Thompson Coburn companion Mackenzie Wallace was the featured visitor on a current episode of AHLA’s Talking of Well being Legislation Podcast, the place she sat down with Bob Paskowski, Consulting Principal, PYA, to debate the most recent developments and challenges going through the supplier and payer in at present’s well being care market. Mackenzie and Bob mentioned among the sensible suggestions they provide shoppers who’re attempting to navigate the present panorama, OIG’s April 2022 report addressing Medicare Benefit denials of prior authorization requests, the affect of the No Surprises Act’s (NSA) unbiased dispute decision course of and way more.
The episode lays out the numerous challenges within the well being care market on each the supplier aspect and the payer aspect. On the supplier aspect, the pair factors out that the well being methods and doctor teams are going through vital headwinds and challenges particularly on their expense aspect of the enterprise. Challenges embody labor shortages each on the medical and the executive aspect and elevated provide prices. On the payer aspect, they are saying points embody attempting to maintain prices down and never succumbing to a request for a charge enhance.
Mackenzie mentioned there are a variety of discussions within the trade about inflation, the price of well being care and the burden on shoppers. Nonetheless, she mentioned, “There was not a variety of dialogue about this specific problem, which is supplier and payer points and the way it impacts that intersection of price and worth and inflation.” The supplier a d the payer have to create options to reduce among the considerations and reduce the executive burden that additional drives prices up for the entire events concerned.
Mackenzie additionally mentioned the OIG report that was issued in April 2022 that addressed Medicare Benefit denials of prior authorization requests and raised considerations about beneficiary entry to medically obligatory care. She mentioned there are a sure share of claims the place no mistake by the supplier was made, and these claims are nonetheless not being paid correctly as a result of a distinct rubric is being utilized than what’s legally required. Mackenzie mentioned, “And that’s actually related to the underlying dispute as a result of when that happens, it will increase closely the executive burden for the suppliers to receives a commission. And the tip result’s the combat that basically led to the NSA, which is that customers are paying an excessive amount of.”