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May 23, 2023 | Volume XII | Issue 21

Senate scrutinizes MA payment denials, including use of algorithms

Rebecca Pifer reports for Healthcare Dive:

Medicare Advantage plans’ use of third-party algorithms for coverage determinations is facing some scrutiny in the Senate.

Lawmakers in a Wednesday hearing argued something must be done to pare back burdensome prior authorization requirements allowing payers to delay or deny medical care that would be covered under traditional Medicare — including the use of artificial intelligence — as insurer profits continue to rise.

“Insurers are in effect denying Americans necessary care in order to fatten and pad their bottom lines, and that phenomenon is unacceptable,” said Sen. Richard Blumenthal, D-Conn.

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Congressional Committee, Regulators Question Cigna System that Lets Its Doctors Deny Claims without Reading Patient Files

Patrick Rucker, Maya Miller and David Armstrong

A key congressional committee asked insurance giant Cigna on Tuesday <5/16/23> to provide corporate documents so that lawmakers can examine the company’s practice of denying health care claims without ever opening a patient file.

The House Committee on Energy and Commerce joined several state and federal regulators in scrutinizing the legality of Cigna rejecting the payment of certain claims using a system known as PXDX.

Rep. Cathy McMorris Rodgers, a Republican from Washington who chairs the committee, noted that policyholders under Cigna’s Medicare Advantage plans appeal about one in five denials for requests for medical procedures, known as prior authorizations. Of those denials, about 80% are overturned.

“If these figures are at all illustrative of Cigna’s commercial appeal and reversal rates, it would suggest that the PXDX review process is leading to policyholders paying out-of-pocket for medical care that should be covered under their health insurance contract,” Rodgers wrote in a letter to Cigna.

The letter follows an investigation by ProPublica and The Capitol Forum that found Cigna doctors blocked payment for certain tests and procedures by automatically labeling them “not medically necessary.”

 In two months last year, Cigna doctors refused to pay for 300,000 claims using the PXDX system, spending an average of 1.2 seconds on each case, according to spreadsheets that tracked how fast they worked.

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A new nasal spray to reverse fentanyl and other opioid overdoses gets FDA approval

AP reports via NPR/WLRN:

WASHINGTON — U.S. health regulators on Monday approved a new easy-to-use version of a medication to reverse overdoses caused by fentanyl and other opioids driving the nation's drug crisis.

Opvee is similar to naloxone, the life-saving drug that has been used for decades to quickly counter overdoses of heroin, fentanyl and prescription painkillers. Both work by blocking the effects of opioids in the brain, which can restore normal breathing and blood pressure in people who have recently overdosed.

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Dr.Badia Podcast: Fixing Healthcare...From the trenches E14


Welcome to another exciting episode of Fixing Healthcare...from the Trenches! I'm your host, Dr. Badia, an orthopedic surgeon and healthcare disruptor passionate about improving the system. Episode 14 is very special because it's our first episode with a patient. Officer Ramirez from the Miami-Dade County Police Department.

He will take us on a journey through the U.S healthcare system as an injured worker with a workers' compensation claim. Together, we will delve into the challenges he faced in accessing quality healthcare and the barriers that hindered his recovery. It's an opportunity to gain valuable insights from the perspective of someone on the front lines.

Watch the video HERE.

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