Every year it feels like it's getting harder and harder to work with Medicare Advantage plans, Essentia Health's senior vice president of revenue services, Melanie Wilson, told Becker's.
Duluth, Minn.-based Essentia is one of nearly 400 organizations backing recently introduced legislation aiming to reform the Medicare Advantage prior authorization process.
If passed, the bill known as the "Improving Seniors’ Timely Access to Care Act" would:
- Establish an electronic prior authorization process for MA plans, including a standardization for transactions and clinical attachments.
- Increase transparency around MA prior authorization requirements and its use.
- Clarify the HHS' authority to establish timeframes for electronic prior authorization requests, including expedited determinations, real-time decisions for routinely approved items and services, and other prior authorization requests.
- Expand beneficiary protections to improve enrollee experiences and outcomes.
- Require HHS and other agencies to report to Congress on program integrity efforts and other ways to further improve the electronic prior authorization process.
Ms. Wilson said over the past several years they've seen an increase in the amount of denials, both proactively and retroactively.
"What I mean by proactively, they made it incredibly burdensome to submit clinical documentation for approval," she said. "I think with some of the focus on that area and some of the heat they've received already from [earlier] legislation that they have moved away from that as a policy management strategy a little bit."
"Now what we're seeing is they're denying care on the backend or are instituting very complex medical necessity rules. So in order to even get an authorization, you also have to jump through these hoops to make sure that it is no longer just authorized but meets their medical necessity policies."
Ms. Wilso said what Essentia is looking for is transparency in the rules.
Andy Askew, Essentia's vice president of public policy, said the system's public affairs team is trying to stay engaged on the federal front when it comes to prior authorization.
"The states are really divided right now on how they handle prior auth oversight," he said. "For example, we serve Minnesota, North Dakota and Wisconsin. Minnesota has made some really great strides this [legislative] session building off some 2020 reforms. So right now there's 48-hour decision timelines on certain services in Minnesota; prohibitions for prior auth on certain mental health services. Over in North Dakota and Wisconsin, there's no oversight that has been codified."
Any variation from state to state creates burden and cost, he said.
"We really think a federal North Star is needed," he said. "I don't think this federal regulation will control all of insurance and we do need states to come along, but the patchwork that's there is really difficult."
York, Pa.-based WellSpan Health is another system backing the proposal.
"I've been in this game for many years now and I will absolutely say the problem appears to be increasing," Nakesha Muldrow, WellSpan's vice president of finance and patient scheduling, told Becker's. "In years past, there were friction points, absolutely, but in the last several years the disruptions have increased and we can see that even in the staff effort and the amount of administrative burden that is happening on our end."
In addition to reducing administrative burden, the legislation has the potential to increase patient safety and access to care.
\"We want to make sure that we pull patients into the system as easily as possible and reduce those friction points because of the changes and strains we're seeing on the healthcare workforce already," she said.
Ms. Wilson said there is a big cost savings that comes with reducing the administrative burden.
"I like to remind people that healthcare, particularly organizations like Essentia Health, we're a not-for-profit organization, so we're not looking to improve the bottom line so that we've suddenly got more money that we can stow away or pay stockholders," she said. "We are looking for improvements so that we can continue to supply the care that we do and invest in our communities."