Author: Rylee Wilson | Becker’s

5/12/2025

UnitedHealthcare has agreed to pay more than $9 million to settle a class-action lawsuit alleging that the insurer wrongfully denied coverage for proton beam therapy, a type of specialized cancer treatment. 

According to court documents filed May 9, the insurer will pay up to $75,000 to members in employer-sponsored plans diagnosed with prostate, primary-central nervous system or cervical cancer who had claims for proton beam therapy denied, and paid for the treatment out-of-pocket. 

The total payments to members will be capped at $6.75 million, according to the document. UnitedHealthcare will also pay $2 million in attorneys fees and awards to lead plaintiffs in the case. The insurer could pay an additional $500,000 in fees. 

UnitedHealthcare will also change its coverage policies for proton beam therapy as part of the agreement, a move the plaintiffs say will make it easier for members to have requests for the therapy approved. As part of the change, UnitedHealthcare will eliminate a list of 13 diagnoses for which proton beam therapy was considered “unproven and not medically necessary,” according to agreement. 

The class-action lawsuit was brought by three UnitedHealthcare members in different employer-sponsored plans in 2019, and consolidated in the U.S. District Court for the District of Massachusetts. The plaintiffs alleged that UnitedHealthcare wrongfully classified proton beam therapy as experimental, forcing them to pay out-of-pocket for the treatment. 

Proton beam therapy is an alternative to traditional radiation therapy, and is particularly effective in treating tumors close to critical organs, according to the National Association for Proton Therapy. The treatment makes up less than 1% of radiation therapy in the U.S. 

There are 90 individuals who submitted post-service claims for proton beam therapy to UnitedHealthcare and 150 who had prior authorization requests denied who will receive a notice of the settlement, according to the agreement. 

UnitedHealthcare does not admit any wrongdoing as part of the settlement, and reached the settlement to avoid “the burden, expense, risk and uncertainty” of continuing litigation. 

Becker’s has reached out to UnitedHealthcare for comment and will update this article if more information becomes available. 

The post UnitedHealth settles cancer coverage suit for $9M appeared first on PayerWatch.

Author: Kendall Smith, MD | Chief Medical Officer & Chief Physician Advisor – PayerWatch & AppealMasters

10/3/24

Navigating the complexities of healthcare finance can be tough, especially when payers don’t play by the rules. For hospitals and health systems, part of a successful denial management strategy should involve reporting unfair practices to state insurance departments and regulatory bodies.

Why It’s Important

We’ve all been there—dealing with claim denials that just don’t make sense, or worse, patterns of unfair reimbursement practices that put your financial health at risk. It’s not just about fixing one claim—it’s about calling attention to payer behaviors that affect the entire healthcare system.

Take the recent case in California: Anthem Blue Cross was hit with an $8.5 million fine for mishandling claims disputes. That didn’t happen overnight; it took persistence from providers and regulatory action to hold Anthem accountable. Reporting these practices brings transparency and shows payers they can’t get away with unfair treatment.

What You Can Do

When a payer denies claims unfairly, the first move is to try to resolve it directly. But when that doesn’t work, don’t let their decision be the last word. Reporting payers to your state’s insurance department—or even federal regulators—can be a game-changer. By submitting a formal complaint with supporting documents, you raise a red flag that regulators can’t ignore.

Why It Works

When enough providers report the same issues, state departments take notice. They can launch investigations, impose fines, and even enforce policy changes. Anthem’s fine is just one example of how reporting can have real consequences for payers. And once a payer is on a regulator’s radar, they’re more likely to clean up their act.

Our Recommendation

At PayerWatch, we don’t just recommend reporting payers—we help you do it. We know the process can feel overwhelming, especially when you’re up against a large payer, but you don’t have to go it alone. Our team has the expertise to guide you through filing complaints and navigating the regulatory landscape.

We’ve helped health systems across the country hold payers accountable, resulting in better outcomes for both providers and patients. Don’t settle for unfair treatment. Let PayerWatch help you take a stand, protect your bottom line, and advocate for a more fair and transparent healthcare system.

The post Best Practices in Denial Management: Holding Payers Accountable by Reporting to State Insurance Departments appeared first on PayerWatch.

Author: Kendall Smith, MD | Chief Medical Officer & Chief Physician Advisor – PayerWatch & AppealMasters

9/18/24

As highlighted in a recent article by HealthLeaders Providers Are Fed Up With Medicare Advantage, hospitals across the country are fed up with the financial havoc caused by Medicare Advantage (MA) plans. At PayerWatch, we see this every day. These plans are systematically undercutting hospitals by denying claims, reducing payments, and dragging out reimbursements—creating a financial nightmare that directly harms patients and communities.

The consequences are clear: hospitals are losing critical revenue, forcing them to cut services, lay off staff, or, in some cases, even shut down. When hospitals can’t get paid for the care they provide, patient care suffers—longer wait times, reduced access to necessary treatments, and the most vulnerable populations are left without life-saving services. MA plans are not just hurting healthcare providers; they’re endangering the health and well-being of entire communities.

At PayerWatch, we refuse to stand by. Our advanced Denial Management technology and expert team are dedicated to overturning these unjust denials, helping hospitals fight back and recover the funds they are rightfully owed. Hospitals shouldn’t have to choose between financial stability and patient care. It’s time to hold Medicare Advantage plans accountable.

The post Medicare Advantage Plans Are Threatening Hospital Finances and Patient Care appeared first on PayerWatch.

Author: PayerWatch & AppealMasters

9/16/24

At PayerWatch, we’ve been closely monitoring the rise of artificial intelligence (AI) in healthcare, especially in relation to claims denials. There’s no denying AI’s potential to streamline processes, but as highlighted in this recent article, AI is now linked to a troubling surge in Medicare Advantage and commercial claims denials. Providers are bearing the brunt of it.

AI may promise efficiency, but without the expertise of seasoned clinicians and legal experts, it’s becoming a tool for payers to increase denials, not reduce them. From the outset, we at PayerWatch were skeptical about AI’s ability to assess and appeal unjust denials as effectively as a human. Unfortunately, this is exactly what we are now witnessing — AI being used to push more denials through, creating new headaches for hospitals.

At PayerWatch, we believe technology should enhance, not replace, human expertise. Our Veracity software leverages industry-recognized tools like robotic process automation (RPA) to assist our team, but it’s our experienced clinicians and legal professionals who drive real results for hospitals. We will continue standing firm for providers, pushing back against this denial surge with the right mix of advanced tools and human expertise.

The post AI and the Rise in Claims Denials appeared first on PayerWatch.

Author: Kendall Smith, MD | Chief Medical Officer & Chief Physician Advisor – PayerWatch & AppealMasters

9/9/2024

Medicare Advantage (MA) plans now cover over 30 million Americans, promising to deliver quality care while managing costs more effectively than traditional Medicare. However, as outlined in Becker’s Hospital Review article, “Medicare Advantage’s Unrealized Potential” (https://www.beckershospitalreview.com/finance/medicare-advantages-unrealized-potential.html), the reality hasn’t quite lived up to the promise. Instead, we’re seeing a system that too often leads to denials of care, financial strain on hospitals, and frustration for both providers and patients.

At PayerWatch, we’re in the trenches with hospitals every day, helping them navigate the difficult landscape of insurance denials. The original goal of MA was to streamline care and save costs, but instead, hospitals are facing a rising tide of denied claims. This doesn’t just hurt the bottom line—it disrupts patient care and erodes trust.

More Denials, Less Care
One of the biggest issues with Medicare Advantage is how often medically necessary care gets denied. What’s frustrating is that these are services hospitals provide in good faith, expecting to be paid, only to find out later that claims have been denied after the fact. This forces hospitals to go through a time-consuming and resource-draining appeals process. And when appeals fail, it’s the patients and the hospitals that get stuck with the financial consequences.

At PayerWatch, we see these stories play out every day. Hospitals are already dealing with staffing shortages and tight budgets. Now, add to that a backlog of denied claims, each requiring hours of paperwork and follow-up. This isn’t sustainable for our healthcare system, and it’s certainly not fair to the patients who rely on these services.

Our Veracity platform is designed to give hospitals the tools they need to fight back. By using real-time tracking and analytics, hospitals can quickly see patterns in denials and put together stronger, evidence-based appeals. Our goal is simple: to make sure hospitals get paid for the care they provide, and patients receive the treatments they need without unnecessary delays.

It’s Time for Real Reform
We agree with the Becker’s article that reform is needed, but it’s not enough to tweak the system. There needs to be real accountability for MA plans when they deny claims that should have been approved. It’s time for stricter oversight and transparency so that hospitals aren’t left holding the bag when payers deny legitimate care.

Right now, hospitals are footing the bill for these denied claims, putting their financial stability at risk. Worse yet, patients are often caught in the middle, facing delays in getting the care they need. We need clear, enforceable standards to ensure MA plans prioritize patient care and stop hiding behind technicalities to deny claims.

Technology Can Help Bridge the Gap
The good news is that technology can play a big role in solving these issues. With platforms like Veracity, hospitals can stay ahead of the denial curve, using data to pinpoint denial trends and take immediate action. When hospitals are equipped with the right tools, they can reduce the administrative burden and focus more on delivering care.

At PayerWatch, we believe that hospitals shouldn’t be fighting this battle alone. By empowering hospitals with the tools and expertise to manage denials, we can start making a real difference in how care is delivered and paid for.

Looking Forward
Medicare Advantage has the potential to do great things, but right now, too much of that potential is unrealized. It’s time for the industry to take a hard look at how these plans are working—or not working—for patients and providers alike. At PayerWatch, we’re committed to being part of the solution, helping hospitals push back on inappropriate denials and make sure that care comes first, not profits.

Let’s work together to bring accountability to the system and make sure MA plans live up to their promise. After all, healthcare should be about helping people—not playing games with their care.

The post Medicare Advantage’s Missed Opportunity: Time for Accountability and Change appeared first on PayerWatch.

Author: Kendall Smith, MD | Chief Medical Officer & Chief Physician Advisor – PayerWatch & AppealMasters

9/5/2024

In response to: Final Denial Rate for Inpatient Claims in 2023 Was More Than 50 Percent Above the Same Rate in 2021, According to Kodiak Solutions Data (yahoo.com)

The recent rise in final denial rates for inpatient claims, reaching 3.4%, is a reminder of the growing challenges hospitals face in securing rightful reimbursement for the care they provide. At PayerWatch, we see firsthand how these denials impact hospitals—not just financially, but in the resources needed to resolve them and the potential delays in patient care.

Hospitals are under pressure to navigate increasingly complex insurance requirements, and it’s more important than ever to have a strong defense against unjust denials. That’s where we step in. Our team at PayerWatch is dedicated to helping hospitals fight back, leveraging clinical expertise and real-time data through our Veracity platform to streamline the denial management process. We ensure hospitals have the tools and support needed to overturn denials, protect revenue, and focus on delivering patient care.

This trend in denial rates highlights the necessity of proactive, strategic approaches. By aligning clinical documentation, coding, and billing efforts, hospitals can reduce the risk of denials and safeguard their financial health. At PayerWatch, we’re proud to partner with hospitals to navigate these challenges and ensure they’re paid for the care they provide.

The post The Importance of Comprehensive Denial Management appeared first on PayerWatch.

8/27/2024

In response to: CMS scrapped Medicare Advantage rule over industry opposition: Report (beckerspayer.com)

CMS’s decision to drop the proposed regulation that would have required Medicare Advantage plans to return overpayments found during chart reviews has significant implications for the healthcare industry. As the Chief Medical Officer for PayerWatch, a company focused on helping hospitals recover denied insurance claims, this decision highlights the importance of a regulatory environment that ensures fair and consistent practices in reimbursement while maintaining the integrity of the healthcare system.

The proposed rule, which was designed to hold Medicare Advantage plans accountable for identifying and returning overpayments, was a step in the right direction for promoting transparency and proper stewardship of Medicare funds. However, the decision to abandon this regulation in response to stakeholder concerns illustrates the complex balance between regulatory goals and industry pressures.

The ongoing civil fraud case against UnitedHealth Group serves as a reminder of the challenges inherent in ensuring compliance across the healthcare spectrum. While insurers may argue that the absence of a finalized rule exempts them from certain responsibilities, the broader issue remains: clear and enforceable guidelines are essential for maintaining trust and accountability in the system.

Dr. Don Berwick’s observation that CMS faces substantial resistance when attempting to advance meaningful reforms is a reality that all stakeholders must acknowledge. For PayerWatch, this situation reinforces our commitment to supporting hospitals in navigating these complexities and recovering revenue that is rightfully theirs. Hospitals and healthcare systems need reliable partners who understand the intricacies of payer practices and can provide the expertise needed to overturn unjust denials and optimize revenue.

PayerWatch remains aligned with our clients—hospitals and healthcare providers—by advocating for fair practices and offering the tools and strategies necessary to thrive in a challenging regulatory environment. As the industry continues to evolve, we remain dedicated to ensuring that hospitals are empowered to secure the reimbursements they deserve, in alignment with both CMS guidelines and ethical standards.

The post CMS Drops Medicare Advantage Overpayment Rule: The Impact on hospitals appeared first on PayerWatch.

July 26, 2024

In today’s complex healthcare landscape, Revenue Cycle leaders face an escalating challenge—protecting their hospital’s financial health while navigating the intricacies of Managed Care contracts. One often overlooked yet vital component of these contracts is the inclusion of audit limits. Why should hospitals prioritize writing audit limits into their agreements? Let’s explore the multifaceted benefits and compelling reasons behind this critical strategy.

Why Audit Limits Matter

Consider this scenario: Your hospital has consistently delivered top-notch care, only to be blindsided by a surge of payer audits demanding extensive documentation and recouping payments without just cause. The result? Unpredictable revenue swings, strained resources, and prolonged disputes. This isn’t a mere hypothetical; it’s a reality many healthcare providers face.

Protecting Financial Stability

Audit limits serve as a protective barrier against excessive and often arbitrary payer audits. By establishing clear boundaries on the scope, frequency, and timelines of audits, hospitals can safeguard their revenue streams. This proactive measure ensures financial stability and offers greater predictability and control in revenue cycle management.

Without audit limits, revenue cycle management can be like navigating a minefield.  Implementing these limits will transform your operations, giving you greater predictability and control.

Reducing Administrative Burden

The administrative burden of responding to unchecked audits can be overwhelming. Revenue Cycle leaders know that every hour spent on audit responses is an hour diverted from patient care and other critical functions. By capping the number and scope of audits, hospitals can streamline their operations and allocate resources more efficiently.

Enhancing Negotiating Power

Wondering how to tip the negotiation scales in your favor? Audit limits are a strategic bargaining chip. When payers know that your hospital insists on reasonable audit terms, they are more likely to respect your overall contract provisions. This leads to fairer agreements and sets a positive precedent for future negotiations.

Crafting Effective Audit Limits

Implementing audit limits requires a thoughtful approach. Here are the key elements Revenue Cycle leaders should consider:

Define Clear Parameters: Specify the maximum number of audits allowed per year, the acceptable scope of each audit, and the timeframe within which audits must be conducted. Clear definitions prevent ambiguity and protect your hospital from potential overreach.

Establish Recoupment Thresholds: Set thresholds for recoupment actions. This ensures that minor discrepancies don’t trigger significant financial repercussions. For instance, only discrepancies exceeding a certain dollar amount should warrant recoupment efforts.

Include Appeal Processes: Incorporate a robust appeals process. This enables your hospital to challenge unjust audit findings effectively. A well-defined appeals mechanism acts as a buffer against arbitrary decisions and ensures due process.

Take Command of Your Contracts

Audit limits aren’t just a formality—they are a necessity. They provide predictability, reduce administrative burdens, and enhance your negotiating power. Most importantly, they protect your hospital’s bottom line, allowing you to focus on what truly matters—providing exceptional patient care.

The post The Crucial Role of Audit Limits in Managed Care Contracts appeared first on PayerWatch.

Informed Consent and Managed Care Contracts: A Call to Action
Informed consent is about ensuring patients know the risks, benefits, and alternatives of their treatments. This concept is rooted in the principles of patient autonomy and ethical treatment, ensuring that individuals can make well-informed decisions about their healthcare. Now, let’s apply this concept to managed care contracts, particularly in the complex world of clinical validation audits. These audits require a thorough understanding of the terms and conditions outlined in the contracts, as well as a commitment to transparency and patient-centered care. By extending the principles of informed consent to managed care, we can enhance the integrity and accountability of healthcare practices.

Understanding Clinical Validation Audits

Clinical validation audits are reviews by insurers to make sure medical records meet their criteria for diagnoses like sepsis, congestive heart failure, and malnutrition. If your documentation doesn’t match their standards, they can deny your claims. The tricky part? These standards often differ from accepted clinical guidelines and can change at any time without notice.

The Impact of Provider Manual Changes

Insurers often update provider manuals with new policies and guidelines that affect how conditions are defined and how claims are processed. These unilateral changes can catch hospitals off guard, impacting revenue and operations. Here’s how it can impact you:

Sepsis: Stricter definitions could mean more denied claims, even with accurate diagnoses.
Congestive Heart Failure: Revised criteria can disrupt your documentation and coding practices, leading to more denied claims.
Malnutrition: New documentation requirements make it harder to meet standards, resulting in more denied claims.

The Case for Mutual Agreement Clauses

To protect your interests, mutual agreement clauses in provider manuals are essential. They ensure hospitals have a say in any revisions. Including these clauses will:

Prevent Unilateral Changes: Promote fairness and transparency.
Ensure Clinical Alignment: Minimize disputes and support consistent coding practices.
Enhance Communication: Foster better communication between hospitals and insurers.
Reduce Revenue Risk: Help hospitals prepare for changes and mitigate revenue loss.

Implementing Mutual Agreement Clauses

When negotiating contracts, hospital revenue cycle executives should advocate for the following clauses:

1. Engage Legal and Clinical Teams: Ensure that proposed clauses are robust and enforceable.
2. Communicate Clearly with Insurers: Emphasize the advantages of mutual agreement.
3. Monitor Provider Manual Updates: Establish a process for timely responses and negotiations.
4. Document Agreements: Maintain detailed records for future reference and dispute resolution.

Conclusion

Informed consent is a cornerstone of ethical patient care, and applying this principle to managed care contracts is essential for maintaining integrity and transparency in healthcare. By understanding the intricacies of clinical validation audits and the ongoing impact of provider manual changes, healthcare providers can better navigate these challenges. Implementing mutual agreement clauses is a critical strategy to safeguard against unilateral changes that can affect revenue and operational efficiency. By fostering collaborative and transparent relationships with insurers, hospitals can ensure more consistent and fair practices that ultimately benefit both providers and patients.

The post Clinical Validation Audits Are Growing Exponentially and Quite Often Hospitals Remain Powerless to Stop Them. appeared first on PayerWatch.

On June 28, 2024, the Supreme Court made a landmark decision to overturn the Chevron doctrine, a principle that granted deference to federal agencies in interpreting ambiguous statutes. This decision marks a significant shift in how regulations are interpreted and implemented across various sectors, including healthcare. For healthcare executives, particularly those involved in Medicare and Medicare Advantage plans, understanding the implications of this ruling is crucial as it may reshape regulatory frameworks and policy implementations in the near future.

Understanding the Chevron Doctrine

Before delving into the potential impacts, it is important to grasp the essence of the Chevron doctrine. Established in the 1984 case Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., this doctrine dictated that courts should defer to a federal agency’s reasonable interpretation of ambiguous statutes, provided that Congress had not spoken directly to the issue at hand. This principle aimed to uphold consistency and coherence in regulatory enforcement, relying on the expertise of administrative agencies to interpret laws within their purview.

Implications of Overturning Chevron

With the Supreme Court’s decision to overturn Chevron, the landscape of administrative law undergoes a notable transformation. This ruling implies that courts may no longer automatically defer to federal agencies’ interpretations of statutes when ambiguity arises. Instead, courts may now conduct their own analyses, potentially leading to more judicial scrutiny and varied interpretations of regulatory statutes.

Impact on Medicare and Medicare Advantage Plans

For healthcare executives overseeing Medicare and Medicare Advantage plans, the repercussions of overturning Chevron could be profound:

1. Increased Judicial Scrutiny: Without Chevron deference, courts may take a more active role in interpreting healthcare-related statutes and regulations. This could lead to varying interpretations across different circuits, potentially creating inconsistencies in how Medicare and Medicare Advantage programs are regulated and administered.
2. Policy Uncertainty: Healthcare policy often hinges on regulatory interpretations and guidance from agencies like the Centers for Medicare & Medicaid Services (CMS). Without Chevron, the clarity and stability provided by agency interpretations may diminish, resulting in uncertainty regarding compliance and strategic planning for healthcare executives.
3. Challenges in Administrative Rulemaking: The ability of federal agencies to promulgate regulations and establish guidelines may face new hurdles. Agencies may encounter increased challenges in defending their interpretations in court, which could slow down the rulemaking process and delay the implementation of new policies affecting Medicare and Medicare Advantage plans.
4. Potential for Industry Litigation: Healthcare providers, insurers, and stakeholders in the Medicare space may increasingly turn to litigation to challenge regulatory decisions or interpretations they find unfavorable. This could lead to a rise in legal disputes that further complicates the regulatory environment and adds to operational burdens for healthcare executives.
5. Need for Adaptation and Advocacy: In response to these changes, healthcare executives may need to enhance their advocacy efforts and engage more actively in regulatory proceedings. Understanding and influencing judicial interpretations of healthcare statutes could become critical to shaping favorable regulatory outcomes.

Strategic Considerations for Healthcare Executives

In light of these potential impacts, healthcare executives should consider several strategic actions:

1. Monitor Judicial Developments: Stay informed about court decisions and judicial interpretations relevant to Medicare and Medicare Advantage. Engage legal counsel to assess potential implications and strategize accordingly.
2. Enhance Regulatory Compliance: Given the potential for increased scrutiny and interpretation variability, prioritize robust compliance programs. Regularly review policies and procedures to ensure alignment with evolving legal standards and interpretations.
3. Advocate for Clarity and Consistency: Collaborate with industry associations and advocacy groups to advocate for clear, consistent regulatory frameworks. Engaging in policy discussions and providing input to lawmakers and regulatory agencies can help shape favorable outcomes.
4. Evaluate Risk Management Strategies: Assess the impact of regulatory uncertainty on business operations and financial planning. Develop contingency plans to mitigate risks associated with potential regulatory changes or legal challenges.
5. Invest in Legal Expertise: Consider bolstering internal legal resources or engaging external counsel with expertise in healthcare regulatory matters. Proactively seek legal guidance to navigate uncertainties and ensure compliance with evolving legal standards.

Conclusion

The Supreme Court’s decision to overturn the Chevron doctrine introduces a new era of regulatory interpretation and enforcement across various sectors, including healthcare. For healthcare executives overseeing Medicare and Medicare Advantage plans, this ruling necessitates heightened awareness, strategic planning, and proactive engagement in regulatory and legal arenas.

The post The Impact of the Supreme Court Overturning Chevron on Medicare and Medicare Advantage Plans appeared first on PayerWatch.