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

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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.”

Contact ProspHire Today

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.

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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.