Health Plan Accountability Update: July 2023


CMS issues final rule for 2024 Medicare Advantage, prescription drug plans

The Centers for Medicare & Medicaid Services April 5 released a final rule that would increase oversight of Medicare Advantage plans and better align them with Traditional Medicare, address access gaps in behavioral health services and further streamline prior authorization processes. The rule also establishes additional health plan utilization management oversight processes to include required annual reviews of MA plans’ policies and coverage denial reviews by health care professionals with relevant expertise. In addition, the rule would tighten MA marketing rules to protect beneficiaries from misleading advertisements and pressure tactics; expand requirements for MA plans to provide culturally and linguistically appropriate services; make changes to MA star ratings to address social determinants of health; and implement Inflation Reduction Act provisions to make prescription drugs more affordable for eligible low-income individuals. Notably, it appears the proposal to change the legal standard for identifying an overpayment, which was of concern to hospitals and health systems, was not codified in the final regulation.

In a statement shared with the media April 5, Ashley Thompson, AHA senior vice president of public policy analysis and development, said, “The AHA commends CMS for finalizing critical policies that will help ensure beneficiaries enrolled in Medicare Advantage have access to the medically necessary health care services to which they are entitled. In addition, we appreciate the agency’s increased attention to oversight of Medicare Advantage plans. Hospitals and health systems have raised the alarm that beneficiaries enrolled in some Medicare Advantage plans are routinely experiencing inappropriate delays and denials for coverage of medically necessary care. This rule will go a long way in protecting patients and ensuring timely access to care, as well as reducing inappropriate administrative burden on an already strained health care workforce.

“The final rule includes helpful provisions to ensure more consistency between Medicare Advantage and traditional Medicare by curtailing overly restrictive coverage policies that can impede access to care and add cost and burden to the health care system. We also applaud CMS’ attention to addressing access gaps in behavioral health and post-acute care services where our members commonly report some of the most significant insurance-related barriers to patient care. The AHA will continue to carefully review the final rule and urges the agency to conduct rigorous oversight and enforcement to ensure meaningful compliance.”

For more details, see the CMS fact sheet on the final rule. The AHA May 10 released a members-only Regulatory Advisory on the Medicare Advantage and Part D Final Rule for CY 2024. Members can read the advisory here.

After Discussions with AHA, UnitedHealthcare Alters GI Policy to Preempt Care Delays and Claims Denials

Following discussions between the American Hospital Association and United Healthcare, the insurer announced May 31 a refocused gastroenterology policy that relies on additional provider education rather than prior authorizations to address the insurer’s concerns about possible overutilization. Members received a Special Bulletin on June 1 recognizing the AHA’s crucial role in the change. The refocused policy avoids potential care denials for patients, particularly vulnerable patients, and will not impact the coverage and payment of claims for these services. The GI policy, which pertains to certain non-screening endoscopy and colonoscopy services, went into effect June 1.

UHC will instead implement a 7-month, or potentially longer, pilot program to collect data that substitutes notification and submission of standard clinical data when services are delivered for prior authorization, removing the risk of potential care delays and claim denials. This data will be applied to UHC’s gold-carding program, beginning sometime in 2024, in order to exempt physicians that are routinely aligned with the insurer’s guidelines. The insurer has yet to determine any additional controls that will be placed on non-gold-carded clinicians at the end of the pilot.

The standard data required in advance of care are member information, requested procedure and diagnosis, referring provider information and rendering provider information and site of service. Other potentially relevant details of a patient’s condition or medical history, including the indication for the procedure and the results of prior testing, may also be requested when necessary.

The data submitted will be reviewed by a board-certified gastroenterologist for adherence with applicable clinical guidelines and used as an opportunity to engage in physician education where appropriate. The focus on provider education should diminish the risk of patient access issues by removing the need for preauthorization in advance of the service and the accompanying risk of coverage or payment denials. The AHA agrees this refocused policy is a better approach and encourages UHC to implement the program in the most efficient way possible to avoid any duplication in the clinical information requested.

“We appreciate UHC refocusing its GI policy on provider education to address member concerns about potential care denials and additional preauthorization requirements,” said Rick Pollack, AHA president and CEO. "We plan to collaborate with UHC to help ensure it meets its goal of providing meaningful education for providers while proactively addressing these concerns.”

Report: Hospitals struggle to collect payments from commercial insurers

One in three inpatient claims submitted by providers to commercial insurers in first quarter 2023 weren’t paid for over three months and 15% of inpatient and outpatient claims were initially denied, according to data from over 1,800 hospitals and 200,000 physicians analyzed by Crowe Revenue Cycle Analytics, AHA reported May 22. That’s nearly three times the number of claims delayed that long in traditional Medicare and over four times the initial denial rate for traditional Medicare claims over the period, the study found. It also found that eight cents of every dollar providers bill to commercial insurers will never be received or will be taken back once received.

“Providers feel that they are being forced to jump through hoops and undergo labor-intensive processes in order to receive payment, especially from commercial payors,” said Colleen Hall, managing principal of the healthcare group at Crowe. “During a time when labor shortages persist and expenses continue to rise, hospitals’ believe that their time and resources should be spent directly on patient care rather than managing increasingly bureaucratic reimbursement issues with insurers.”

Infographic: New Consumer Poll Finds Patients Are Concerned about Commercial Insurer Barriers to Care

AHA July 11 released and infographic showcasing findings of three new surveys conducted by Morning Consult that examined how some commercial insurer practices impact the patient and provider health care experience. The surveys found that the vast majority of patients, nurses and physicians say insurer policies and practices are reducing access to medical care, driving up health care costs and increasing clinician burden and burnout.

Perspective: Let’s End Commercial Insurer Barriers that Reduce Access to Care

In his July 14 Perspective column, AHA President and CEO Rick Pollack wrote “many commercial health insurance policies and practices often disrupt, delay and deny medically necessary care to patients …Irresponsible commercial insurer policies don’t just limit health care access for patients, they also interfere with doctors’, nurses’ and other clinicians’ ability to do their jobs during a time of severe workforce challenges.” Read the column here.


Senate investigates Medicare Advantage coverage denials and delays

AHA May 17 shared with the Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations its concern that some MA plans inappropriately restrict beneficiary access to medically necessary covered services and urged Congress to increase its oversight of these plans.

“These problems with MA plan utilization management and coverage policies have grown so large — and have lasted for so long — that strong, decisive and immediate enforcement action is needed to protect sick and elderly patients, the providers who care for them and American taxpayers who pay MA plans more to administer Medicare benefits to MA enrollees than they do to the Traditional Medicare program,” AHA said in a statement submitted to the subcommittee for a hearing on the issue.

To ensure timely patient access, consumer protection and meaningful enforcement of new Centers for Medicare & Medicaid Services’ rules to better align MA coverage policies with Traditional Medicare, AHA urged Congress to direct further oversight of the MA program, including greater data collection and reporting on plan performance and more streamlined pathways to report suspected violations of federal rules.

Testifying at the hearing were the widow of an MA enrollee and witnesses from the Department of Health and Human Services’ Office of Inspector General, Kaiser Family Foundation, Greater Wisconsin Agency on Aging Resources, and Marquette University College of Nursing.

AHA Statement to Senate Subcommittee on Medicare Advantage Delays and Denials

AHA submitted a statement to the Senate Subcommittee on Medicare Advantage Delays and Denials May 17. Read the full text of the statement here.

CMS releases details on Medicare Advantage model extension

The Centers for Medicare & Medicaid Services April 5 released additional information on the Medicare Advantage Value-Based Insurance Design Model extension for calendar years 2025 through 2030. Announced last month, the model extension will introduce changes intended to more fully address the health-related social needs of patients, advance health equity and improve care coordination for patients with serious illness. Fifty-two Medicare Advantage organizations representing over 9.3 million enrollees are participating in this year’s model, which focuses on MA plan innovations intended to reduce costs, increase quality and improve care coordination

CMS to extend Medicare Advantage value-based model through 2030

TThe Centers for Medicare & Medicaid Services plans to extend the Medicare Advantage Value-Based Insurance Design Model for an additional five years, from 2025 through 2030, introducing changes to support health-related social needs and health equity, AHA reported March 23. Fifty-two Medicare Advantage organizations representing over 9.3 million enrollees are participating in this year’s model, which focuses on MA plan innovations intended to reduce costs, increase quality and improve care coordination. The Center for Medicare and Medicaid Innovation expects to share more information on model updates once available.




We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.

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Michelle Kielty Millerick
Senior Associate Director
Health Insurance & Coverage Policy
Molly Smith
Group Vice President
Public Policy