Author: LBodnarchuk

Addressing New Concerns for Prior Authorizations in Medicare Advantage

OIG Study
The Office of Inspector General (OIG) recently published a report on a study completed showing significant issues in prior authorizations for Medicare Advantage members. The investigation was sparked by a concern that Medicare Advantage organizations were denying or delaying coverage for procedures and services allowed by the Centers for Medicare and Medicaid Services in both Medicare Advantage Plans and covered under traditional Medicare benefits. In a randomly selected sample, the OIG determined that prior authorization determinations in some cases were not consistent with Medicare coverage rules and Medicare Advantage billing rules. The findings in this study were consistent with previous studies published in 2018. 

OIG Findings
In this study, 13% of the denied services met Medicare coverage rules. The study provided examples related to decisions for the payor incorrectly time limiting a follow-up MRI scan.  Another example was denying a post-polio patient a walker that had previously used a cane.  One of the issues identified in the study was the fact that Medicare Advantage Organizations were applying clinical criteria that Medicare does not require.

In the second part of the study, the OIG investigated payment denials resulting in an 18% error rate based on Medicare Advantage billing rules. One of the reasons cited in the study for the issues was human errors during the manual review process. Examples included denial of a claim for a non-par provider in an in-network facility and a reviewer missing a prior authorization that led to claim denial for radiation treatment. Other errors were related to programming issues in claims processing systems, such as incorrectly identifying tax identification numbers or incorrect time-frame identification for coverage. Another was related to a more restrictive policy requiring an x-ray before an MRI or a MRI before therapy. Other treatments were inconsistent with Medicare National Coverage Decisions governing the plan.

The list of issues identified in the study is extensive. The OIG provided CMS with recommendations that will require Medicare Advantage Organizations to consider the similar problems they may have in their prior authorization processes and procedures. CMS agreed with the OIG recommendation to issue new guidance on clinical criteria, update audit protocols and direct Medicare Advantage Organizations to take additional steps to identify and remedy issues in manual and system errors.

How ProspHire Can Help
At ProspHire, our team of utilization management experts can rapidly assess your current policies, procedures and processes for prior authorization issues and provide a detailed playbook for addressing problems identified in the assessment.  We will help you navigate the issues and mitigate potential audit risks represented by the OIG report. Working with your team, we can support the implementation of the playbook, including updating policies, training staff and executing transformation to processes and systems to remedy potential errors. We will review current prior authorization criteria and improve the accuracy and the workflow issues that may be causing problems. We believe proactive evaluation and execution can limit the risks to the organization while enhancing processes that may be causing issues for the organization. 

To read the full OIG Report: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

SBA WOSB certified

ProspHire Awarded WOSB Certification by SBA

PITTSBURGH, PA – ProspHire, a national management consulting firm focused on healthcare advisory, project delivery and strategic resourcing, is proud to announce that it has been awarded the Women-owned Small Business (WOSB) certification by the Small Business Association (SBA). This certification helps small businesses owned, operated and controlled by women to compete for federal contracts. The federal government’s goal is to award at least 5% of all federal contracting dollars to women-owned small businesses each year.

“We are honored to officially be designated as a certified Women-owned Small Business,” says Lauren Miladinovich, ProspHire’s Managing Principal and CEO. “This is an opportunity to connect with and serve companies who share our commitment to diversity and inclusion. Companies that have the need or desire to diversify their partnerships can now utilize ProspHire to fulfill those requirements.”

About ProspHire
ProspHire is a national management consulting firm focused on healthcare advisory, project delivery and strategic sourcing. Founded on the core value of relationships, with the goal to “prosper together”, ProspHire partners with clients to identify and solve their most significant people, process and technology challenges. The women-owned and rapidly growing Pittsburgh-based firm has nearly a 100 dedicated practitioners and consultants who deliver on projects and services across the U.S.

Modern Healthcare Best Places to Work 2021 and 2020 logo

ProspHire Ranks on Modern Healthcare’s Best Places to Work List Again

PITTSBURGH, PA – ProspHire, a national management consulting firm focused on healthcare advisory, project delivery and strategic resourcing, announced today that for the 2nd year in a row, the Firm has ranked in the top ten on the Modern Healthcare Best Places to Work List under the category of healthcare supplier. In 2021 ranking 8th and 2020 ranking 5th, respectively. The award recognizes high performing and successful teams, regard for employee’s well-being, acknowledgement of contributions and respect to the experience and dedication in helping maintain a level of harmony during the pandemic. This program singles out and recognizes outstanding employers in the healthcare industry on a national level.

“Thank you to Modern Healthcare for recognizing our emphasis on the compassion and respect that is essential to an engaged and productive workforce. During an incredibly trying time for the industry, and the world, it’s inspiring and humbling to see the dedication of our employees to strive for growth,” said Lauren Miladinovich, ProspHire’s Managing Principal and CEO.

Christopher Miladinovich, ProspHire’s Principal and COO, said, “Being a great place to work means having great people and compassionate leadership. We’re nearing 100 employees, with offices in Pittsburgh and Philadelphia and celebrating rapid growth since our founding in 2015. This is a direct result of the relentless dedication of our people who have helped scale this organization so responsibly.”

The executive leadership at ProspHire believes that to be successful you must start internally with employees who then lead you to great clients. “We leverage mentoring and training programs to build an environment that focuses on the right thing to do for our clients, the Firm and the individuals involved.” says Dan Crogan, Principal and SVP of Consulting at ProspHire. “In turn, it empowers our employees to think creatively, make decisions and build trusting relationships with our clients.”

2021 has been another award-winning year for ProspHire. The Firm ranked in the top ten on the Pittsburgh Business Times Fast 50 List of the fastest growing private companies in the Pittsburgh Region. The award recognizes the Firm for its 95.68% revenue growth between 2018 and 2020. ProspHire was also named an unprecedented 2 years in a row to 2021 Inc. Magazine’s annual list of America’s Fastest-Growing Private Companies – the Inc. 5000.

About ProspHire
ProspHire is a national management consulting firm focused on healthcare advisory, project delivery and strategic sourcing. Founded on the core value of relationships, with the goal to “prosper together”, ProspHire partners with clients to identify and solve their most significant people, process and technology challenges. The women-owned and rapidly growing Pittsburgh-based firm has nearly a 100 dedicated practitioners and consultants who deliver on projects and services across the U.S.

What Employers Should Consider for Post-Pandemic Health Care Offerings

Insight into what employers should keep in mind when developing health care offerings that address the post-pandemic needs of their employees.

The COVID-19 pandemic has been a once-in-a-century event that few of us could have predicted. We mourn the tragic loss of life globally and in the U.S., while we also manage through the surge in the Delta variant and continue forward with optimism as our children return to schools. Adversity has also driven perseverance, ingenuity, and adaptation. There is no question that the impact of the pandemic has changed how we work, socialize, shop, and how we consume health care. For example, a study from the Journal of the American Medical Association reported that telemedicine services grew by more than 1000% in March of 2020 and more than 4000% in April of 2020.

While these numbers were early in the pandemic, many professionals expect the use of telehealth services to continue, with notable hospitals such as UCLA anticipating that about 20% of volume will continue via telehealth. Reinforcing this future trend are the positive impacts from telehealth, such as increased access to specialists, avoided hospitalizations, and improved outcomes, as noted by the American Hospital Association in a letter to the U.S. Senate. Through necessity, the pandemic has rapidly advanced adoption of telehealth in a short time. As we move ahead, we also hear about increasing needs for post-pandemic behavioral health and we must still address rising healthcare costs that predated the pandemic.

So, how do health plans, employers, and health systems plan for post-pandemic needs?

At ProspHire, our research and our experience with health plan and hospital system clients shows the need to focus in three key areas:

  1. Increase support for telehealth.
  2. Prepare for behavioral health needs.
  3. Use data to manage costs to narrow networks and value-based arrangements.

Increase Support for Telehealth

As employers, health plans, and health systems consider strategies for the post-pandemic needs of their employees, members, and patients, it is important to encourage and support access to telehealth options across all types of care. Telehealth serves to reduce barriers to care and serves an important role in augmenting rather than replacing traditional care. In January 2021, U.S. News cited a 2020 JAMA study in stating that “the increase in telemedicine only offset about 40% of the decline in office visits” suggesting that both traditional visits and telehealth are important tools. The article further cited a common scenario in which a diabetic patient missed a visit due to transportation issues, which is a common social determinant factor. Telehealth helped the care provider to engage the patient and to continue monitoring overall wellness and compliance with a prescribed course of care … potentially avoiding more acute and higher-cost issues in the future. Employer and health plan support for telehealth coverage will encourage providers to continue and even to expand telehealth options.

Prepare for Behavioral Health Needs

Our ability to use telehealth for care needs, to continue work and school safely via virtual meetings, or even to attend social events through Zoom or other platforms has saved us time and money that we previously spent commuting or traveling. However, all these virtual connections don’t fully replace the in-person relationships and interactions that we enjoy, potentially leading to feelings of isolation, stress, or other factors. Better integrated behavioral health was already identified as a need prior to the pandemic, addressing whole-person wellness, and helping to avoid hospitalizations or unnecessary ER visits. A 2019 study by BlueCross BlueShield of Kansas City (BCBSKC), and reported by the National Institute of Health, showed 10.8% savings in costs for a group of BCBSKC members with integrated behavioral health. Employers and health plans should embrace the opportunity to integrate behavioral health services and improve outcomes and costs.

Use Data to Manage Costs with Narrow Networks and Value-Based Arrangements

Balancing the “quadruple-aim” of better outcomes, better patient experience, better provider experience and lower costs is a challenge. Managing this effectively means using data-driven insights to seek out opportunities to control costs and align incentives without compromising quality or creating administrative burden. Value based contracting combined with narrow network arrangements can help to achieve this balance. A 2018 Change Healthcare study cited in Health Payer Intelligence quoted an average of approximately 5.6% savings because of value-based arrangements. Aligning employees and members in partnership with health systems can shift risk, cap costs, and align care incentives.

The pandemic has created a leap forward in health care – driving adoption in telehealth and bringing focus to behavioral health that may have required years of change and regulatory intervention. Employers and health plans can embrace and amplify these trends through benefit designs, care programs, and value-based incentives in partnership with health systems. These measures will drive a more integrated care model that delivers on the promise of better outcomes, better experience, and more affordable care,

This blog was featured in Member Perspectives by The Chamber of Commerce for Greater Philadelphia.