WAKE UP about Health Insurance

https://www.levernews.com/why-is-aarp-boosting-medicare-privatization/

@RayM920964 

Actually it isn’t just UHC that is doing the prior authorization and the denials or processing the appeals for the denials - it is all of the MA insurers.  

CMS has long been a supporter of utilization management - yes, they also do it in original Medicare as much as they can feasibly do it.  Now they are issuing further rules in how these can be accomplished with the insurers with transparency and simplicity.  They have already initialted some of the changes for 2025 and more will be forthcoming in 2026.  

CMS.gov 11/26/2024 - Press Release - Medicare Advantage and Medicare Part D Prescription Drug Proposals that Aim to Improve Care and Access for Enrollees 

CMS and other government health related programs have always supported utilization management.  It is but one way to keep down unnecessary and unapproved treatments.  Has it gotten out of control - it appears so and now it is time for CMS to act and set down specific paths for this process.

from the link: 

In recent years, there have been increasing calls for reforms related to MA prior authorization, utilization management, and coverage decisions. CMS remains concerned about barriers to accessing care and high burden on the system. For example, data reported to CMS by MA plans indicate that, on average, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan. These data also show that less than 4% of denied claims are appealed in the first place, meaning many more denials could potentially be overturned by the plan if they were appealed. Ultimately, what these and other data show is that MA enrollees may not be getting access to the care they need. The proposed rule builds on CMS’ work to remove unnecessary barriers to care resulting from the inappropriate use of prior authorization and internal coverage criteria. The rule would also increase guardrails on the use of artificial intelligence (AI) to protect access to health services. Other proposed policies will promote competition on the things that matter to people enrolled in MA and Part D plans, further addressing misleading marketing practices, and enhancing consumer tools on Medicare.gov. 

Our loved ones with Medicare deserve care that puts their interests first. HHS is proposing to improve transparency, accountability, and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care,” said HHS Secretary Xavier Becerra. “To achieve that, we want to remove barriers that delay care or deny people services and medications they need to be healthy. In addition, we continue to promote competition for pharmacies and other health care businesses.”

So we are gonna have to work together along with the insurers to come up with a plan to control and simplify this procedure.  It’s a fact of life that controls have to be initiated - to insurers and to providers - but which produce best practices.  This isn’t just for MA plans, MAPD plans, or Part D free-standing plans - it is for the entire system including Traditional Medicare.