CMS Takes Aim At Prior Authorization Requirements In Medicare Advantage

Home Health Care News / By Audrie Martin

The Centers for Medicare & Medicaid Services (CMS) is proposing new limits on Medicare Advantage (MA) plans regarding prior authorization, utilization management, coverage decisions and the use of artificial intelligence (AI). These proposed changes aim to address the barriers to accessing care identified by CMS.
 
Data reported to CMS by MA plans show that, on average, these plans overturn 80% of their claim denial decisions when appealed. However, less than 4% of denied claims are actually appealed, indicating that many more denials could potentially be reversed through the appeals process. This data suggests that MA enrollees may not be receiving necessary care. 
 
CMS is actively working to mitigate inappropriate prior authorization and other utilization management practices that limit access to care, create system-wide burden and negatively impact health care providers. 
 
CMS’ utilization management audits, conducted throughout 2024 and into 2025, have informed the proposals outlined in this rule. 
 
“We continue to hear from people enrolled in Medicare Advantage who are having difficulty accessing the care they need and are entitled to. CMS remains focused on removing these barriers,” Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, said in a statement. “No senior or person with disabilities on Medicare should have to face challenges in navigating options, affording lifesaving medications prescribed by their doctor, or receiving the inpatient or rehabilitation care they need to recover.” 
 
Some health plans have already begun to undo some burdensome prior authorization requirements…

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UnitedHealthcare CEO Kept a Low Public Profile. Then He Was Shot to Death in New York

Associated Press / By Adam Geller and Tom Murphy

NEW YORK (AP) — Brian Thompson led one of the biggest health insurers in the U.S. but was unknown to millions of people his decisions affected.

Then Wednesday’s targeted fatal shooting of the UnitedHealthcare CEO on a midtown Manhattan sidewalk thrust the executive and his business into the national spotlight.

Thompson, who was 50, had worked at the giant UnitedHealth Group Inc for 20 years and run the insurance arm since 2021 after running its Medicare and retirement business.

As CEO, Thompson led a firm that provides health coverage to more than 49 million Americans — more than the population of Spain. United is the largest provider of Medicare Advantage plans, the privately run versions of the U.S. government’s Medicare program for people age 65 and older. The company also sells individual insurance and administers health-insurance coverage for thousands of employers and state-and federally funded Medicaid programs.

The business run by Thompson brought in $281 billion in revenue last year, making it the largest subsidiary of the Minnetonka, Minnesota-based UnitedHealth Group. His $10.2 million annual pay package, including salary, bonus and stock options awards, made him one of the company’s highest-paid executives.

The University of Iowa graduate began his career as a certified public accountant at PwC and had little name recognition beyond the health care industry. Even to investors who own its stock, the parent company’s face belonged to CEO Andrew Witty, a knighted British triathlete who has testified before Congress.

When Thompson did occasionally draw attention, it was because of his role in shaping the way Americans get health care.

At an investor meeting last year, he outlined his company’s shift to “value-based care,” paying doctors and other caregivers to keep patients healthy rather than focusing on treating them once sick.

“Health care should be easier for people,” Thompson said at the time. “We are cognizant of the challenges. But navigating a future through value-based care unlocks a situation where the … family doesn’t have to make the decisions on their own.”

Thompson also drew attention in 2021 when the insurer, like its competitors, was widely criticized for a plan to start denying payment for what it deemed non-critical visits to hospital emergency rooms…

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Medicaid Threats in the Upcoming Congress

Center on Budget & Policy Priorities / By Allison Orris and Gideon Lukens
 
Deeply damaging health coverage proposals recently advanced by Republican congressional leaders and conservative think tanks could gain traction in Congress next year.[1] Cutting Medicaid would harm enrollees — including the millions of children, people with disabilities, and elderly people with low incomes who are covered by Medicaid — and increase health inequities.

About 72 million people receive health coverage through Medicaid.[2] It pays for 2 in 5 births in the U.S.[3] and is the nation’s largest payer both of behavioral health services, which include mental health and substance use disorder treatment,[4] and long-term care services, either at home or in nursing facilities.[5] (See Figure 1, and more details in the Appendix.) Medicaid helps children develop into healthy adults and helps adults stay healthy. And it’s an overwhelmingly popular program.[6]

Despite this, various Republican legislative proposals seek to cut Medicaid by eliminating or severely underfunding the Affordable Care Act (ACA) Medicaid expansion, by restructuring and cutting federal funding for the program as a whole, or by weakening long-standing program protections for enrollees.[7] Republicans often use improving program efficiency and program integrity as a rationale for their proposed cuts, but the real common thread in the proposals is that they would lead to widespread cuts in eligibility, benefits, and provider payment rates, potentially leaving millions without health care coverage and access to care they need.

For example, the proposed Medicaid cuts would jeopardize people’s ability to access and afford life-saving medications, treatment to manage chronic conditions, and care for acute illnesses. People with cancer would be diagnosed at later stages and face higher risks of mortality. People with chronic conditions such as cardiovascular disease, obesity, and liver disease would go untreated and have worse health outcomes. People under serious psychological distress would delay or forgo the care they need. And families would have more medical debt and less financial security. A large body of evidence bears this out: Medicaid improves health, prevents premature deaths, and reduces medical debt and the likelihood of catastrophic out-of-pocket medical costs.[8]

To be sure, there also is plenty of damage the incoming Trump Administration could inflict on Medicaid through administrative actions, as we saw during the first Trump Administration.[9] This paper, however, focuses on harmful legislative Medicaid proposals that Republicans have floated in the past[10] and that Congress should continue to resist.

The ACA expanded Medicaid to adults with household incomes up to 138 percent of the poverty level ($20,783 a year for an individual), with the federal government picking up most of the cost. The Supreme Court later made the expansion optional for states, but 40 states plus the District of Columbia have adopted it and now cover more than 20 million adults aged 19 to 64.[11]

Recent GOP budget plans have proposed reducing the 90 percent federal matching rate for Medicaid expansion to each state’s regular Medicaid matching rate.[12] The Congressional Budget Office (CBO) previously estimated this would cut $752 billion from Medicaid over nine years, beginning in fiscal year 2024.[13] CBO’s estimate assumes that in response to the federal change, no states would newly opt to expand, some states would drop expansion, and some states would replace only half of the lost federal funding, on average. Other proposals, in addition to reducing the expansion group matching rate, would explicitly limit the Medicaid expansion group to those with incomes up to 100 percent of the poverty level, leaving individuals over that income level to either find other coverage with higher out-of-pocket costs or become uninsured.[14]…

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As Home Health Providers Dive Into AI, Study Examines Its Effect On Reducing Documentation Time

Home Health Care News / By Audrie Martin

Artificial intelligence-powered documentation does not enhance clinician efficiency but may improve their work-life balance, according to a study published in the New England Journal of Medicine.

Researchers at Atrium Health in Charlotte, North Carolina, and the Wake Forest University School of Medicine conducted a study in mid-2023 comparing 112 primary care clinicians who used Nuance’s Dragon Ambient eXperience (DAX) Copilot clinical documentation software with a control group of 103 clinicians who did not use the tool.

DAX Copilot is an AI-enabled scribe software integrated with electronic health records (EHR). It creates a preliminary clinical note by “listening” to the conversation between a clinician and a patient during their visit.

The purpose of this tool is to reduce administrative burdens, allowing clinicians to concentrate more on patient care. In doing so, AI-powered clinical documentation tools could help mitigate physician burnout and enhance the efficiency of health care delivery.

Home health providers are hoping AI tools can do the same for their nurses.

At the beginning of the day, clinicians log into the EHR and open DAX through a link. Before entering a patient’s room, they launch the smartphone application and begin recording while still outside the room to capture the patient’s name, reason for the visit and other relevant information.

Once the visit concludes, the clinician stops the recording, and the application generates the preliminary note within 30 seconds. The draft is available for review either in the smartphone app or in a preview window on the computer. Both options allow the clinician to edit the note. However, research indicates that most clinicians do not use this editing feature. Typically, they transfer the note to the EHR using voice commands or the “copy” button and make further edits within the EHR before finalizing the note.

The primary outcomes of EHR usage and its financial impact were evaluated over 180 days. The DAX group divided participants into two subgroups: active users and high users. Active users transferred approximately 25% of DAX notes, while high users transferred around 60%.

Exploratory analyses indicated that high DAX usage could lead to small reductions in documentation hours, mainly when implemented with low-volume clinicians and in family medicine practices.

“In this evaluation, we found no statistically significant differences in EHR-related and financial metrics between DAX users and the control group,” the researchers wrote. “However, exploratory results suggested that modest reductions in documentation time could occur when using DAX at a high utilization level or when targeting specific clinical subgroups. Overall, these findings imply that the efficiencies gained from AI-enhanced documentation may reduce burnout indicators for a subset of clinicians and potentially on a broader scale if DAX is adopted widely. However, implementing DAX in its current form will unlikely lead to substantial productivity gains for health care systems.”

Users agree AI aids work-life balance

While researchers couldn’t identify significant improvements in documentation or financial metrics, a subset of clinicians noted that the tool saved them time. Instead of seeing more patients, this extra time allowed them to get more sleep, reduce their work hours at home, and personalize and focus on existing patient encounters. These changes may contribute to better patient outcomes and greater satisfaction, not to mention better work-life balance.

To that end, Kathy Hoffman, chief clinical officer at Pinnacle Home Care, told Home Health Care News earlier this year that using an AI-powered language model has helped streamline operations, saving time on documentation and giving clinicians more downtime at home…

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