The Centers for Medicare & Medicaid Services (CMS) has introduced significant updates to clarify the definition and processes related to Medicare Advantage organization determinations, particularly in inpatient settings. The proposed rule reaffirms that decisions made during concurrent reviews, such as reclassifying an inpatient admission to outpatient or denying inpatient coverage, qualify as organization determinations under […]
Medicare Advantage (MA) plans, a type of private health insurance, have become increasingly popular among seniors. These plans offer additional benefits beyond traditional Medicare, but they also come with their own set of complexities. One of the most significant issues faced by MA beneficiaries is Medicare Advantage denials for medical services. Recent data has revealed […]
Medicare coverage is the federal health insurance program for Americans 65 and older, as well as younger individuals with long-term disabilities. It covers a wide range of medical services, including hospitalizations, doctor’s visits, prescription drugs, and specialized care like skilled nursing, home health, hospice, and preventive services There are two primary ways to receive Medicare […]
The prior authorization burdens associated with the process have long been a source of frustration for healthcare providers and patients. These burdens can impede optimal care by creating delays in treatment and increasing administrative tasks. However, recent legislative changes and insurer policies aim to alleviate these concerns and streamline the prior authorization process. A radiation […]
Medicare Advantage (MA) has become a dominant force in the Medicare landscape, accounting for over 54% of overall Medicare enrollment. This trend is expected to continue, with penetration rates projected to reach 64% by 2033. However, the future of the Medicare Advantage market is not without its challenges. The Slowdown Begins While MA has experienced […]
Surge in MA Prior Authorization Denials: New Study Reveals A new study highlights significant variation among Medicare Advantage plans regarding the number of determinations made and the frequency of denials. Notably, MA Prior Authorization Denials surged between 2021 and 2022, according to a recent analysis from health policy research. Researchers examined data from the Centers […]
Prior Authorization Challenges are a growing hurdle for medical practices dealing with Medicare Advantage plans. Recent investigations reveal concerning trends: improper denials and a lack of transparency from some insurers. This can significantly delay or even block essential care for patients. The Problem with Prior Authorizations Improper Denials: A government investigation found that Medicare Advantage […]
Prior Authorization Reform, a lengthy and often frustrating process for payers to control costs, remains a major challenge for doctors. A recent AMA survey of 1,001 physicians found that 89% of physicians believe prior licensure hurts clinical practice. A surprising 33% said the worst things, such as death or hospitalization, were rights-related. The AMA recognized […]
Prior authorization transformation of consent is a source of worry and concern for everyone involved: patients, members, providers, and payers. What was needed was a structure to coordinate all stakeholders and organize the program. In January 2024, the Centers for Medicare and Medicaid Services (CMS) finalized requirements to expedite the authorization process; this requirement will […]
The Rising Denial Rates in Healthcare Claims Processing Initial Claim Denials: In a new survey conducted by healthcare Company an increased percentage of initial claims are denied by private payers, including pre-approvals for medical claims. Hospitals, health systems, and post-acute care providers may have a difficult time getting paid for medical services. The survey respondents […]