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 newest tendencies and challenges going through the supplier and payer in immediately’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 influence of the No Surprises Act’s (NSA) impartial dispute decision course of and rather more.
The episode lays out the numerous challenges within the well being care market on each the supplier facet and the payer facet. On the supplier facet, the pair factors out that the well being techniques and doctor teams are going through important headwinds and challenges particularly on their expense facet of the enterprise. Challenges embrace labor shortages each on the medical and the executive facet and elevated provide prices. On the payer facet, they are saying points embrace attempting to maintain prices down and never succumbing to a request for a charge enhance.
Mackenzie stated there are plenty of discussions within the business about inflation, the price of well being care and the burden on shoppers. Nonetheless, she stated, “There was not plenty of dialogue about this explicit subject, 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 minimize among the issues 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 issues about beneficiary entry to medically mandatory care. She stated there are a sure proportion 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 stated, “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 struggle that basically led to the NSA, which is that buyers are paying an excessive amount of.”
