KFF: A Look at Prior Authorization Trends in Medicare Advantage

Fierce Healthcare | By Paige Minemyer
 
Prior authorization denials in Medicare Advantage (MA) jumped between 2021 and 2022, according to a new analysis from KFF.
 
Researchers dived into data from the Centers for Medicare & Medicaid Services and found that 46 million requests for prior auth were submitted to MA insurers in 2022, or about 1.7 requests per enrollee.
 
Of those requests, 3.4 million or 7.4% were denied, according to the report. By comparison, 5.8% of requests were denied in 2021, as were 5.6% in 2020 and 5.7% in 2019. Meanwhile, the number of requests per enrollee in 2022 was on par with the number submitted in 2019, the study found.
 
The study noted that there is notable variation between MA plans in terms of how many determinations were made as well as how many were denied.
 
For example, prior authorization requests were highest for Humana plans, with 2.9 requests per enrollee. Kaiser Permanente plans had the lowest rate at 0.5 requests per enrollee, though the analysis acknowledges that the healthcare giant is something of a unique case given how many services it provides to its own members.
 
Among traditional insurers, UnitedHealthcare and Cigna were on the low end with 0.9 requests per enrollee.
 
"Differences across Medicare Advantage insurers in the number of prior authorization requests per enrollee likely reflect some combination of differences in the services subject to prior authorization requirements, the frequency with which contracted providers are exempted from those requirements, how onerous the prior authorization process is for a particular insurer relative to others, and differences in enrollees’ health conditions and the health care services they use," the researchers wrote.
 
Anthem MA plans had the lowest denial rate at 4.2%, with CVS Health's Aetna at the highest rate of 13%. The analysts said that generally the plans with higher numbers of requests had lower denial rates.
 
Exceptions to this trend were Centene, which had 2.2 requests per enrollee as well as a denial rate of 9.5%. Cigna had a low rate of submissions as well as a below-average denial rate of 5.8%.
 
The report also found that it was relatively rare for enrollees to appeal denied claims. Appeal rates ranged from 3.5% for Kaiser Permanente enrollees to 15.2% in Anthem plans. Cigna was, again, an outlier with 50.4% of denials appealed, but the researchers noted that it had both low submission rates and low rates of denials.
 
When plan members did appeal prior authorization denials, they were frequently successful. For Humana members, 68.4% of appeals were successful, and that rate jumps to 90.8% for CVS and 95.3% at Centene, according to the report.

Claim Denials Becoming More of a Headache for Providers: Report

Modern Healthcare | By Caroline Hudson
 
Insurance claim denials continue to be a vexing problem for healthcare providers, forcing them to expend more resources to reverse payers' decisions in an already-inflated cost environment.
 
One common approach among insurers is denying payment until the provider submits additional information. Payers say it's a way to ensure their dollars are being spent appropriately, but many providers argue it's a stalling tactic. 
 
Requests for more information are a growing burden on providers, but some payer programs are worse than others, according to a report published Thursday by consulting firm Kodiak Solutions. 
 
Kodiak’s quarterly benchmarking report examines data from the company's revenue cycle analytics platform, which is used by more than 1,900 hospitals and 250,000 physicians. The report categorizes any initial claim rejected pending more information as a denial.
Here are five takeaways from the report.
 
1. Payers are increasingly asking for more information.
 
Payers initially denied 3.8% of billed charges in the first five months of 2024 requesting more information. Monthly data showed an uptick to 4% in May, from 3.9% in January.
Payers often ask for medical records confirming the level of care was appropriate, including itemized statements of the charges and details on coordination of benefits, said Matt Szaflarski, revenue cycle intelligence leader at Kodiak.
 
"Providers have tried to figure out ways to be proactive about sending medical records with the first claim ... but oftentimes payer systems aren't set up to accept those records until the claim is denied," Szaflarski said.
 
2. Providers burdened with higher administrative costs.
 
Providers face rising administrative costs for staffing and other resources needed to handle requests for more information and to follow up with patients when a claim or parts or it are denied.
 
Providers spent $1.9 billion in the first five months of 2024 responding to requests for more information, the report found, compared with $1.7 billion for the same period in 2023 and 
$1.5 billion in 2022.
 
Kodiak projects providers will spend nearly $4.6 billion for the full year. Comparative numbers for 2023 were not included in the report.
 
3. Provider claims aren’t necessarily getting sloppy.
 
Most claims initially denied pending additional nformation end up being approved.
Kodiak assessed more than 39,000 initial claim denials at five unnamed health systems in 2023 and found that insurers eventually paid 88.4% of those claims once more information was provided. 
 
Szaflarski noted that even if claims are ultimately paid, many of those payments have been delayed for months.
 
4. Providers see more denials on inpatient claims.
 
From January through May, payers initially denied 4.5% of inpatient billed charges, compared with 3% of outpatient charges. Full-year data for 2023 followed a similar pattern, with payers denying 4.3% of inpatient billed charges and 2.9% of outpatient charges.
"The inpatient cases are the ones that have the highest levels of reimbursement, and so that's where there's a lot more due diligence," Szaflarski said.
 
He said many denials are related to sepsis cases because payers and providers often dispute the criteria and coding for a sepsis diagnosis.
 
5. Medicaid and commercial payers issue the most denials. 
 
Traditional Medicaid programs initially denied 9.2% of billed charges in the first five months of 2024. Szaflarski said the trend could be related to constantly changing Medicaid rules and multistate providers dealing with different rules in different states. Medicaid patients also tend to move in and out of those programs more frequently, he said.
Commercial payers initially denied 8.1% of billed charges from January through May.
 
"It's the commercial bucket that has just become more and more challenging and especially as Medicare beneficiaries have moved over to the commercial space," Szaflarski said.
 
Medicaid managed care programs initially denied 5.5% of billed charges, and Medicare Advantage programs denied 2.7%, according to the report. Traditional Medicare programs initially denied 0.5% of billed charges.

Adaptive Brain Stimulation a 'Game Changer' for Parkinson's?

Medscape | By Megan Brooks 

Personalized, adaptive deep brain stimulation (DBS) can enhance the control of motor symptoms of Parkinson's disease (PD) compared with standard DBS, new research suggests.

In a blinded randomized crossover pilot trial involving four patients, adaptive DBS reduced the time spent with motor symptoms by half and improved patients' quality of life compared with standard DBS.

"This is the future of deep brain stimulation for Parkinson's disease," study investigator Philip Starr, MD, PhD, professor of neurological surgery and co-director of the University of California San Francisco (UCSF) Movement Disorders and Neuromodulation Center, said in a statement.

"Adaptive DBS represents a major breakthrough in managing the symptom fluctuations in Parkinson's disease by tailoring stimulation in real time to patients' specific needs," Carina Oehrn, MD, PhD, research fellow in the Starr Lab at UCSF, told Medscape Medical News.

The study was published online on August 19 in Nature Medicine.

A New Era of DBS?

DBS is a standard therapy for advanced PD. Standard DBS provides continuous, fixed stimulation that is unresponsive to patient activities or variations in severity of symptoms during daily life.

"While this approach effectively reduces motor symptoms for many patients, it does not account for the dynamic nature of PD symptoms, which can fluctuate throughout the day — for example, in response to medication. As a result, patients can experience breakthrough PD symptoms at times when they theoretically require more stimulation and stimulation-induced side effects when they would need less," Oehrn told Medscape Medical News.

Illustration of the adaptive paradigm starting with real-life sensing of brain activity.

Adaptive DBS adjusts the intensity of stimulation based on the patient's need — increasing stimulation when PD symptoms break through and decreasing stimulation at other times to prevent potential side effects caused by stimulation, she explained.

For their pilot trial, the UCSF team recruited four men with PD from a population undergoing DBS implantation for motor fluctuations, with each patient receiving adaptive DBS and continuous DBS.

Using a data-driven approach, they identified brain activity signals in the subthalamic nucleus and motor cortex that were reliable biomarkers of medication fluctuations and associated PD motor symptoms and used it to personalize the DBS parameters.

They found that adaptive DBS reduced the duration of motor symptoms by 50% compared with clinically optimized standard DBS. Objective measurements obtained by wearable devices confirmed the superiority of adaptive vs standard DBS. Three of the four patients also reported improved quality of life with adaptive DBS.

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Medicare Advantage Consensus Waning Ahead of 2024 Election

Fierce Healthcare / By Noah Tong
 
Both political parties are more open to Medicare Advantage (MA) reform than in previous election cycles, a shift former federal officials warned should be a warning call for the health insurance industry to refocus its messaging and advocacy efforts surrounding the plans.

Scrutiny is ramping up among Democrats concerned MA is not a good deal for taxpayers and within a group of more populist Republicans, whereas there used to be more bipartisan agreement on the program’s importance.

“I think the consensus around MA is eroding somewhat,” said Alex Azar, former Department of Health and Human Services secretary for President Donald Trump, during a recent webinar hosted by consulting firm Avalere.

The Centers for Medicare & Medicaid Services (CMS) finalized its 0.16% cut of MA benchmark payments in March, causing an uproar of pushback from insurers saying the decision would result in layoffs, a retreat from service areas and fewer supplemental benefits for members.

Some lawmakers hoped CMS wouldn’t go through with the plan, while others pointed to a MedPAC report that found Medicare is projected to overpay MA plans by $88 billion as compared to what traditional Medicare would’ve received.

“I think some of those [cuts] may come back to haunt them on Oct. 15 when open enrollment comes and we see either increased cost sharing, reduced benefits or increased premiums as a result of what they’ve done two weeks before the election,” Azar said.
Avalere Health Managing Director Sean Creighton said the MedPAC analysis was flawed, echoing Azar’s belief that the report is “nonsense” and “terrible.”

“I do think it behooves the industry to do a lot of myth busting out there on MA,” said Azar. “That’s not to say there aren’t problems with maybe how certain operators have done things. It is a fallacy that MA plans are so profitable and high margin.”

Next month, AHIP will spend seven figures on digital advertising to persuade older Americans to protect MA, Politico reported. The industry is attempting to rebuff efforts to minimize its importance, with more than 32 million enrollees.
 
Morgan Health CEO Dan Mendelson agrees that both parties are looking to crack down on bad behavior in MA.
 
“I think there’s a real opportunity right now for the plans to engage in a positive way, to find the value proposition and stabilize things," he said.
 
He also expects Democrats to push for adding dental and vision to the base of Medicare, a policy backed by Bernie Sanders, I-Vermont, and progressive Democrats, though Vice President Kamala Harris' campaign has retreated from her original "Medicare for All" stance…
 
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