Category Archives: Prior Authorization

Insurer under fire for millions in unpaid claims

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Anthem has captured the attention of multiple hospitals and health systems across the U.S. as allegations of underpayment and inappropriate denials accumulate.

The insurer has been forced to pay millions already and continues to face off with providers.

Anthem is facing allegations of $70 million in unpaid claims from Portland-based MaineHealth. The health system said earlier this year that its flagship hospital, Maine Medical Center, would no longer contract with the insurer after its contract expires next year. Jeffrey Barkin, MD, president of the Maine Medical Association, said other providers in the state are leaving Anthem for the same reason.

In Georgia, the state insurance commissioner fined Anthem Blue Cross Blue Shield $5 million in March for failing to pay in a timely manner, delays in loading provider contracts and inaccurate provider directories.

VCU Health in Richmond, Va., said last year that 40 percent of its claims with Anthem were more than 90 days old and the insurer owed $385 million, according to the Richmond Times-Dispatch. The Virginia Hospital and Healthcare Association said Anthem has hundreds of millions of dollars in late and unpaid claims to hospitals across the state.

Eleven Indiana hospitals have also had trouble with Anthem. The hospitals alleged Anthem’s reimbursement system added a $50 triage fee and asked for additional patient records to avoid denial for 60 to 70 percent of thousands of emergency room claims from 2017-20. The hospitals alleged the strategy breached their contract with Anthem because hospitals are required to stabilize all patients requesting emergency services. A federal arbiter recently ordered Anthem to pay $4.5 million to the hospitals and said the insurer cannot use its list of diagnostic codes to downgrade or deny claims.

The Indiana hospitals are still counting the denied claims and said they are owed $12 million from Anthem due to downgraded claims.

The American Hospital Association accused Anthem of asking for prior authorizations for routine surgeries as roadblocks to patient care in a letter sent to the insurer last year. In 2021, 53 percent of Anthem’s medical bills for the second quarter were unpaid, amounting to $2.5 billion, according to the Times-Dispatch report.

How insurers are covering COVID-19

Posted on by • Posted in American Hospital Association (AHA), Clinical Testing, Coronavirus, Health Insurance Coverage Adequacy, Health Insurance Industry, Out of Pocket Expenses, Periodic Interim Payments (PIP), Prior Authorization, Rev Cycle Management, Self Insured Employers, Underinsured • Leave a comment

https://www.healthcaredive.com/news/how-insurers-are-covering-covid-19/575372/

Private Health Coverage of COVID-19: Key Facts and Issues | The ...

Insurers are weighing how best to respond to the outbreak of the novel coronavirus as cases swell in the U.S. Here is a tracker to follow the latest policy and coverage decisions from the nation’s largest insurers.

The nation’s health insurers are responding to the coronavirus pandemic with changes to coverage associated with COVID-19 as the number of cases continues to swell across the U.S.

The biggest payers have said they will waive patient cost-sharing — copays, coinsurance and deductibles — for testing. Although some, such as Cigna and Humana, have gone farther by eliminating cost-sharing for all COVID-19 treatment.

In addition to coverage decisions, insurers are weighing the ways they can reduce administrative barriers to promote quicker access to care for those infected with the novel coronavirus. All are cutting back on prior authorization in various ways to ease access to care.

Hospitals say that’s not enough, and are calling on the biggest payers to follow actions taken by Congress and CMS to help resolve cash flow issues, by accelerating payments or opting into releasing interim periodic payments. The American Hospital Association also is urging payers to eliminate administrative burdens such as prior authorizations.

“This crisis is challenging for all of us, and everyone has a role to play,” AHA said in its letter to the nation’s largest insurers. “You could make a significant difference in whether a hospital or health system keeps their doors open during this critical time.”

Despite the policy changes by payers, employers with self-funded plans can opt out of these policies. A majority of workers are covered by self-insured plans, which essentially allow employers to decide coverage decisions given they’re paying for the claims and having insurers simply perform administrative services.

Below is a tracker with the latest coverage decisions for the nation’s largest insurers.

Blue Cross Blue Shield Association

The BCBSA is eliminating cost-sharing for COVID-19 diagnostic testing. It will also waive cost-sharing for treatment at in-network or Medciare rates through May 31, including inpatient stays.

BCBSA will remove prior authorization requirements for testing and for services that are medically necessary to treat an infected patient. BCBSA also is waiving limits on early refills to make it easier to access medications and expanding access to telehealth services.

Molina

Molina is halting cost-sharing for testing and treatment. That policy applies to Medicare, Medicaid and marketplace members nationwide.

Aetna (CVS)

Aetna will waive cost-sharing for certain members admitted to an in-network hospital with COVID-19 or complications from the disease. The policy applies to all of Aetna’s commercial plans, though self-insured members can opt out. The policy will apply to admissions through June 1. Aetna also is waiving cost-sharing for testing and associated visits, including telehealth.

Aetna also is attempting to make access to hospitalization faster for those with COVID-19 by easing prior authorization requirements, particularly in areas hard hit by the outbreak like New York and Washington.

Anthem

The nation’s second largest commercial insurer will waive cost-sharing for COVID-19 treatment and will reimburse providers at either in-network or Medicare rates through May 31. The policy applies to Anthem’s fully insured, individual, Medicaid and Medicare Advantage members. Self-insured plans can opt out. Anthem also is waiving cost-sharing for COVID-19 testing and in-network visits associated with testing whether it’s conducted at a physician’s office, urgent care or ER.

Anthem also is easing its limits on early refills for 30-day prescriptions. Anthem said it would waive cost sharing for telehealth visits, including those for mental health for a period of 90 days starting March 17. Self-insured plans have the option to opt in the new virtual care policy.

Centene

Centene will waive cost-sharing for COVID-19 related screening, testing and treatment for its Medicaid, Medicare and Marketplace members through June 30.

Centene also will eliminate prior authorization requirements for care for all its Medicare, Medicaid and Marketplace members. The company is also working to supply federally qualified health centers with personal protective equipment and assistance in providing small business loans to behavioral health providers and long-term service support organizations.

Cigna

Cigna will waive cost-sharing for all COVID-19 treatment, including testing and telehealth screenings through May 31. The policy applies to Cigna’s fully-insured group plans, individual coverage and Medicare Advantage plans. Self-insured plans can opt out.

Cigna will reimburse providers either at in-network or Medicare rates depending on the member. Cigna also is easing access to maintenance medication by offering free shipping for a 90-day supply. Cigna is easing prior authorization requirements for patients being discharged from the hospital to post-acure stays.

Humana

Humana is waiving cost-sharing for testing and treatment, including hospital admissions for COVID-19 cases. The policy applies to its Medicare Advantage plans, fully-insured commercial plans, Medicare supplement and its Medicaid plans. The policy is indefinite with no current end date. Cost-sharing will be waived for all telehealth visits and members can opt to refill prescriptions early.

Humana also is easing administrative barriers to allow infected patients to easily move from a hospital to post-acute care settings. It’s suspending prior authorization and referral requirements and requesting notification within 24 hours. It’s also implementing an expedited claims process to reimburse providers faster, Humana said.

UnitedHealthcare

The nation’s largest commercial insurer, will waive cost-sharing for COVID-19 treatment through May 31. The policy applies to its fully-insured commercial, Medicare Advantage and Medicaid plans. United also is waiving cost-sharing for COVID-19 testing at approved locations in accordance with Centers for Disease Control guidelines. There will be no cost-sharing for visits related to testing including at physician offices, urgent care, ERs and telehealth visits. The policy applies to United’s commercial, Medicare Advantage and Medicaid members.

UnitedHealthcare is opening a special enrollment period for some of its commercial members who opted out of coverage during the traditional enrollment period with their employers. This enrollment period will end April 6. The insurer also is easing prior authorization requirements through May 31, suspending prior approval for post-acute care and switching to a new provider.