Latest news with #MedicareAdvantage
Axios
5 hours ago
- Business
- Axios
Traditional Medicare to add prior authorizations
Medicare is requiring more pre-treatment approvals in its fee-for-service program in a bid to root out unnecessary care, federal regulators announced Friday. The big picture: Traditional Medicare historically hasn't required prior authorizations to access most drugs or services, a major perk for enrollees. Prior authorization in privately-run Medicare Advantage plans has become a hot-button issue, with Congress and federal regulators working to rein in the practice. Federal inspectors found in 2022 that prior authorization in MA prevented some seniors from getting medically necessary care. Major health insurers this week made a voluntary pledge to streamline and improve the prior authorization process across all health insurance markets. State of play: Medicare's innovation center announced that it will solicit applications from companies to run the prior authorization program. Medicare is looking for companies with experience using AI and other tools to manage pre-approvals for other payers, and with clinicians who can conduct medical reviews to check coverage determinations. The program will start Jan. 1, 2026 and run through the end of 2031. It will only apply to providers and patients in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. The change will apply to 17 items and services, including skin substitutes, deep brain stimulation for Parkinson's Disease, impotence treatment and arthroscopy for knee osteoarthritis. CMS selected the services based on previous reports and evidence of fraud, waste and abuse, as well as what's already subject to prior authorization in Medicare Advantage. Overuse of skin substitutes to help heal wounds has especially come under fire in recent years. Medicare spent more than $10 billion on the products in 2024 — more than double what was spent the year before, according to the New York Times. CMS noted that it may make other services subject to the prior authorization program in future years. Providers in the geographic areas can choose whether or not they want to submit an authorization request before delivering a service. But if they decide not to, they'll be subject to post-claim review and risk not getting paid for a service that was already delivered. "In general, this model will require the same information and clinical documentation that is already required to support Medicare FFS payment but earlier in the process, namely, prior to the service being furnished," the notice reads. Zoom in: The companies hired to manage the program will be paid based on how much they saved the government by stopping payments for unnecessary services. "Under the model, we will work to avoid any adverse impact on beneficiaries or providers/suppliers," CMS wrote in the notice.
Health Line
7 hours ago
- Health
- Health Line
Does Medicare Cover Famotidine?
Famotidine is a generic drug that doctors prescribe to treat conditions related to excess stomach acid production, such as stomach ulcers and gastroesophageal reflux disease (GERD). It's available in over-the-counter (OTC) and prescription strengths, and companies may sell it under the brand names Pepcid AC or Zantac 360. Medicare Part D drug plans generally cover prescription famotidine, though there may be some variation based on the specific plan. Original Medicare doesn't cover OTC famotidine. However, some Medicare Advantage (Part C) plans may include OTC benefits that members can use toward this medication. Part D coverage for famotidine Medicare-approved private insurance companies sell Part D prescription drug plans. If you have Original Medicare, you can buy a stand-alone Part D plan, whereas people with Medicare Advantage plans often have Part D plans in their coverage. Each plan has a formulary. This is a list of medications that the plan covers. Part D plans generally include prescription famotidine in their formularies. However, since specifics vary by insurance carrier, plan, and location, there's no guarantee that all plans include coverage for famotidine. To learn whether your Medicare drug plan includes coverage for famotidine, consult your plan details or a representative. Over-the-counter famotidine and Medicare Many Medicare Advantage plans include coverage for OTC products as part of their additional benefits. If your Medicare Advantage plan includes OTC benefits, you can likely use them to buy famotidine. Generally, with OTC benefits, members can get a benefits card that works like a debit card. The plan adds funds to the card at regular intervals, and you can use it at participating retailers to buy eligible products. The specific retailer and product lists may depend on the plan, but Walgreens, for example, offers various famotidine products in different strengths and quantities through its OTC benefits program. Famotidine cost with Medicare The cost of famotidine may depend on its strength, quantity, form, and whether it's a generic or brand-name product. Formularies place covered drugs into tiers. These tiers typically correspond with a drug's cost, with lower tier drugs often carrying lower copayments or coinsurance. A plan's formulary may cover multiple versions of famotidine. If so, the oral tablet form is likely to be a tier 1 drug, whereas the oral suspension may be a tier 4 drug. However, this may not be the case for all plans that cover famotidine.
Yahoo
13 hours ago
- Health
- Yahoo
Trella Health Launches Its Latest Medicare Advantage (MA) Data to Help Post-Acute Providers Thrive in the Expanding MA Market
Now available in Marketscape Insights, this upgraded dataset delivers greater visibility into Medicare Advantage referral patterns, payer trends, patient flows, and additional strategic insights. ATLANTA, June 27, 2025 /PRNewswire/ -- Trella Health, the leading source for actionable post-acute analytics and insights, today announced the release of its Latest Medicare Advantage (MA) Data — a comprehensive new dataset designed to empower home health and skilled nursing organizations to thrive in the rapidly expanding MA market. With Medicare Advantage enrollment surpassing traditional Medicare — now accounting for 55.4% of all Medicare beneficiaries — the demand for timely, targeted, and granular MA insights is reshaping provider growth strategies in an MA-first landscape. This release delivers payer-level referral intelligence — offering unprecedented visibility into where MA patients come from, where they're referred, and where strategic referral relationships are taking shape across hospitals, physicians, and post-acute providers. "As Medicare Advantage continues to grow, providers need deeper visibility into referral behavior, patient flow, and payer dynamics," said Kathy Ford, Chief Product Officer at Trella Health. "This new dataset unlocks critical insights that help our users align their network strategies with high-value MA opportunities." The Latest MA Data Upgrade is available as an add-on to Trella's Marketscape Insights platform for both home health and skilled nursing users, with data refreshed quarterly in alignment with Trella's fee-for-service update schedule. This enhanced MA dataset enables users to: Identify High-Value MA Referral Sources: discover hospitals and physicians referring MA patients to Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) using metrics such as payer name, annual patient counts, and affiliation percentages. Evaluate MA Payer Trends and Strategic Alignment: assess trends in MA volumes using annual patient counts and payer-specific referral data to identify providers treating target populations. Monitor Referral Leakage and Strengthen Relationships: track MA patient movement using referral destination data, affiliation percentages, and facility-level patient counts to uncover referral shifts over time. Trella Health's latest Medicare Advantage data release reflects the company's continued investment in data innovation — expanding access to timely, targeted insights that support smarter growth, value-based care strategies, and improved patient outcomes. For more information or to request a demo, visit About Trella HealthTrella Health's unmatched market intelligence and purpose-built CRM allow post-acute providers, HME, and Infusion organizations to drive more effective performance and growth. Trella's solutions allow post-acute, HME, and Infusion organizations to identify the highest-potential referral targets, evaluate new market opportunities, and monitor performance metrics. Paired with CRM and EHR integrations, business development teams can better manage referral relationships to advance their organizations with certainty by improving their sales and marketing strategy. For more information on Trella Health and its post-acute, HME, and Infusion growth solutions, visit or follow Trella on Facebook, Twitter, and LinkedIn. Media Contact: Chandani Patel, press@ View original content to download multimedia: SOURCE Trella Health Sign in to access your portfolio
Los Angeles Times
14 hours ago
- Health
- Los Angeles Times
5 takeaways from health insurers' new pledge to improve prior authorization
Nearly seven months after the fatal shooting of an insurance CEO in New York drew widespread attention to health insurers' practice of denying or delaying doctor-ordered care, the largest U.S. insurers agreed Monday to streamline their often cumbersome preapproval system. Dozens of insurance companies, including Cigna, Aetna, Humana, and UnitedHealthcare, agreed to several measures, which include making fewer medical procedures subject to prior authorization and speeding up the review process. Insurers also pledged to use clear language when communicating with patients and promised that medical professionals would review coverage denials. While Trump administration officials applauded the insurance industry for its willingness to change, they acknowledged limitations of the agreement. 'The pledge is not a mandate,' Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a news conference. 'This is an opportunity for the industry to show itself.' Oz said he wants insurers to eliminate preapprovals for knee arthroscopy, a common, minimally invasive procedure to diagnose and treat knee problems. Chris Klomp, director of the Center for Medicare at CMS, recommended prior authorization be eliminated for vaginal deliveries, colonoscopies, and cataract surgeries, among other procedures. Health insurers said the changes would benefit most Americans, including those with commercial or private coverage, Medicare Advantage, and Medicaid managed care. The insurers have also agreed that patients who switch insurance plans may continue receiving treatment or other health care services for 90 days without facing immediate prior authorization requirements imposed by their new insurer. But health policy analysts say prior authorization — a system that forces some people to delay care or abandon treatment — may continue to pose serious health consequences for affected patients. That said, many people may not notice a difference, even if insurers follow through on their new commitments. 'So much of the prior authorization process is behind the black box,' said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News. Often, she said, patients aren't even aware that they're subject to prior authorization requirements until they face a denial. 'I'm not sure how this changes that,' Pestaina said. Oz acknowledged 'violence in the streets' prompted Monday's announcement. Klomp told KFF Health News that insurers were reacting to the shooting because the problem has 'reached a fever pitch.' Health insurance CEOs now move with security details wherever they go, Klomp said. 'There's no question that health insurers have a reputation problem,' said Robert Hartwig, an insurance expert and a clinical associate professor at the University of South Carolina. The pledge shows that insurers are hoping to stave off 'more draconian' legislation or regulation in the future, Hartwig said. But government interventions to improve prior authorization will be used 'if we're forced to use them,' Oz said during the news conference. 'The administration has made it clear we're not going to tolerate it anymore,' he said. 'So either you fix it or we're going to fix it.' Here are the key takeaways for consumers: 1. Prior authorization isn't going anywhere. Health insurers will still be allowed to deny doctor-recommended care, which is arguably the biggest criticism that patients and providers level against insurance companies. And it isn't clear how the new commitments will protect the sickest patients, such as those diagnosed with cancer, who need the most expensive treatment. 2. Reform efforts aren't new. Most states have already passed at least one law imposing requirements on insurers, often intended to reduce the time patients spend waiting for answers from their insurance company and to require transparency from insurers about which prescriptions and procedures require preapproval. Some states have also enacted 'gold card' programs for doctors that allow physicians with a robust record of prior authorization approvals to bypass the requirements. Nationally, rules proposed by the first Trump administration and finalized by the Biden administration are already set to take effect next year. They will require insurers to respond to requests within seven days or 72 hours, depending on their urgency, and to process prior authorization requests electronically, instead of by phone or fax, among other changes. Those rules apply only to certain categories of insurance, including Medicare Advantage and Medicaid. Beyond that, some insurance companies committed to improvement long before Monday's announcement. Earlier this year, UnitedHealthcare pledged to reduce prior authorization volume by 10%. Cigna announced its own set of improvements in February. 3. Insurance companies are already supposed to be doing some of these things. For example, the Affordable Care Act already requires insurers to communicate with patients in plain language about health plan benefits and coverage. But denial letters remain confusing because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term 'non-approved requests' in Monday's announcement. Insurers also pledged that medical professionals would continue to review prior authorization denials. AHIP claims this is 'a standard already in place.' But recent lawsuits allege otherwise, accusing companies of denying claims in a matter of seconds. 4. Health insurers will increasingly rely on artificial intelligence. Health insurers issue millions of denials every year, though most prior authorization requests are quickly, sometimes even instantly, approved. The use of AI in making prior authorization decisions isn't new — and it will probably continue to ramp up, with insurers pledging Monday to issue 80% of prior authorization decisions 'in real-time' by 2027. 'Artificial intelligence should help this tremendously,' Rep. Gregory Murphy (R-N.C.), a physician, said during the news conference. 'But remember, artificial intelligence is only as good as what you put into it,' he added. Results from a survey published by the American Medical Association in February indicated 61% of physicians are concerned that the use of AI by insurance companies is already increasing denials. 5. Key details remain up in the air. Oz said CMS will post a full list of participating insurers this summer, while other details will become public by January. He said insurers have agreed to post data about their use of prior authorization on a public dashboard, but it isn't clear when that platform will be unveiled. The same holds true for 'performance targets' that Oz spoke of during the news conference. He did not name specific targets, indicate how they will be made public, or specify how the government would enforce them. While the AMA, which represents doctors, applauded the announcement, 'patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions,' the association's president, Bobby Mukkamala, said in a statement. He noted that health insurers made 'past promises' to improve prior authorization in 2018. Meanwhile, it also remains unclear what services insurers will ultimately agree to release from prior authorization requirements. Patient advocates are in the process of identifying 'low-value codes,' Oz said, that should not require preapproval, but it is unknown when those codes will be made public or when insurers will agree to release them from prior authorization rules. Sausser and Galewitz write for KFF Health News, a national newsroom focused on in-depth journalism about health issues and a core program of KFF, a non-profit organization specializing in health policy research, polling, and journalism.
Forbes
2 days ago
- Health
- Forbes
What Industry Leaders Can Do To Combat Healthcare Fraud
Paulina Wierzbicka | Executive Director of SNAH Healthcare Software Management. The U.S. Department of Justice has launched an investigation into UnitedHealth Group, the nation's largest health insurance provider, over allegations of Medicare fraud. According to an article from The Wall Street Journal (registration required), the investigation focuses on suspicions that UnitedHealth engaged in upcoding. This is a practice in which insurers record diagnoses that allow them to collect larger reimbursements from Medicare. While UnitedHealth has denied any wrongdoing, the implications of a probe like this stretch far beyond one corporation's reputation. It brings attention to what I see as a deeply flawed healthcare system, one that is riddled with loopholes, obscured by bureaucracy and increasingly out of reach for the average American. This system has the potential to leave patients behind and inflate the cost of care for everyone. The Real Price Of Upcoding Medicare Advantage, a program originally designed to offer a cost-effective and flexible alternative to traditional Medicare, can be exploited. Through upcoding, insurers can extract billions in overpayments from the government. In fact, while the billing codes may make patients look sicker on paper, the services they receive likely remain unchanged. The U.S. Department of Justice has said that healthcare fraud, waste and abuse could cost over $100 billion annually. A study from RAND (via Axios) also suggested than billions of dollars of hospital payments in 2019 were made due to an increase in upcoding. Money lost to fraud could be going toward better treatments, staffing or innovation. The Costs To Patients Statistics like these underscore to me how broken the U.S. healthcare system has become, especially for those who need it most. Patients are drowning in complexity. They must navigate multiple apps just to schedule appointments, understand their coverage or check medical records. Each insurance company seems to have its own labyrinth of portals and billing procedures. Transparency is another issue: Pricing for procedures varies wildly and is often hidden until the bill arrives. Meanwhile, insured individuals may be hesitant to seek care due to expensive co-pays, high deductibles, unpredictable out-of-pocket charges, surprise bills and bureaucratic hurdles. The system isn't just failing—it's actively discouraging people from getting the care they need. The Relationship Between Fraud And Healthcare Costs In 2024, medical inflation rose to 3.3%, outpacing general consumer inflation. Fraud like upcoding doesn't just skim money off the top—it sets inflated benchmarks that could drive future cost increases. When insurers game the system, they can distort payment models and inflate the entire marketplace. Every fraudulent claim becomes part of the data used to set next year's rates, creating a feedback loop where today's deceit has the potential to become tomorrow's financial burden. I believe this is one reason why healthcare in America continues to grow more expensive and less accessible, especially for vulnerable populations. Resistance To Reform There are solutions. A number of tools and platforms are available that can help streamline administrative processes, integrate billing systems and improve transparency. (Full disclaimer: My company offers a platform like this, as do others.) These tools have the potential to reduce inefficiencies and curb fraudulent practices. But real change is hard to achieve. Why? The U.S. healthcare system was worth trillions of dollars (by spending) as of 2023 and in my experience, is affected by a mix of corporate power, slow-moving politics and rules, as well as a focus on making money. Even the best new ideas often struggle to make progress in Washington or with major insurance companies. What Industry Leaders Can Do If wrongdoing in this case is proven, I believe it could lead not only to fines and stricter oversight, but also to a shift in how Medicare Advantage is monitored and paid. Regardless of the outcome, industry players can take a few important steps to support change: • Strengthen oversight. Fraud shouldn't take years to detect. If you're building tech in this space, partner with regulators and integrate real-time fraud detection into your infrastructure. AI, automation, pattern recognition—use the tools we already have to flag abuse before it spirals. This isn't about compliance. It's about responsibility. • Reform payment models. I think we need to stop paying for codes and start paying for care. This shift starts at the top. If you're leading a hospital system, an insurer or a healthtech platform, ask yourself: Are we rewarding results or rewarding manipulation? Build systems that measure outcomes. Incentivize recovery. The future belongs to leaders who put value over volume—and mean it. • Enhance transparency. Patients shouldn't have to play a guessing game. They should know what care costs, what's covered and what to expect. Leaders should stop hiding behind complexity and start leading with clarity. Publish your pricing. Share your audit data. Make it simple. Trust isn't something you demand. It's something you earn. • Protect whistleblowers. Fraud isn't usually uncovered by audits—it's exposed by people. However, those people won't speak up unless you make it safe for them to do so. If you lead a healthcare company or tech platform, your culture should encourage integrity, not fear. Protect your whistleblowers. Back them. Because the real signals that something's wrong rarely come from the outside—they come from within. • Support innovation. We don't need more apps. We need real solutions. Innovation has to scale. It has to simplify care, close gaps and put patients first. If you're in a position to build or fund the next generation of healthcare tools, focus on what actually reduces friction and improves access. Anything else is noise. Healthcare fraud isn't just a financial crime—it's a betrayal of public trust. It can jeopardize care that the elderly have earned, inflate premiums for working families and drain critical resources from an already strained system. We have a rare opportunity to examine the dark corners of a healthcare system that too often prioritizes profits over patients. Whether lawmakers, regulators and industry leaders seize this moment or squander it could help determine whether the U.S. healthcare system sinks further or finally begins to heal. Forbes Business Council is the foremost growth and networking organization for business owners and leaders. Do I qualify?
