On Monday, a cohort of around 50 health insurance plans, including UnitedHealthcare, Scan Health Plan, Kaiser Permanente, Humana and others, announced a government-sponsored pledge to reduce prior approvals.
Advocates in the home care industry praised the move to reduce pre-approval and reduce turnaround times, but noted that they are blessed with adequate responses to prior approval in post-acute settings, including home health.
“We hope that these efforts will be meaningfully expanded to the setting of care after acute phase – particularly skilled nursing facilities (SNFS) and home healthcare institutions – are the most frequent and often most harmful for delays.” “Patients leaving hospitals after acute phase face the highest rate of approval for refusal or delays. So far, announcements from insurance companies have not addressed prior approval practices in these settings and have not acknowledged the burden of ongoing concurrent review requirements.”
Washington, DC-based Reading is an association of over 5,000 non-profit aging service providers and organizations.
Fallon also said many of the promised improvements are consistent with existing regulatory requirements or requirements already planned for implementation.
At a press conference held by US Department of Health and Human Services (HHS) Director Robert F. Kennedy Jr. and Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), OZ specified that OZ's contract is not an order.
“This is not a bill or a rule,” he said. “This is not legislation. This is an opportunity for the industry to show itself. Participation is voluntary, but it's a good start by the fact that three-quarters of the domestic patients are already covered by participants in this pledge.
Roughly, prior approval requires that you receive inheritance from your healthcare plan before you can provide medical services or prescribe prescription medication.
Health insurers who participated in the pledge said the move would provide greater access to patient care and provide a more efficient process for providers.
“The healthcare system is fragmented and burdened by outdated manual processes, which makes it unhappy with patients and providers,” said Mike Taffin, president and CEO of American Health Insurance Plans (AHIP), at a press conference. “Health Planning has a voluntary commitment to providing a more seamless patient experience, allowing providers to focus on patient care and helping modernize the system.”
Ahip is a Washington, DC-based national trade association representing the health insurance industry.
Some of the key steps health insurance companies are committed to are standardizing electronic pre-authorization, reducing the scope of claims covered by pre-authorization, and ensuring continuity of care when patient planning changes occur.
Additionally, Health Insurance Plans are committed to improving communication and transparency regarding decisions, expanding real-time responses, and ensuring medical reviews of unapproved requests.
“These measurable commitments to address improvements such as timeliness, scope, and streamlining take meaningful steps in our work in our work to create a better system of health,” said Kim Keck, president and CEO of the Blue Cross Blue Shield Association in a statement. “This is an important foundation for addressing bigger issues at a time when technology and interoperability can bring about real improvements to the patient's experience.”
Ultimately, Better at the Medicare Alliance believes that health insurance companies' announcements are a step in the right direction.
“Advanced permission helps keep costs down and ensure patients get the best care, but that should be easier,” Mary Beth Donahue, president and CEO of the Better Medicare Alliance, said in a statement. “These commitments will positively make the difference between reducing unnecessary delays and rejections for millions of Americans, including seniors who are registered in the Medicare advantage. We are commendable for this step and working to captivate policymakers on this important issue.”
Oz also noted that this pledge is the first step in promoting greater modernization.
“It's not just about previous permission,” he said. “This is a template for simplifying management, a template for taking paperwork out of the process and putting documents on patients. There is a single FHIR-based electronic workflow. FHIR is a fast healthcare interoperability resource. So it's a standardized method for system-wide information exchange. Technology practices on a daily basis when they interact with insurance companies and in their office practice.”
