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Payers And Provider

Insurance Providers

Payers And Provider Groups Laud CMS’ New Authorization Rule

Editorial Team

December 15, 2022
3 min read

There are a few states namely Missouri, Montana, Mississippi, and Montana whose lawmakers are expected to propose legislation that would facilitate pregnant mothers enrolled in Medicaid with an entire year of funded healthcare. Throughout the COVID-19 public health emergency, continuous postpartum coverage for Medicaid-enrolled patients is assured. But, support for governments extending the standard 60-day mandatory coverage duration until the emergency's ultimate termination has been growing. As per records, Medicaid covers more than 40% of births nationally. The agency’s main aim is to ensure that pregnant women get uninterrupted medical treatment and increase postpartum coverage attempts to lower the risk of pregnancy-related diseases and deaths. The Washington district and thirty-five states have previously extended, or are in the process of extending, postpartum eligibility in their Medicaid programs. Texas and Wisconsin are included in the total number of states; however, they still need to adopt the American Rescue Plan Act clause and have instead suggested shorter extensions of 180 days and 90 days. Republican Governor Greg Gianforte of Montana and Charlie Brereton, director of the department of public health and human services, introduced 12-month postpartum eligibility in this year’s budget proposal. According to the plan, it would cost over nine million dollars in federal and state money over the following two years, with the federal government covering approximately 70%. A study from the U.S. Department of Health and Human Services from 2021 predicted that the move would help approximately 2,000 women in Montana. According to state health department representative Jon Ebelt, the state official’s estimate is half that amount. The reason for the variation is still not clear. He terms the expansion move as a pro-life, pro-family initiative. To make this a binding law, the plan needs to be approved by state legislators once the legislative session starts in January. At the Children's Legislative Forum on November 30 in Helena, state Representative Mary Caferro emphasized the significance of women's continued eligibility. State Representative Bob Keenan said, he hasn't reviewed the budget proposal but intends to take an opinion from his fellow lawmakers and medical professionals over the postpartum extension. Federal health officials report that one in three pregnancy-related fatalities occur between a week and a year post-birth of the child, and more than one in five moms lose their insurance within a period of 180 days of giving birth nationwide. A Commonwealth Fund survey gathered data for 2020 indicating that the U.S. had the highest maternal mortality rate among developed countries, with 24 deaths per 100,000 births. The rate for Black women in the U.S. is much higher, with 55 fatalities per 100,000 births. The research suggests that high death rates are due to a lack of treatment opportunities. Annie Glover a senior research scientist for the University of Montana stated: “Governor’s proposal to extend postpartum Medicaid coverage could make a significant difference in improving overall maternal health in Montana. The university was awarded a federal grant this year for such efforts, particularly to lower the mortality rate among Native Americans. This state measure could further reduce rates. The reason has to do with maintaining access to care during this very critical period.”

Insurance Providers

More states to consider postpartum coverage beyond two months

Editorial Team

December 15, 2022
3 min read

Texas Medical Association files third suit against No Surprise Act, claiming arbitration process is unfair to providers the No Surprise Act 2021 is a federal law that aims to assist consumers when they are stuck with hefty medical bills and are in dispute with their provider over payer pricing. The law establishes a process under which payers and providers seek third-party arbitration to settle pricing disputes, both parties submit a price they think is appropriate for the service in question to the arbitrator who then picks the price they think is most appropriate. In this process, patients are removed from the dispute. The Act has been facing legal challenges since 2020. The first lawsuit that the Texas Medical Association (TMA) filed against the Act and won had to do with its implementation. The victory forced regulators to make changes to the language in the final rule. Previously, arbitrators were instructed to begin with the assumption that the qualifying payment amount (QPA), that is the median in-network rate for a specific service in a specific region, was an appropriate amount. Providers fought against this stipulation arguing that this set a ceiling on prices and in a February ruling, a federal judge agreed to strike down this language. The Associate, however, was still not satisfied with how the judge drafted the final rule and claimed that the ruling still unfairly benefited insurers. This was because arbitrators were still putting undue weight on the QPA and so, a second suit was filed in September. In the latest lawsuit that the TMA has filed, they allege that certain aspects of how the QPA is calculated automatically deflate prices. In the final ruling, arbitrators were instructed to consider QPA when picking between a provider’s and payer's proposed amounts, the TMA argues that there are several ways in which the QPA can be calculated by payers that deflate the value of the QPA, meaning that inevitably payers will have to pay a low amount. For example, insurers can include “ghost rates” when calculating their QPA which essentially are rates that are the contracted amounts with the providers for the services that are not subject to arbitration. Insurers are able to include the rates of healthcare providers that are not necessarily in the same specialty as the provider in the payment dispute. “TMA is concerned that these provisions unfairly disadvantage physicians in payment disputes with health insurers and will ultimately rob patients of access to physicians’ care,” said TMA President Gary Floyd. Floyd further explained how all these factors rig the arbitration process in favor of insurance companies to the detriment t of providers and patients. Another objection against the ruling is that the ruling goes against Congress’s intent of the law as the body could not have intended to introduce a benchmark average rate for the arbitration process.

Insurance Providers

Texas Medical Association files third suit against No Surprise Act, claiming arbitration process is unfair to providers

Editorial Team

December 6, 2022
3 min read

Covid health emergency

Health Insurance Providers

Covid health emergency to extend well into January in the U.S.

Editorial Team

November 19, 2022
3 min read

Highmark

Insurance Providers

Highmark Ramps Up Prescription Digital Therapies Coverage

Editorial Team

October 31, 2022
3 min read