RISE summarizes recent regulatory-related news.

STAT report: MA plans use AI algorithms to deny care

A disturbing investigation by STAT finds that some Medicare Advantage (MA) plans are using unregulated predictive artificial intelligence algorithms to determine when they can cut off payment for care. These denials have led to disputes between physicians and MA plans, delaying treatment of seriously ill patients.

The STAT team said they reviewed hundreds of pages of federal records, court filings, and confidential corporate documents. The investigation also included interviews with physicians, insurance executives, policy experts, lawyers, patient advocates, and the family members of MA members. STAT found that MA carriers are using the tools to decide which treatments should be paid for and they do under limited oversight.

Clinicians told the publication that they frequently receive MA payment denials for care that is routinely covered in traditional Medicare. Indeed, patient advocates told STAT that algorithms are supposed to deliver personalized care and better outcomes. But in many cases the reverse happens, and recommendations don’t consider an individual’s circumstances and conflict with the rules on what Medicare plans must cover.

If their MA plan denies treatment, patients can file an appeal, but it could take months to recover their costs. “We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital in Bronx, N.Y., told the publication. “So what happens is the appeal outlasts the beneficiary.”

Click here to read the full report.

AHIP leads coalition to help Medicaid enrollees during redeterminations

Now that pandemic protections are coming to an end and states begin the process of redetermining whether Medicaid enrollees are still eligible for the program, AHIP is leading a national coalition committed to provide resources and information about Medicaid redetermination.

The Connecting to Coverage Coalition (CCC) includes organizations that support people with disabilities, care providers, employer-related groups, and health insurance providers have come together to launch the CCC. The group wants to become a source of trusted information about the process. It intends to convene stakeholders to support information sharing, build on best practices, and develop solutions to ensure Americans are able to enroll in coverage that is right for themselves and their families. By working together, the CCC aims to support a smooth transition back to normal Medicaid eligibility during the redetermination process, connect Americans to resources, and help them connect to coverage through other available health insurance, such as individual market or Affordable Care Act (ACA) marketplace coverage, employer-provided coverage, or separate coverage under the Children’s Health Insurance Program (CHIP).

In addition to AHIP, founding members of the CCC include American Cancer Society Cancer Action Network, The Arc of the United States, Cystic Fibrosis Foundation, Cancer Support Community, Mental Health America, Catholic Health Association of the United States, Unidos US, American Benefits Council, National Association of Benefits and Insurance Professionals, National Association of Community Health Centers, Federation of American Hospitals, American Health Care Association, Association for Community Affiliated Plans, Blue Cross Blue Shield Association, and Medicaid Health Plans of America.

Report: MA offers $2,400 in annual cost savings for seniors 

A new analysis by ATI Advisory finds MA outperforms fee-for-service Medicare on cost protects by delivering lower premiums and out-of-pocket spending for Medicare beneficiaries.

The independent analysis was commissioned by Better Medicare Alliance. It found MA beneficiaries report saving more $2,400 annually on out-of-pocket costs and premiums compared to Fee-for Service (FFS) Medicare beneficiaries. Furthermore, among low-income Medicare beneficiaries, those enrolled in FFS were twice as likely as MA beneficiaries to experience cost burden from their health care expenses.

As more Americans are enrolling in MA, savings have continued to rise year-over-year, with a $400 jump from last year’s reported $2,000 annual savings. Cost savings are even higher for clinically complex beneficiaries. Patients with three or more chronic conditions enrolled in MA spend on average $2,583 less compared with FFS Medicare.

MA beneficiaries report high rates of health care satisfaction and access to care. From ATI’s findings, 95 percent of enrollees are satisfied with health care quality; 97 percent are satisfied with ease of getting to the doctor; and 95 percent report having a usual source of care.