Insurers should immediately end their overreach into medical decision-making and work with medical providers and their patients to ensure timely care for all.

The post Insurer “Delay and Deny” Practices Continue to Threaten Patients’ Timely Access to Gastrointestinal Care – It’s Time for Reform appeared first on MedCity News.

As the role of AI in healthcare settings continues to evolve and generate debate, here are seven things to keep an eye on.

The post Seven Trends to Watch in Healthtech AI appeared first on MedCity News.

At the Payer Insights sessions on Day 1 of ViVE 2024, a panel on prior authorization offered compelling insights from speakers who shared the positive developments in this area after years of mounting frustration. Speakers also shared challenges as they work with providers to figure out how policy developments and technology will work in practice.

The post At ViVE 2024, Panelists Share Prior Authorization Progress and Frustration in Payer Insights Program appeared first on MedCity News.

AI can improve the prior authorization process, but there needs to be more transparency, experts said during a recent panel held by KFF.

The post Is AI in Prior Authorization Promising or Dangerous? appeared first on MedCity News.

CMS finalized a rule on Wednesday that included set deadlines for affected payers to complete prior authorization requests. Several organizations came out in support of the rule.

The post CMS Finalizes Rule Streamlining Prior Authorization Process appeared first on MedCity News.

The real-time, automated nature of green lighting offers precise control without the setbacks or manual efforts inherent to conventional gold carding programs. This innovative new approach also ensures adherence to state-level and other gold carding regulations

The post Unlocking Prior Authorization Access With a Green Lighting Approach appeared first on MedCity News.

Nearly half of physicians are equally excited and concerned about the use of AI in their field, according to a new AMA survey. Those who felt optimistic about AI cited reduced administrative burden as the number one benefit they’re seeking. Patient privacy and the impact to the patient-physician relationship were the most common reasons physicians cited for having reservations about AI.

The post What Do Physicians Really Think of AI? appeared first on MedCity News.

In a letter to CMS, four senators asked for better data collection on the practices of Medicare Advantage plans, including when it comes to prior authorization.

The post 4 Senators Urge CMS To Collect, Publish More Data on MA Plans appeared first on MedCity News.

CMS proposed a new rule that would set a flat amount — $632 — that MA plans can pay agents and brokers when they help enroll a person into any MA plan. The proposed rule also addresses behavioral health access and prior authorization.

The post CMS Proposed Rule Tamps Down On MA Predatory Marketing appeared first on MedCity News.

During a panel at MedCity News’ INVEST Digital Health conference, three executives representing a provider, a payer and a technology vendor shared their thoughts on how to heal the rocky relationship between hospitals and health plans. For instance, one leader encouraged payers and providers not to be afraid to give up some control, and another urged them to build comprehensive risk models.

The post 3 Tips That Could Reduce Friction in Payer-Provider Relationships appeared first on MedCity News.

Cigna removed 25% of medical services from prior authorization requirements. This represents more than 600 codes, and includes 100 surgical codes, nearly 200 genetic testing codes, durable medical equipment, orthoses and prosthetics and other services, said Dr. Scott Josephs, chief medical officer of Cigna Healthcare.

The post Cigna Cuts 25% of Medical Services from Prior Authorization Requirements appeared first on MedCity News.

U.S. Representative Frank Pallone, Jr. (D-New Jersey) announced that he is looking into high prior authorization denial rates by Medicaid managed care health plans. It follows a report by the Office of Inspector General that found that Medicaid MCOs denied one out of every eight prior authorization requests in 2019.

The post Congressman Launches Investigation into Medicaid Prior Authorization Denials appeared first on MedCity News.

We need a streamlined approach where stakeholders can perform all critical tasks — from enrollment and patient consent to prior authorization, from real-time benefit checks to financial assistance — on a central platform powered by a business rules engine, automated workflows, and real-time analytics.

The post From Bottlenecks to Breakthroughs: Using Technology to Transform Specialty Medication Access and Affordability appeared first on MedCity News.

Medicaid managed care organizations deny prior authorization requests at high rates, according to a recent report by the Office of Inspector General. Of the 115 MCOs the OIG analyzed, 12 had prior authorization denial rates above 25%.

The post Medicaid MCOs Denied 1 out of 8 Prior Authorization Requests in 2019 appeared first on MedCity News.

In a recent interview, Dr. Jesse Ehrenfeld, the president-elect at the American Medical Association, outlined how the major pain point of physicians has gone from the EHR to prior authorizations requests. But none of the individual efforts that payers are making is enough.

The post Payers Can Reform Prior Authorization to Make it Faster, Smoother But Will It Satisfy the AMA? appeared first on MedCity News.

There were more than 35 million prior authorization requests submitted to MA plans in 2021, and 2 million were denied, according to KFF. Of those denied, just 11% were appealed. However, most of those appeals led to the denial being overturned.

The post MA Plans Rejected 2M Prior Authorization Requests in 2021 appeared first on MedCity News.

It’s time to stop thinking about prior authorizations as a transaction. Rather, PA is the start of a care episode that should be a smooth, well-coordinated journey for patients, their providers and their health plan.

The post 5 Ways To Drive Intelligence Into the Prior Authorization Process appeared first on MedCity News.

Remaining at or near the top of employers’ and consumers’ choices when it comes to health coverage will require insurers to make large investments in infrastructure, processes and people to overcome the status quo.

The post Mission (Im)possible: Overcoming the Status Quo In Health Coverage to Offer More Personalization appeared first on MedCity News.

Less than 1% of hospitals and health systems said their relationship is improving and the rest said it has stayed the same. The American Hospital Association specifically called out commercial insurers for their practices on prior authorization and claims denials and delays.

The post AHA: 78% of Hospitals Say Experience With Commercial Insurers Is Worsening appeared first on MedCity News.

The bill sets requirements relating to the prior authorization process for Medicare Advantage plans. The House’s decision is supported by several healthcare advocacy organizations, including Better Medicare Alliance and the American Hospital Association. AHIP, however, neither criticized nor celebrated the passage.

The post Senior healthcare advocates applaud House passage of MA prior authorization bill appeared first on MedCity News.

Commercial insurers’ practices, such as prior authorization and white bagging, are needed to reduce costs for patients, said Kristine Grow, senior vice president of communications at AHIP.

The post American Hospital Association turns up the heat on commercial insurers in scathing report appeared first on MedCity News.

Geisinger Health Plan is licensing Cohere Health’s AI-driven utilization management technology and services platform, designed to support value-based care delivery and streamline the prior authorization process.

The post Geisinger Health Plan addresses burdensome prior auth process with Cohere Health’s platform appeared first on MedCity News.

Pharma companies often take the blame for high prescription costs. But a new, industry-sponsored survey shifts attention to insurance industry practices.

The post Drug-industry survey blames insurer practices for barriers to care appeared first on MedCity News.

An intelligent authorization platform relies on AI and machine learning to extract patient-specific data from a number of sources including the EHR. This helps health plans better anticipate, manage and optimize member outcomes.

The post Overhauling prior authorization: How to achieve better outcomes at a lower cost appeared first on MedCity News.

Insurers’ abuse of prior authorization is creating health risks for patients and contributing to higher downstream costs for both beneficiaries and the larger health care system.

The post Insurance company abuses are putting more patients’ care out of reach appeared first on MedCity News.

To get to the root of existing reimbursement problems, health plans should consider tackling genomic benefits management in a way that addresses test ordering and billing challenges.

The post Take a holistic approach to genomic testing reimbursement appeared first on MedCity News.

The bill, if enacted into law, will establish an electronic prior authorization process and require Medicare Advantage plans to report on their use of prior authorization and the rate of approvals or denials to CMS. It has 227 co-sponsors in the U.S. House, indicating strong support from both Republicans and Democrats.

The post Bill aiming to streamline MA prior authorization gains House majority support appeared first on MedCity News.

Beginning July 1, Aetna now requires prior authorization for all cataract surgeries, across all its members and plans. Here in California and across the country, ophthalmologists are going to great lengths to secure approval from Aetna for cataract surgery, while the backlog caused by prior authorization and delayed elective care during the Covid-19 pandemic only grows.

The post Aetna’s prior authorization policy harms California patients appeared first on MedCity News.

It’s time to embrace electronic prior authorization that, according to a 2021 AHIP study, has been found to reduce the mean time from PA request to decision by 69%. In addition, 71% of providers using ePA reported “faster time to patient care.”

The post It’s time to relieve electronic prior authorization bottlenecks appeared first on MedCity News.

The value of tech-enablement in a clinician’s day-to-day goes beyond our current outbreak scenarios. So much is still done by hand and faxed around that it screams of mid-90s nostalgia, but not in a charming way.

The post Opinion: Our country’s health IT infrastructure needs an upgrade appeared first on MedCity News.