Skip to player
Skip to main content
Search
Connect
Watch fullscreen
Like
Bookmark
Share
More
Add to Playlist
Report
'One Step Forward, Two Steps Back': Delbene Rips New Medicare Advantage Claims Processing System
Forbes Breaking News
Follow
5 months ago
During a House Ways and Means Committee hearing in July, Rep. Suzan DelBene (D-WA) spoke about Medicare Advantage's claims processing system.
Category
🗞
News
Transcript
Display full video transcript
00:00
I now recognize Ms. Delbeni.
00:03
Thank you, Mr. Chairman, and thank you to our witnesses for joining us today.
00:07
I'm glad we're here to discuss health care.
00:10
With the Republican mega bill stripping over 15 million Americans off of their health coverage,
00:16
I can't think of a timelier topic.
00:18
And while coverage is incredibly important,
00:21
many Medicare Advantage beneficiaries know that coverage is just the first step to receiving needed care.
00:28
One thing I consistently hear from seniors in my district is the frustration,
00:33
and many have talked about this,
00:34
the frustration they have with getting procedures and treatments approved by their insurer.
00:39
We all know that this is prior authorization.
00:43
This practice has denied life-saving care to Medicare beneficiaries.
00:47
It shouldn't take multiple phone calls or even faxes to get a routine procedure approved.
00:54
The Trump administration recently announced a voluntary agreement
00:57
it reached with the health insurance plans
00:59
to alleviate some of the problems with prior authorization.
01:03
However, four days later,
01:05
CMS announced a plan to increase the use of prior authorization in traditional Medicare.
01:13
And who is allowed to contract with CMS to review prior authorization claims?
01:19
The Medicare Advantage plans.
01:21
So, this is a case of one step forward and two step back.
01:27
In 2023, Medicare Advantage plans made 50 million determinations,
01:32
and of those determinations that were denied, over 80 percent were eventually approved.
01:37
Mr. Fielder, how much time did these appeals take,
01:42
and how much does it cost to constantly re-review these claims?
01:46
Mr. So, I'm not aware of data that speaks specifically to the amount of time consumed
01:52
in navigating appeals, but we do have data looking at how much time providers spend
01:57
navigating prior authorization processes generally.
02:02
You know, if you're talking about physicians, it's, you know, hours out of their work week.
02:05
If you're talking about non-physician practitioners, it's often more.
02:08
And, of course, the administrative staff that work for them,
02:11
it can be a, you know, substantial fraction of what they do all day.
02:14
So, it is a substantial consumer of time for physician's offices,
02:20
for other types of health care providers.
02:22
And, obviously, you know, that means it's a substantial driver of cost as well.
02:27
And not actually going towards providing health care at that moment.
02:31
My colleagues and I agree that this is an issue,
02:34
and we've been working for years to reform prior authorization.
02:38
Recently, the Trump administration hosted a roundtable
02:41
that highlighted the negative impacts of prior authorization.
02:45
And after years of effort to reform prior authorization,
02:48
it seemed like we were all on the same page.
02:50
However, just days after the administration's roundtable,
02:53
CMS announced their new WISER model,
02:57
which contracts with private companies, including Medicare Advantage plans,
03:01
to increase the utilization of prior authorization in traditional Medicare.
03:05
This model is running in six states, including in my home state of Washington.
03:11
To make matters worse, CMS has indicated that model participants will be compensated
03:16
based on a share of averted expenditures.
03:20
This approach appears to reward participants based on the volume or cost of care
03:25
they prevent from being delivered or paid,
03:28
once again creating this perverse incentive to deny care in order to make a profit.
03:33
Mr. Fielder, with all that we know about the abuses of prior authorization,
03:38
is it a good idea to implement this tactic in traditional Medicare?
03:42
So as some of my fellow panelists have talked about,
03:45
I think it's about striking the balance.
03:47
I think broader use of prior authorization in traditional Medicare
03:50
could be appropriate if it's done in a thoughtful way.
03:53
That being said, I'm sympathetic to the concern
03:57
that the particular compensation structure that CMS is thinking about here
04:01
does create incentives for plans to, or for the contractors in this case,
04:07
to deny requests that should be approved.
04:10
And I'm, it's, I think, not clear that the safeguards that the model notionally has an effect
04:15
to address those concerns are going to be adequate to the task.
04:18
So I think this is the place where the devil is really in the details.
04:21
And I guess, you know, probably the most important thing is,
04:25
will this model make it easier for seniors to get the care that they deserve?
04:28
I think, whatever its merits, it's hard to see how it would expand access to care.
04:33
And I think that's got to be an important priority for everyone here.
04:38
Thank you all.
04:38
I yield back, Mr. Chairman.
04:41
Ms. Miller, you...
Be the first to comment
Add your comment
Recommended
0:40
|
Up next
SPIDER-MAN : BRAND NEW DAY Teaser (2026)
FilmsActu
5 months ago
0:39
SPIDER-MAN: BRAND NEW DAY Teaser (2026)
Fresh Movie Trailers
5 months ago
1:20
Lizzo Name-Drops Sydney Sweeney in New Song Over American Eagle Jeans Ad | THR News Video
The Hollywood Reporter
5 months ago
4:58
'We're Hearing This Over & Over': Carol Miller Blasts Medicare Advantage Over Low Reimbursements
Forbes Breaking News
5 months ago
5:24
'Reigning In Waste, Fraud, & Abuse': Doggett Backs Cassidy's Push To End Medicare Advantage Upcoding
Forbes Breaking News
4 months ago
5:42
Blake Moore Discusses Using Data To Inform Healthcare Coverage To Stop Medicare Advantage Upcoding
Forbes Breaking News
5 months ago
2:45
Vern Buchanan: 'Excess Prior Authorization And Payment Delays' Mar Medicare Advatage
Forbes Breaking News
4 months ago
5:17
Beth Van Duyne Rips Medicare Advantage Over 'Heartbreaking Stories' Of Patients Waiting For Authorization
Forbes Breaking News
5 months ago
5:00
'I Am As Confused As Can Be': Aaron Bean Slams High Cost For Medicare Programs
Forbes Breaking News
4 months ago
5:45
Nathaniel Moran Bemoans 'Really Unworkable' Prior Authorization Rules For Medicare Advantage
Forbes Breaking News
5 months ago
4:42
Terri Sewell Warns Medicare Cuts In BBB Will Lead To 'Chaos And Upheaval' In Healthcare System
Forbes Breaking News
4 months ago
5:13
Panetta Accuses Medicare Advantage 'Ghost Networks' Of 'Delays In Care' & 'Inappropriate Treatment'
Forbes Breaking News
4 months ago
1:12
Andy Harris Calls Medicaid Spending ‘Out Of Control,’ Urges Reform To ‘Preserve It For The Future’
Forbes Breaking News
8 months ago
5:06
'That's A Huge Problem': Mike Kelly Slams Long Waits For Medicare Advantage Authorizations
Forbes Breaking News
4 months ago
6:42
Smith Decries Healthcare Companies 'Inflating' Patients' Level Of Sickness To Boost Reimbursements
Forbes Breaking News
5 months ago
1:02
Andy Harris Touts Progress In Eliminating ‘Fraud, Waste, And Abuse’ Of Medicaid System
Forbes Breaking News
7 months ago
1:26
Medicare's Money Crunch: Part A Depletion Moved Up
Money Explainers
6 months ago
6:02
'Republicans Cut 17 Million Americans' Healthcare': Sánchez Shreds Big Beautiful Bill Medicaid Cuts
Forbes Breaking News
5 months ago
5:29
‘Devastating’: Herb Conaway Warns Of Medicaid Cut Impacts On Strained Rural Veteran Health Programs
Forbes Breaking News
5 months ago
3:58
'It's Demographics, It's Math': David Schweikert Sounds The Alarm On Medicare Part A Fund Depletion
Forbes Breaking News
5 months ago
5:57
'Our Whole System, To Me, Is Broken': Vern Buchanan Slams Medicare System, Calls It Too Expensive
Forbes Breaking News
4 months ago
5:19
Kevin Hern Accuses Biden Administration Of 'Heavyhanded Actions' That Hurt Medicare Advantage Patients
Forbes Breaking News
4 months ago
19:03
'I Got Some Math Problems': David Schweikert Sounds The Alarm On Future Healthcare Costs
Forbes Breaking News
5 months ago
13:00:35
House Ways And Means Committee Holds Marathon Hearing On GOP Reconciliation Bill: Part 2
Forbes Breaking News
8 months ago
5:06
'I'm Very Concerned About Straight-Up Fraud': Adrian Smith Decries Medicare Abuses, Demands Reform
Forbes Breaking News
4 months ago
Be the first to comment