to deny healthcare coverage, ensuring that medical treatment decisions are made by licensed healthcare providers. Key points: - AI will no longer be used to deny, delay, or modify healthcare coverage. - Licensed physicians must review any care denial based on medical necessity. - This legislation aims to prevent errors in AI-driven denials and safeguard patient access to quality care. - California sets a precedent for responsible AI regulation in healthcare. #Healthcare #AI #medicalinsurance #insuranceindustry Benefits for Expats Inc | Insurance Consulting and Digital Marketing

The Healthcare Justice Coalition, an organization which collaborates with providers to ensure fair payment from insurers, filed a lawsuit in Ohio state court on January 30th, 2024 against Aetna to pursue payment for services owed to ED physicians. Aetna attempted to remove the case based on three arguments: the No Surprises Act, ERISA, and diversity jurisdiction. However, the judge rejected all of Aetna's arguments and remanded the case back to Ohio state court. Key points from this case: • The court rejected Aetna's NSA interpretation, stating the NSA lays out an optional IDR process that defers to state law for payment disputes. (this decision is highly remarkable; while this was a position the plaintiff had maintained from the beginning, we have not seen any decisions with this level of clarity directly on point. • ERISA preemption was dismissed as irrelevant since claims were for payments to providers, not patients. • Aetna’s argument that Meritain, the health plan administrator, wasn’t an insurer was rejected, with the court concluding Meritain had obligations for the services provided. This allowed HJC to defeat diversity jurisdiction. This ruling is a battle won for emergency physicians in the war to hold big health insurance accountable. It is a reminder that deference to state law is achievable when pursuing this type of litigation. #HealthcareLitigation Allia Group

🎯🏥Congress takes aim at Brazilian health insurers Lawmakers from both the left and right called this week for a select committee to investigate Brazilian private health insurers, following reports that companies have unilaterally revoked thousands of insurance contracts with patients suffering from chronic conditions. Congresswoman Maria Rosas of the Republicans party — dominated by evangelical preachers — criticized federal private health regulator ANS during a House public hearing on Tuesday. She argued that the ANS has “clearly not done enough” and added that insurers have become too comfortable publicly admitting they canceled plans for financial reasons, which is illegal. Current legislation allows insurers to revoke individual contracts only in cases of fraud or default, and collective contracts can only be revoked by the employer or under a previously agreed notice period. 🔗Read more in our full article by Cedê Silva here 👇 https://lnkd.in/dKzTxttB #Congress #Health #Brazil #Insurance

The Deadline for Submitting Gag Clause Attestation Is Dec. 31, 2024 Effective in 2020, the Consolidated Appropriations Act, 2021 (CAA) prohibits health plans and health insurance issuers from entering into contracts with health care providers, third-party administrators (TPAs) or other service providers that contain gag clauses (i.e., clauses restricting the plan or issuer from providing, accessing or sharing certain information about provider price and quality and de-identified claims). Plans and issuers must annually submit an attestation of compliance with the CAA’s gag clause prohibition to the Departments of Labor, Health and Human Services, and the Treasury (Departments). The first attestation was due on Dec. 31, 2023. The next attestation is due Dec. 31, 2024, covering the period since the last attestation. Click the Link for more Info! https://lnkd.in/gB37PvNQ

The Closest Appropriate Facility Versus Patient Choice: A Delicate Balancing Act for the Stable Patient - https://ow.ly/SVP050UHRvn How does an EMS system weigh a patient’s interests with those of an EMS system and the community? There are four pillars of medical ethics that can guide this conflict: 1. Beneficence (help the patient) 2. Non-maleficence (do no harm) 3. Autonomy (respect the patient’s wishes) 4. Justice (be equitable to all persons in the community) Giving the patient a degree of autonomy when they are in your care is advantageous. It increases their trust in the healthcare system, improves the patient-provider relationship and even mental health. Regarding beneficence, patients may benefit from bypass due to remaining in the same medical system where they are receiving long-term care or because they need to stay in network for their health insurance.