Medicare
Advantage
plans
use
a
series
of
policies
that
hurt
Medicare
beneficiaries,
lead
to
physician
burnout
and
bring
up
healthcare
costs,
the
American
Hospital
Association
(AHA)
argued
in
a
recent
report.
To
combat
these
issues,
AHA
is
calling
for
legislative
action.
Specifically,
AHA
argues
that
some
MA
plans
have
stricter
medical
necessity
criteria
than
traditional
Medicare
plans,
use
“excessive”
prior
authorization
requirements,
use
unnecessary
utilization
management
tools
and
require
repetitive
clinical
documentation
submissions
for
services.
“These
practices
result
in
delays
in
care
and
can
cause
direct
patient
harm,”
AHA
declared.
“In
addition,
they
add
financial
burden
and
strain
onto
the
health
care
system,
requiring
increased
staffing
and
technology
costs
to
comply
with
plan
requirements,
while
also
contributing
significantly
to
healthcare
worker
burnout.”
AHA’s
report
comes
after
the
U.S.
House
of
Representatives
passed
the
Improving
Seniors’
Timely
Access
to
Care
Act
last
week.
The
bill
would
establish
several
requirements
for
the
prior
authorization
process
under
MA
plans.
Prior
authorization
determines
if
a
payer
will
cover
a
healthcare
service.
While
AHA
supports
the
bill,
it
believes
additional
action
is
needed
by
the
government.
In
the
report,
it
specifically
calls
on
Congress
to:
-
Create
penalties
on
MA
plans
when
prior
authorization
processes
delay
care -
Increase
oversight
by
the
Centers
for
Medicare
and
Medicaid
Services
(CMS).
This
includes
more
plan
reporting
on
coverage
denials,
appeals
and
grievances;
making
plan
performance
data
publicly
available;
and
providing
targeted
audits
based
on
plan
performance. -
Establish
a
process
for
providers
to
submit
complaints
to
CMS -
Make
medical
necessity
criteria
equal
between
MA
and
traditional
Medicare
plans -
Expand
network
adequacy
requirements
for
certain
post-acute
care
sites.
Network
adequacy
refers
to
having
a
large
enough
network
of
providers
in
a
health
plan
so
patients
can
have
reasonable
access
to
care.
“Congressional
action
is
needed
to
specifically
prohibit
MA
plans
from
using
medical
necessity
criteria
that
is
more
restrictive
than
the
criteria
used
for
patients
enrolled
in
traditional
Medicare,”
AHA
said
in
the
report.
“This
effectively
results
in
patients
being
denied
medically
necessary
care
that
should
be
covered
and
creates
inequities
in
access
to
care
between
those
enrolled
in
MA
plans
versus
traditional
Medicare.”
In
response
to
the
AHA
report,
America’s
Health
Insurance
Plans
(AHIP),
an
advocacy
organization
for
payers,
shot
back
that
some
of
these
practices
are
needed
to
avoid
unnecessary
care
and
reduce
costs.
A
2019
JAMA
study
found
that
the
estimated
cost
of
waste
in
the
U.S.
healthcare
system
ranges
from
to
$760
billion
to
$935
billion,
which
equates
to
about
25%
of
all
healthcare
spending.
“Health
insurance
providers
advocate
for
the
people
they
serve
by
ensuring
that
the
right
care
is
delivered
at
the
right
time
in
the
right
setting
—
and
covered
at
a
cost
that
patients
can
afford.
Prior
authorization
prevents
waste
and
improves
affordability
for
patients,
consumers,
and
employers,”
Kristine
Grow,
AHIP
spokesperson,
wrote
in
an
email.
“Health
insurance
providers
have
a
comprehensive
view
of
the
health
care
system
and
each
patient’s
medical
claims
history
and
work
to
ensure
that
medications
or
treatments
prescribed
by
clinicians
are
safe,
effective,
and
affordable
for
patients.
This
results
in
better
outcomes
and
lower
costs
for
patients.”
That
doesn’t
mean
some
practices
can’t
be
improved,
though.
To
streamline
the
prior
authorization
process,
Grow
recommends
adopting
electronic
prior
authorization.
In
2020,
AHIP
launched
the
Fast
Prior
Authorization
Technology
Highway
initiative
to
determine
the
effectiveness
of
electronic
prior
authorization.
It
found
that
71%
of
providers
who
adopted
the
electronic
process
for
most
or
all
of
their
patients
reported
that
patients
received
faster
care.
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Bet_Noire,
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