Prior Authorization; Underpaying Providers for Vaccines

Prior Authorization Process Due for Reform

The prior authorization process is coming under scrutiny at both the federal and state level.
Last week, legislation in the U.S. Senate was introduced that would create guideposts for the use of prior authorization in Medicare Advantage (MA) plans. And in Massachusetts, the Health Policy Commission (HPC) has included prior authorization among the topics it is investigating as part of its administrative simplification efforts. The HPC helped fund a study from NEHI this summer that proposed a series of steps to improve the prior authorization process. In addition, the Mass Health Data Consortium and its New England Healthcare Exchange Network (NEHEN) is piloting an automated process for prior authorizations.
Prior authorization (PA) is when a provider, on behalf of a patient, must request approval from the patient’s insurer before delivering a treatment or service. Insurers say PAs are necessary to make sure patients are getting the correct type of appropriate care and that care services are not overutilized, which drives up costs. Providers say the process often delays care, requires multiple administratively burdensome steps that vary from insurer to insurer, which leads to provider burnout and actually drives up costs.
Last week, Senators Roger Marshall (R-Kan.), Kyrsten Sinema (D-Ariz.), and John Thune (R-S.D.) introduced S. 3018, The Seniors' Timely Access to Care Act. It matches similar legislation (H.R. 3173) introduced in the U.S. House in May. The Seniors' Timely Access to Care Act would, among other things, establish an electronic prior authorization (ePA) program and require Medicare Advantage (MA) plans to adopt ePA capabilities; require the Secretary of Health and Human Services to establish a list of items and services eligible for real-time decisions under an MA ePA program; standardize and streamline the prior authorization process for routinely approved items and services, and ensure prior authorization requests are reviewed by qualified medical personnel.
In the commonwealth, the Massachusetts Health Data Consortium will be launching a standards-based, digital prior authorization prototype with one of Massachusetts' leading specialty hospitals and a leading insurer to automate prior authorization and reduce the administrative burdens imposed on patients and clinicians. Also in the Massachusetts, NEHI (Network for Excellence in Health Innovation) issued Streamlining Prior Authorization: Final Report & Recommendations earlier this year. The report – funded by the HPC and the Mass Collaborative, of which MHA is a member – focused on four key issues: the frequency with which PA is applied; the variation among payers in services/pharmaceuticals subject to PA; the variation in PA criteria; and the variation in documentation required by payers to satisfy PA criteria. Among NEHI’s recommendations is one calling for a reduction in the number of PAs associated with treatments for extended courses of care, especially those associated with chronic conditions; and expanded use of “family codes.” NEHI wrote: “A reduction in administrative denials may be achieved by grouping like codes together in approving PA requests. Work to develop additional groupings will continue a number of reviews payers have already begun.”
To increase appropriate access to care and address the ongoing mental health crisis, language in MHA’s omnibus behavioral health bill (H.1061) would eliminate prior authorization for medically necessary mental health services and would put medical necessity determinations directly in the hands of the treating provider, similar to a measure passed in Massachusetts for substance use disorder in 2016.
MHA’s Senior Director of Managed Care Karen Granoff said, “We look forward to collaborating with other key stakeholders to advance the recommendations made in the NEHI report and to addressing the challenges providers and patients face as a result of prior authorization requirements.”

UnitedHealth Underpaid Providers for Vaxes by 40%

The big national insurer UnitedHealth Group said last week it will reprocess all claims from providers for COVID-19 vaccine administration after the insurer conceded it was paying the providers 40% less than the standard Medicare rate for the vaccinations.
In a letter to UnitedHealth’s CEO Andrew Witty, the Chair of the U.S. Senate Special Committee on Aging Bob Casey (D-Penn.) wrote that “UnitedHealth’s past policies appeared to have created access barriers for children seeking COVID-19 vaccination from their primary care pediatrician—barriers that affected younger and older Americans alike.” Casey noted that other insurers quickly adopted the Medicare rate structure, but for four months UnitedHealth paid providers 40% below the rate. He added, “Aging Committee staff have heard concerns from providers that the reimbursement issues pediatricians experienced with UnitedHealth earlier this year could resurface when the FDA authorizes a COVID-19 vaccine for 5–11-year-olds, which will carry a different billing code.”
The insurer will reprocess all claims from mid-March to July 1. The review will be automatic, meaning providers will not have to resubmit claims. Casey called on UnitedHealth to report to the committee no later than November 5 on how many claims will be reprocessed, the average difference between the initial payment and the reprocessed claim payment, and details on the steps the insurer is taking to ensure providers are paid in a timely and fair manner going forward.

Telemedicine Coalition Seeks to Address the Digital Divide

The tMED coalition has made its ask for a slice of the American Rescue Plan Act (ARPA) funding that the Massachusetts legislature and Baker Administration is deciding how to apportion.
Approximately $5 billion in federal ARPA money is available. In testimony before the Joint Ways & Means committees and the House Committee on Federal Stimulus & Census Oversight, tMED stated: “Over the course of the COVID-19 pandemic, telehealth has been critical in maintaining and expanding access to care for patients across the commonwealth. Initial statewide data indicates that the utilization of telehealth for certain patient populations increased by 5,100% in March 2020 when compared to March 2019 … The COVID-19 pandemic has also made us acutely aware of the digital divide in our state. Many patients who would otherwise take advantage of telehealth services have been precluded because they lack access to broadband, devices, and/or digital fluency. As such, the tMED Coalition respectfully requests the legislature devote $1,000,000 of American Rescue Plan Act (ARPA) funding to establish a statewide Digital Bridge Pilot Program and a Digital Health Navigator Tech Literacy Program.”
The Digital Bridge would provide healthcare and human service providers, and their patients and clients with funding to purchase telecommunications, information services, and connected devices necessary for telehealth services. The Digital Health Navigator Tech Literacy Program would provide culturally and linguistically competent hands-on support to educate patients on how to access broadband and wireless services and use them to receive telehealth care.
“Without further investments, members of our most vulnerable communities—for no fault of their own—will continue to struggle to access safe, timely healthcare,” tMED wrote.

The New Massachusetts Center on Child Wellbeing and Trauma

The Office of the Child Advocate, in partnership with Commonwealth Medicine and UMass Chan Medical School has launched the Massachusetts Center on Child Wellbeing and Trauma. Its purpose is to support child-serving organizations and systems in becoming trauma-informed and responsive through training, technical assistance, communities of practice, and other support.


Trauma results from an event, series of events, or set of circumstances experienced by an individual that is physically or emotionally harmful or life-threatening, and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual wellbeing. According to the new center, 26% of children in the United States will witness or experience a traumatic event before the age of four, and more than two-thirds of children reported at least one traumatic event by age 16.


“Every organization that works with children most likely works with children who have experienced trauma, whether they know it or not,” according to the center. “Yet all too often, child-serving organizations and systems are not properly equipped to provide children with the supports and healing environment they need.”


To learn more how the Massachusetts Center on Child Wellbeing and Trauma can help your organization, or how you can share with it a successful trauma program that is working, visit childwellbeingandtrauma.org.

Addressing Sepsis in Disaster Zones

Healthcare providers are often on the frontlines of disasters and one of the issues they must deal with in such environments is the risk of sepsis in patients. Last week, the federal Assistant Secretary for Preparedness and Response announced a new 70-minute, online training module entitled Disaster Medicine: Sepsis
It provides recommendations to identify and manage sepsis under what are termed “austere conditions.” According to the CDC, nearly 87% of sepsis originate outside the hospital, making it critical to identify these patients early on within non-traditional clinical environments. By focusing on disaster scenarios, the training module emphasizes the identification, screening, stabilization, and evacuation of those suspected of developing sepsis and septic patients in austere conditions, with non-traditional clinical environments, and where there is a lack of laboratory testing.
Healthcare professionals can receive AMA PRA Category 1 Credit or nursing continuing education contact hours upon successful completion of the training.


Marcela G. del Carmen, M.D., has been named president of the Massachusetts General Physicians Organization (MGPO) and executive vice president of Mass General Brigham. She has served as interim MGPO president for the past six months. An oncologic surgeon, del Carmen attended Emory University and then medical school and residency at Johns Hopkins. She earned a master’s degree from the Harvard School of Public Health in 2006, and is a professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.

Annual Human Resources and Labor Forum

Tuesday, October 26, 2021; 9 a.m. – 11:15 a.m. ET

Human resources professionals in the healthcare field face an ever-evolving labor and employment landscape. Join us for a virtual program where we will examine trends, best practices, and current policy in the human resources field through a healthcare lens. We will be joined by expert leaders that are currently practicing innovative HR strategy and provide insight into how to integrate these practices into your organization. This program is geared toward human resources executives and professionals, or leaders seeking learning opportunities on employee onboarding and training. Register here.

John LoDico, Editor