Centene, Aetna, Kaiser Lead in Medicare Advantage Denials: KFF

Modern Healthcare / By Nona Tepper

Aetna, Centene and Kaiser Permanente denied at least one in 10 Medicare Advantage prior authorization requests in 2023, according to a KFF analysis published Tuesday. 

Across the industry, Medicare Advantage insurers increased their use of prior authorization by 7.8% to 49.8 million total requests in 2023, the health policy think tank determined using Centers for Medicare and Medicaid Services data. The increase in requests is in line with enrollment growth, KFF said. Insurers denied slightly fewer prior authorization requests in 2023, refusing to cover 6.8% of claims compared with 7.4% in 2022. 

Related: Medicare Advantage prior authorization, marketing limits proposed

Legislators and regulators have called out the use of prior authorization in Medicare Advantage in recent years as a growing number of policyholders report confronting barriers to care, particularly in post-acute settings.

People in their last year of life were more than twice as likely to switch from Medicare Advantage to traditional Medicare over care access concerns, according to a 2021 report by the Health and Human Services Office of the Inspector General. Those switching from Medicare Advantage to traditional Medicare cost the federal government 27% more than those who were continuously enrolled in the fee-for-service program, KFF reported in December. At the same time, CMS has fined insurance companies for exaggerating patient conditions to improperly inflate federal reimbursements…

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CTA/BOI Reporting Remains Voluntary

 SESCO Management Consultants

• The filing of Beneficial Ownership Information (BOI) Reports that was required by the Corporate Transparency Act (CTA) remains voluntary.

• The US Treasury Department's Financial Crimes Enforcement Network (FinCEN) has noted: "On January 23, 2025, the U.S. Supreme Court granted the government's motion to stay a nationwide injunction issued by a federal judge in Texas (Texas Top Cop Shop, Inc. v. McHenry). As a separate nationwide order issued by a different federal judge in Texas (Smith v. U.S. Department of the Treasury) still remains in place, employers are not currently required to file BOI reports with FinCEN despite the Supreme Court's action in Texas Top Cop Shop."

• FinCEN has also stated that employers are not subject to liability if they fail to file BOI Reports with FinCEN while the Smith order remains in force.

If you are not a retainer client, contact us to learn about our services by calling 423-764-4127 or click here.

Yes, the Pain Is All in Your Head

Medscape / By F. Perry Wilson

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr F. Perry Wilson from the Yale School of Medicine.

I’ve been thinking about Dune a lot lately. I think I might be the only person in the world who prefers the bizarre and grotesque David Lynch movie version to the elegantly crafted Villeneuve oeuvre, including David Lynch himself. We lost a real artist with his passing, and a rewatch of Twin Peaks is very much on my to-do list for this winter.

But back to Dune, because one of the pivotal scenes in the novel and both movie versions is one where young Paul Atreides is tested by the Machiavellian Bene Gesserit. Atreides has to put his hand in a box. What is inside? Pain. Ever increasing pain. He must keep his hand in the box, despite all his instincts telling him to pull it out to prove his fundamental humanity — his ability to exercise control over his own instincts.

Because, as the Reverend Mother points out after the ordeal, his hand is unharmed. The pain is a fabrication — pain by nerve induction, she says. There is no physical damage. It’s all in his mind.

And, of course, that’s true of all pain, isn’t it? It’s not your toe that hurts when you stub it. Signals are sent from your toe, up a nerve to your spinal cord, up another nerve to your thalamus, and then onto the cortex to give it context, emotion, intensity, reality. If that chain is broken, pain simply does not occur. It’s all in your mind.

That’s what makes pain so difficult to treat. It is fundamentally subjective. I’ve had patients with wounds that would make me scream for my mother, yet they sat stoically silent while we worked on them. And I’ve had those who, well, seemed like they were hamming it up a bit…

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White House Rescinds Federal Funding Pause

Alliance Daily

On Monday evening, January 27, the Trump Administration’s Office of Management and Budget (OMB) issued guidance pausing Federal Financial Assistance until an appointee could review whether the spending was in-line with Administration priorities. Due to the wording of the memorandum, specifically a footnote specifying that Medicare and Social Security would not be impacted, some media outlets and policymakers raised concerns that Medicaid payments would, in fact, be subject to the payment pause. However, it is important to note that Medicaid, just like Medicare and Social Security, is an entitlement and not discretionary grant funding. The mandatory nature of the funding should prevent it from being paused.

On January 29, the White House Office of Management and Budget (OMB) rescinded its earlier memo that temporarily paused certain federal grants, loans, and financial assistance programs. The initial memo, issued earlier in the week, led to some confusion about its scope and impact. While OMB had clarified that entitlement programs like Medicare and Medicaid were not affected, uncertainties remained regarding which specific grants, loans, or programs would be subject to the freeze and how these determinations would be made.

See our Alliance Daily article for additional details about the pause. This funding pause was temporarily stayed by a federal court until at least February 3, pending further legal proceedings. The Alliance will continue to monitor for any further developments.

Despite the clarification that Medicaid is not subject to the funding freeze, several news outlets are reporting that State Medicaid Officials are unable to access the Medicaid “payment management system.” This could result in some delay in payments; however, it is likely that this is a short-term issue that is tied to the broader payment freeze and is likely to be resolved once the Administration is able to implement exceptions to the halt on disbursement. The Alliance will keep members informed as we learn more about the future of these funds.

The original OMB memo is available HERE.