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Payer Behavior: Network Pool Restrictions
In 2023, more payers opted for narrower provider networks as a method of controlling costs than ever before. Not only does this lead to decreased overall satisfaction by patient members - but this can also cause delays in care with the potential to put patients in harms way.
According to a recent article in Consumer Reports, narrow network plans typically “have 25 percent or less of the physicians in the local area participating. The most restrictive plans have less than 10 percent of local doctors signed on.” Plans like these use restricted networks to ensure increased volume to a smaller number of approved providers, thus driving down cost. Private payers, ACA health exchanges, and Medicare Advantage are all capable of providing plans with such restrictions.
Furthermore, many Americans with narrow network plans do not realize they are under increased provider restrictions until after they have sought care. The article states that one in ten Americans were surprised to find out the healthcare provider they had elected to perform a service was not part of their network. Exacerbating this issue is the fact that a decreasing number of plans sold on the individual health insurance market offer any out-of-network coverage whatsoever - just 29% in 2018.
Read the full article here and learn more about HURC’s ability to optimize payer return.
Payer Behavior: Rapid-Fire Policy Change
Every year, changes to Payer policies and regulations can number in the tens to hundreds of thousands. These changes are constant, sometimes seemingly arbitrary, and are often lacking in guidance. Ultimately, providers bare the burden of navigating this constantly changing landscape to ensure yield loss is discovered and minimized.
HURC can help. Learn more about HURC’s ability to optimize payer return here.
Payer Behavior: Automated Denials
the AI powered algorithm ‘nH Predict’, developed by naviHealth and leveraged by UnitedHealthcare and Cigna Healthcare, has yielded increased wrongful denials for member medical claims.
As a result, the organizations are currently facing a legal action filed in November of 2023. Cigna Group is also navigating litigation surrounding the wrongful denials of large batches of claims as a result of another automated claims review process called: PxDx.
Becker’s Healthcare reports that, “The lawsuit alleges the algorithm predicts how long a patient will need to remain in skilled nursing care and overrides physicians' determinations for the patient.” Optum, the care management company that acquired naviHealth in 2020 issued a statement saying, with regard to use of the nH Predict tool, “The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home. Coverage decisions are based on CMS coverage criteria and the terms of the member's plan. This lawsuit has no merit, and we will defend ourselves vigorously."
Read more here.
This news showcases the potential harm to patients as organizations seek to incorporate further automation and experiment with AI-driven algorithms - and highlights the benefits of partnership with an organization like HURC. With increased oversight on claims denials and embedded operators working alongside existing provider FTEs, HURC can identify and rectify wrongful claims generated by irresponsible and unethical automation in real-time.
Let HURC bridge the gap between payer and provider - allowing clinicians to focus on what matters most: the patient.
Payer Behavior: Blurred Lines
the “Payvider”
In recent years, a concerning trend has emerged in the healthcare industry: payers are increasingly assuming the role of healthcare providers, often to the detriment of patients and quality of care. While the integration of insurance and healthcare services may seem beneficial in theory, it has led to a multitude of challenges that compromise the quality of care provided.
By exerting control over medical decisions and prioritizing cost reduction, insurance companies may hinder patient access to necessary treatments and limit the autonomy of healthcare providers. This shift blurs the line between insurers and caregivers, raising concerns about conflicts of interest and prioritization of profit over patient well-being. As insurance companies continue to expand their presence in the healthcare landscape, it is crucial to strike a balance that allows for affordable coverage without compromising the quality and integrity of patient care.