Medicare Advantage organizations (MAOs) may be improperly issuing denials for skilled nursing and post-acute care, according to two related reports by the Department of Health and Human Services Office of Inspector General.
In the first, MAOs were found to have overturned nearly all prior authorization denials for skilled nursing...CMS Rules
Last week, the Departments of Health and Human Services (HHS), Treasury and Labor in partnership with the White House Office of Personnel Management (OPM) finalized a rule that would overhaul the dispute resolution framework for the No Surprises Act.
The rule will reduce administrative fees for disputes from $115 to $15 per dispute,...Arizona News
A new analysis looked at the rates of claims denials among ACA Marketplace plans in 2023 and found that nearly one in five in-network claims and 37% of out-of-network claims were denied.
The denial rate varied from plan to plan with some plans reaching in-network denials of 54% and some as low as 1%. The KFF analysis also showed that...CMS Rules
The Centers for Medicare and Medicaid Services (CMS) revealed their proposals for Medicare Advantage plans in 2025, but the Biden administration appears to be pulling punches that it otherwise let fly in non-election years.
CMS said on Wednesday that it expects the average benchmark payment for MA plans to decrease by 0.2% in 2025...National News
Last week, the Medicaid and CHIP Payment and Access Commission (MACPAC) held its annual meeting where the draft of the annual March Report to Congress on Medicaid and the Children's Health Insurance Program (CHIP) was presented.
In the meeting, the commission discussed and voted on seven recommendations to change the mechanism for...National News
UnitedHealth Group (UHG) is facing a class action lawsuit initiated by two families of deceased Medicare Advantage policyholders who say that the insurer's use of proprietary AI software developed by UGH subsidiary NaviHealth, denied coverage for post-acute care and left them with an untenable bill.
The family members filed suit in...Top of The Day
A new report by Syntellis and the American Hospital Association (AHA) could drive the fight between hospitals and Medicare Advantage providers to reach a head, as the analysis shows MA plans' claims denials are directly contributing to declines in cash reserves.
Claims denials increased 56% for the median hospital between January 2022...
As public and political pressure has risen against prior authorization, insurers are scaling back use of the policy and are openly reforming the process.
Back in February, the American Medical Association (AMA) led 118 other medical organizations to write a letter to the Centers for Medicare and Medicaid Services, specifically...
Rural hospitals experience unique issues as providers across the medical industry, and specifically in regards to Medicare Advantage (MA). Plan availability, the structure of available plans, and difficulties with processing payments are all reasons rural health systems are increasingly fighting MA.
A new study by Milliman highlights...
In December, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule that would require all health plans, including Medicare Advantage plans, to limit prior authorization deliberations to seven days. On Monday, the public comment for that rule closed.
Many providers believed that the rule doesn't go far enough,...
It was a big week for studies and reports on Medicare Advantage, both positive and negative for the industry as a whole.
The Better Medicare Alliance recruited ATI Advisory to conduct a study on how much Medicare Advantage beneficiaries save by comparison to beneficiaries with traditional Medicare. It found that MA enrollees save a...
A new report from Kaiser Family Foundation (KFF) that used claims data from the Centers for Medicare and Medicaid Services (CMS) on appeals and denials for non-group qualified health plans offered through the Affordable Care Act (ACA) federal marketplace found that nearly one-fifth of in-network claims were denied and 72% of reported...
