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The Hill
9 hours ago
- Health
- The Hill
HHS promotes insurer pledge to scale back prior authorization
Federal health officials on Monday touted pledges they have received from the health insurance industry to streamline and reform the prior authorization process for Medicare Advantage, Medicaid Managed Care and Affordable Care Act Health Insurance Marketplace plans which account for most insured Americans. Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services Administrator Mehmet Oz took part in a roundtable discussion with insurers in which the payers pledged commitments to six key reforms to the prior authorization process. Health care providers must obtain approval from an insurer before a specific service is covered, and they've criticized that process for being time-consuming and a drag on providing health care. According to Oz, the roundtable included the CEOs of health insurance companies who cover about 75 percent of Americans. The CMS administrator said he would like fewer services to be subject to preauthorization. Medicare Director Chris Klomp gave the example of colonoscopies or cataract surgeries as procedures that could be moved out of the prior authorization process. Referencing the biblical passage that reads 'the meek will inherit the earth,' Oz said in a press briefing that health insurance companies and hospital systems have 'agreed to sheath their swords, to be meek for a while.' Major health insurers including Cigna, UnitedHealthcare and Aetna said they would be simplifying the process and reducing the number of health care claims subject to prior authorization. The voluntary commitments include standardizing the electronic prior authorization process; reducing the number of claims subject to prior authorization; ensuring continuity of care when patients change plans; enhancing communication and transparency when it comes to determinations; increasing the numbers of real time responses; and ensuring medical review of denied requests. By cutting down on red tape, Oz said 'tens of billions of dollars of administrative waste' could be saved. Kennedy acknowledged that similar commitments have been made by the health insurance industry in the past, but said this instance was different because of the number of insurers who have signed on to the voluntary agreement. 'The other difference is we have standards this time. We have, we have deliverables. We have specificity on those deliverables, we have metrics, and we have deadlines, and we have oversight,' said Kennedy. Oz suggested another difference was a change in Americans' current consensus on prior authorization compared to the past. 'I mean, there's violence in the streets over these issues. This is not something that is a passively accepted reality anymore. Americans are upset about it,' said Oz. 'I think the major factor is the industry realizes that some of the things that are preauthorized just don't make any sense.' 'The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system,' said Mike Tuffin, president and CEO of the health insurance trade association AHIP. According to a 2024 survey by the American Medical Association, 91 percent of physicians said the prior authorization process can lead to negative clinical outcomes and 82 percent said it could lead to patients abandoning their course of treatment. Acknowledging the voluntary nature of the commitments, Oz said, 'If the insurance industry cannot address the needs of preauthorization by themselves, there are government opportunities to get involved. They might not be as nimble, but they will be used if we're forced to use them.' Actor Eric Dane, who recently disclosed his diagnosis of amyotrophic lateral sclerosis (ALS), appeared at the press conference to put his support behind the move. Dane famously played a physician on the show 'Grey's Anatomy.' 'I'm here today to speak briefly as a patient battling ALS, also known as Lou Gehrig's disease. When that diagnosis hits and you find out that you're sick, your life becomes filled with great uncertainty,' said Dane. 'The worst thing that we can do is add even more uncertainty for patients and their loved ones with unnecessary prior authorization.' Sen. Roger Marshall (R-Kan.) and Rep. Greg Murphy (R-N.C.) joined Kennedy and Oz at HHS headquarters. Both lawmakers have previously introduced legislation seeking to reform and streamline the prior authorization process under Medicare. Marshall and Murphy, both physicians, touched on how the prior authorization process has negatively impacted their patients. 'I vividly remember a patient I once had scheduled for an infertility surgery. She'd taken time off work and arranged help at home, only to be told the morning of a procedure that her insurance company had added another step to the prior authorization process, abruptly canceling her surgery,' Marshall recounted. 'Now, whether you need a hip replacement or a heart catheterization, many patients feel their critical care has been delayed by an opaque and burdensome prior authorization process.' The senator from Kansas said he was still committed to codifying preauthorization reforms despite the commitments made Monday. Describing himself as a 'skeptic,' Murphy said he would be keeping an eye on insurers to make sure they're 'doing what they're saying they're going to do.' He touched on the role of artificial intelligence in today's prior authorization process. 'Artificial intelligence should help this tremendously, tremendously, and it should take out a lot of the variances that happen between doctors, hospitals, regions of the country, etc. But remember, artificial intelligence only is as good as what you put into it,' said Murphy. Physicians have previously expressed concerns about the role of artificial intelligence in the preauthorization process, with some evidence suggesting AI-use results in higher rates of denials. In March, Murphy joined with bipartisan House colleagues in reintroducing the Reducing Medically Unnecessary Delays in Care Act. Among other measures, the bill would bar Medicare administrative contractors from denying coverage of health care services solely because it does not meet an evidence-based standard and would require input from practicing physicians prior to establishing clinical criteria for preauthorization review.
Yahoo
09-04-2025
- Health
- Yahoo
Tensions erupt in House over DeSantis-backed Hope Florida program's $10M windfall
For two hours Tuesday, a panel of House lawmakers asked pointed questions of leaders for the state's main health care administration agency. Rep. Alex Andrade, who chairs the House Health Care Budget Subcommittee, didn't like the answers. 'I'm more stunned, than anything else, by the responses, the demeanor, the flippancy (toward) the serious questions we have,' Andrade, R-Pensacola, told reporters after the hearing. 'This is an endemic problem in state agencies right now and it's something that we've got to work on.' Shevaun Harris, the secretary of the Agency for Health Care Administration, had struggled to answer questions on a series of issues related to Hope Florida, a program spearheaded by First Lady Casey DeSantis that tries to connect Floridians receiving welfare and Medicaid with other services to help move them off government assistance. Andrade and other members of the panel expressed alarm over $10 million that went to the Hope Florida Foundation as part of a settlement between AHCA and Centene, a large provider of services under Florida's Medicaid managed care plans. Under state law, money from settlements must be reported by state agencies to the Legislature, but this wasn't. As Harris explained, the overall settlement was $67 million, with $57 million going to AHCA. It had to do with overpayments related to pharmacy benefit managers, she said, but the other $10 million was a donation from Centene to the Hope Florida Foundation, so the money never came to AHCA and was therefore was not state funds reportable to the Legislature. The settlement was reached in October; Harris didn't take the helm at AHCA until February. 'The settlement agreement had a lot of attorneys involved, taking great care to make sure everything was done appropriately,' she said. But Andrade, an attorney, maintains the funds are taxpayer money and the settlement violates state law: 'The reference to that $10 million not being taxpayer dollars I find offensive,' Andrade said at one point in the hearing. He noted the settlement was for repaying overpayments from the state's Medicaid program. 'At what point did it suddenly become not taxpayer money?' asked Andrade, a state representative since 2018. Andrade also raised concerns about Hope Florida getting preferential treatment in the state's Medicaid Managed Care contracts. Specifically, health care insurers must cooperate with Hope Florida as part of the contract. Another gripe from the committee was the alleged lack of transparency surrounding Hope Florida. 'I still don't get a clear response over who is responsible for Hope Florida,' said Rep. Marie Woodson, D-Hollywood. 'We need to have some names.' Harris explained that the Hope Florida program uses state employees at many different agencies to help connect those in need with services throughout state government and with nonprofits, including churches, who can provide food, clothing and shelter for those in crisis. That means there is no executive director of the Hope Florida program, she added. But the Hope Florida Foundation, which is a nonprofit, is a separate entity. She said that group has a board and later in the hearing said its chairman is Josh Hay, CEO of Indelible Solutions, a Tallahassee-based management consulting firm. As a nonprofit, the Hope Florida Foundation is required to file tax forms with the IRS that are required to be made available upon request by members of the public, but reporters from the Miami Herald/Tampa Bay Times Tallahassee Bureau have said they were turned away after making such a request at the Department of Children and Families headquarters in the capital. The heightened scrutiny of Hope Florida comes as Casey DeSantis is said to be considering a run for governor in 2026 to replace her husband, Gov. Ron DeSantis, who is term-limited. DeSantis has pushed lawmakers to codify Hope Florida, which was started by Casey DeSantis in 2021, into law. At one point in the hearing, Harris said the Hope Florida program was simply trying to help those in need and implied lawmakers weren't sharing that goal. 'I'm not sure why we're here," Harris said. "And I understand there are questions being asked and we're doing our best to be transparent to answer but it does feel like we're not aligned in this overall goal of helping families. 'It's kind of sad, genuinely," she added. "This is the goal of helping individuals get back on their feet. I don't know what's wrong with that.' 'I'm going to take umbrage at that claim,' Andrade replied. 'We're a separate government body tasked with oversight and direction of state agencies and we discover that state agencies are redirecting money secretly, at the eleventh hour, in a legal settlement without giving us any notice? And the accusation is that we don't care about helping Florida families? I take personal issue at that insinuation, Secretary.' Gray Rohrer is a reporter with the USA TODAY Network-Florida Capital Bureau. He can be reached at grohrer@ Follow him on X: @GrayRohrer. This article originally appeared on Tallahassee Democrat: Hope Florida under fire for lack of oversight, $10M settlement
