seogyan on LinkedIn: CA hospitals sue Anthem insurance, allege treatment delays- CalMatters (2024)

We’ve been piloting Sidecar Health. If you don’t know it, it’s a disruptive model that was born out of the (totally reasonable and universal) frustrations of the undeniably broken US healthcare system. So what are my thoughts so far? In a word: impressed. Customer service is a giant leap above traditional carriers. Providers realize revenue faster. It’s more efficient for all players. No such thing as “out of network”. And get this, patients and customers can save $ greatly. I’m hoping the experience we’ve had is a sign of things to come. And in time, as more entities get to know Sidecar and its model, the time it sometimes takes to explain how it works to offices and billing folks will get easier.

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📢 States Step Up to Reform Prior Authorization Practices Amid Healthcare Delays 🏥💼A wave of state legislation is sweeping across the US, aimed at reigning in the contentious practice of prior authorization by health insurance companies. This movement seeks to address the growing concerns voiced by both #HealthcareProviders and #Patients over the delays and denials of care due to these #preapproval processes. 🚨With New Jersey leading the charge through recent legislation that mandates insurance decisions within 24 to 72 hours depending on the urgency, and Washington state implementing similar laws, the message is clear: the current system needs an overhaul. Over 20 states have passed prior authorization bills in 2023 alone, reflecting a nationwide push towards more efficient healthcare delivery. 📜🕒These state-level initiatives, often more stringent than the proposed federal regulations by the , signify a critical step towards streamlining patient care and reducing unnecessary administrative burdens on providers. The move has been widely supported by healthcare advocates and professional associations who have long criticized prior authorization for its role in escalating healthcare costs and frustrations among consumers. 🩺💡While some insurers have begun to roll back these policies, the widespread call for transparency, adherence to clinical guidelines, and swift decision-making underscores a pressing need for systemic change.#HealthcareReform #PriorAuthorization #Legislation #PatientCare #HealthInsurance

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New Jersey's recent legislative move to streamline the prior authorization process is a significant step towards enhancing patient care and reducing bureaucratic barriers. The new law mandates health insurance companies to make decisions within three days, or within 24 hours for urgent cases, promising to alleviate the distress many patients and doctors face due to prolonged waits.The necessity of this reform is further underscored by alarming statistics from 2021, revealing that out of the 2 million prior authorization denials by Medicare Advantage insurers, more than 80% were overturned on appeal. The majority of denials, however, were not appealed. Across all insurers, just over 212,000 prior authorization determinations, or 11 percent of all denials, were appealed.This discrepancy not only questions the efficiency of initial determinations but also highlights the undue delay in necessary medical care, potentially compromising patient health. It signals the need for more streamlined, transparent, and patient-centric approaches in the prior authorization process.New Jersey's new law may serve as a model for other states and a step forward in reforming healthcare policies to prioritize patient well-being over administrative hurdles.#HealthcareReform #PatientCare #PriorAuthorization #NewJerseyLegislation #MedicareAdvantage

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The Biden administration introduces rules to limit private health insurance companies' prior authorization practices, aiming to expedite approval, mandate reasons for denials, and enhance transparency. The regulations affect federal program insurers, impacting about 105 million individuals, but exclude employer-sponsored plans, affecting an additional 158 million. Advocates appreciate the effort but criticize its limitations, arguing it fails to address the extent of the issue. Insurance companies claim prior authorization controls costs, yet patients often face delays and denials for necessary care. Individuals like Carly Morton and Megan Shirk recount arduous battles to obtain coverage for medical treatments, highlighting the emotional and physical toll of navigating the system. While steps are welcomed, advocates stress the need for broader reforms to ensure timely and equitable access to healthcare.Our RCM team streamlines prior authorization procedures, facilitating timely approvals and reducing administrative burdens for providers. By optimizing billing processes and ensuring compliance, we support patients in accessing necessary treatments efficiently.We are the One!https://lnkd.in/gTgRcZC4#revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner The Guardian

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In their new Forefront article, Paul R. Shafer, David M. Anderson, Michal Horný, and Stacie B. Dusetzina from Boston University, Duke University, Emory University, and Vanderbilt University discuss how annual cost-sharing limits have been the default and indeed the only option since health insurance was a novelty in the aftermath of World War II. It’s time for a change, they argue."For years, proponents of value-based insurance design have tried to make patients’ out-of-pocket costs more directly related to the value of care—with higher-value care costing less. For example, the Affordable Care Act (ACA) made certain high-value preventive services free to patients, although this policy is currently under threat in Braidwood v. Becerra. Another example is the monthly copayment cap on insulin costs for Medicare beneficiaries in the Inflation Reduction Act, which has helped nearly four million Americans. The White House is pushing Congress to make this policy applicable to all insured individuals, and nearly half of all states have passed insulin copayment caps to date."Read the full article here: https://bit.ly/3sRWwGU

PRIMARY HEALTH INSURANCE POLICIES CAN BE SOLD FOR ANOTHER YEAR!CMS Exemption Extension: The Council for Medical Schemes (CMS) has extended the exemption allowing the sale of primary healthcare insurance policies by one year.Primary Healthcare Policies: An estimated 800,000 to 1.5 million consumers have these policies, which cover services like GP and dentist consultations.LCBO Framework Delay: The CMS has been developing a regulatory framework for low-cost benefit options (LCBOs) since 2016, but there’s a delay in finalizing the guidelines.Industry Conflict: There’s ongoing litigation between the Board of Healthcare Funders (BHF) and the CMS over the LCBO framework and the exemption for primary healthcare insurance policies.

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More great reporting from ProPublica on healthcare claims. This article investigates physicians alleged of medical malpractice who are then paid to provide medical reviews for health insurance companies. Patients are entitled to know who denied their health claim. And, as the article underscores, it is important for patients to know the credentials of the physician whose opinion is relied upon for the denial. It can be difficult for patients to ascertain who was involved in making the decision to deny their health claim. Is it the person who signed the denial letter? Is it an unnamed physician only referenced in the denial letter (i.e. "a physician board certified in xyz medicine was consulted in making this determination")? Is it a committee, or a nurse? What are the credentials of the person who did a medical review on the claim? The answers to these questions can help patients understand whether their claim was properly reviewed by the health plan.#erisa #healthcare #healthbenefits #healthinsurance

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(WASHINGTON EXAMINER) - "Medicare Advantage plans are a bargaining chip in negotiations between hospitals and insurers."In their negotiations with health insurers, hospital systems have found a new tactic: removing themselves from the networks of Medicare Advantage plans.Find The Most AFFORDABLE Health Insurance Plans At: HI4E.org#NetworkProviderNetworks #InNetwork #HospitalNetworkContracts #MedicareManagedCare #MedicareAdvantagePlans #MedicareAdvantageEnrollment #BidenHealthcare #BidenMedicare #MedicarePremiumIncreases #MedicareAdvantagePlanCuts #SupplyChainPriceIncreases #MedicareAdvantagePriceHikes #MedicareReform #MedicareCostOfLivingIncreases #Inflation #BidenInflation #MedicalCostIncreases #PhysicianBillingIncreases #HospitalPriceIncreases #CostOfLiving #MedicareBenefits #HI4E.Org #SocialSecurityInsolvency #MedicareAdvantagePlans #MedicareFundingDepleted #Retirees #SeniorBenefits #WashingtonExaminer #HealthAndLifeSolutions #HealthInsuranceForEveryone

(AXIOS) - "Hospitals Are In The Hotseat For Their Billing Practices."Some measures under discussion could cost hospitals hundreds of billions of dollars, by paring payments that critics say are excessive and costing taxpayers and patients.#HospitalBillingErrors #HospitalBillingAudits #CPTCodes #HospitalERBills #NoSurprisesAct #OutOfNetworkProviders #DishonestHospitalBilling #SurpriseMedicalBilling #TrumpHospitalPriceTransparencyRules #TrumpHealthPlans #TrumpDrugPriceControls #TrumpHealthcareReforms #ObamacareLimitedDoctors #TrumpSurpriseMedicalBillsRule #HospitalBillings #HI4E.Org #SurpriseMedicalBills #MedicalBilling #AirAmbulanceBillings #TrumpMedicalTransparencyPricingRules #TrumpCanadianDrugImportRules #HealthcareCosts #Axios #HealthInsuranceForEveryone #ObamacareLimitedProviderNetworks #ObamacareHighOutOfPocketExpenses #HealthAndLifeSolutionsLLC #ObamacareHigherDeductibles #ObamacarePlansLimitedDoctors Finally Access To AFFORDABLE Health Insurance Plans At: HI4E.org

Medicaid provides health insurance for more than one in four Washingtonians, with federal and state spending around $17 billion. With so much at stake, our recent performance audit reviewed the Health Care Authority (HCA) and its work with five managed care organizations (MCOs). A summary can be found here:https://ow.ly/1Mf750Q2Nf1The state Health Care Authority (HCA) contracts with five managed care organizations (MCOs) to provide services. Our audit examined the three largest MCOs and found they are taking key steps to prevent fraud and ensure the use of accurate data about patient care and costs. Our report offers a robust set of recommendations for improving their processes, especially in terms of providing accurate information used to establish the premiums paid by the state. Each improvement in a large, complex system can potentially yield substantial rewards. By putting in place our detailed recommendations to improve program integrity, HCA can do even more to prevent fraud, reduce overall costs, and ensure Medicaid funding is available to deliver care to millions of Washingtonians.Our full audit report is here: https://ow.ly/nKp650Q2Nf0