Through consolidation and prior authorization, medical insurance payments reach the lowest point in history


Mike Adelberg, head of Faegre Drinker Consulting, said: “Many improper payments are not the result of fraud, but the result of insufficient documents and codes. These documents and codes are between the provider and the CMS contractor. There are divergent themes.” “Reducing improper payments is good news. But it will not automatically translate into reducing fraud and abuse.”

CMS attributed the decrease in improper bills to an increase in provider education, which resulted in a decrease of $1.8 billion in improper payments to inpatient rehabilitation facilities from 2018 to 2021. Expansion of targeted audit programs and prior authorization requirements for certain durable medical equipment items also triggered a $388 federal agency that stated that from 2020, improper payments have been reduced by $1 million.

Adelberg said that most of the work began about ten years ago, when the overcharge of electric scooters and other items caught the attention of regulators. In order to combat unnecessary expenditures, regulators have introduced prior authorization requirements for certain services. Adelberg said these administrative tasks have been increasing in recent years.

Last year, CMS announced that it would expand the pre-authorization requirements for repetitive, scheduled, non-emergency ambulance transportation nationwide. Previously, a federal analysis found that non-emergency vehicles were used to send some patients to doctors, saving the federal government More than 550 million U.S. dollars. Two years.

Together with prior authorization, Supplier integration Wolters Kluwer Medical Informatics and Health Language Professional Consulting Director Dr. Michael Stearns said it also helped reduce improper health insurance payments.

According to a report, in January 2021, nearly 70% of doctors were employed by hospitals or companies such as private equity companies and health insurance companies. Avalere Health AnalysisThe company also stated that the COVID-19 pandemic has accelerated the integration trend.

Adjust independent doctors Stearns said the larger health system provides them with access to software used to record patient conditions and codes. He added that the integration between suppliers is driving growth in the revenue cycle management area.

Revenue cycle management According to data from Modern Healthcare’s digital health business and technology, in 2021, the company has raised US$344.5 million in venture capital, an increase of 78.8% from last year’s US$192.6 million.

Some health systems do not have contracts with technology suppliers, such as SSM health They are redistributing their revenue cycle staff, adding pressure to the business of companies such as UnitedHealth Group’s Optum Health Services Department.

“Now you can have doctors check documents together in the room and improve compliance,” Stearns said. “Small practices actually don’t have enough bandwidth to absorb it.”

At the same time, Medicare Advantage insurance companies’ improper payments accounted for $23.1 billion. CMS stated that in fiscal 2021, 10% of all payments for the privatization government program for senior citizens were inappropriate. The agency recently changed the way it reviews Medicare Advantage insurance company claims, and regulators said they did not have enough data to determine trends from one year to the next.

But looking ahead, automated coding by clinicians will reduce improper payments for these two projects, Stearns said. However, using technology to record patient status will be a more difficult task to simplify, because time-critical doctors may not always write down the status of each patient, leaving gaps in the collected data. He said this will continue to pose a threat to improper medical insurance payments.

“It’s really hard to ask them to slow down and record information about situations that have nothing to do with that point in time,” Adelberg said. “I think we may see documentation become the most challenging area that Medicare needs to address.”

Medical insurance and Medicaid have different analysis of improper payment. Although Medicare charges for services and Medicare Advantage payments are measured annually at the national level, improper payments for child health insurance plans and Medicaid plans are calculated by averaging survey results in some states over three years.

Among the government insurance plans for low-income Americans, CHIP accounted for the largest proportion of inappropriate CMS payments, at $5.3 billion, accounting for 31.8% of the total reimbursements classified as inappropriate. However, the state’s Medicaid program caused a large number of improper payments, at $98.7 billion, accounting for 21.6% of the total reimbursement.

Service-based medical insurance accounted for 13.9% of total improper payments, while Medicaid managed care accounted for 0.04% of improper payments.this Error rate For managed care, only the monthly per capita payment at the state level is measured, while the service charge varies by service, provider, insurance company, and other factors.

Andy Schneider, a professor of practical studies at Georgetown University’s McCourt School of Public Policy, said these rates must also take into account information about the eligibility of the insured, which may make the provider’s documentation more complicated than medical insurance. CMS stated that most improper Medicaid and CHIP payments were due to insufficient documentation regarding membership.

“Medicaid is an income-based plan, so you have to figure out whether their income meets the conditions,” Schneider said. “The dynamics are very, very different. The operating requirements of the income test plan are much higher than those of the social insurance plan.”



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